Understanding Malaria Persistence: A Mixed-Methods Study on the Effectiveness of Malaria Elimination Strategies in South-Central Vietnam

Abstract

Despite the scale-up of vector control, diagnosis and treatment, and health information campaigns, malaria persists in the forested areas of South-Central Vietnam, home to ethnic minority populations. A mixed-methods study using an exploratory sequential design was conducted in 10 Ra-glai villages in Bac Ai district of Ninh Thuan province to examine which social factors limited the effectiveness of the national malaria elimination strategy in the local setting. Territorial arrangements and mobility were found to directly limit the effectiveness of indoor residual spraying and long-lasting insectidical treated nets (LLINs). Households (n=410) were resettled in the “new villages” by the government, where they received brick houses (87.1%) and sufficient LLINs (97.3%). However, 97.6% of households went back to their “old villages” to continue slash-and-burn agriculture. In the old village, 48.5% of households lived in open-structured plot huts and only 5.7% of them had sufficient LLIN coverage. Household representatives believed malaria could be cured with antimalarials (57.8%), but also perceived non-malarial medicines, rituals, and vitamin supplements to be effective against malaria. Household members (n = 1,957) used public health services for their most recent illness (62.9%), but also reported to buy low-cost medicines from the private sector to treat fevers and discomfort as these were perceived to be the most cost-effective treatment option for slash-and-burn farmers. The study shows the relevance of understanding social factors to improve the uptake of public health interventions and calls for contextually adapted strategies for malaria elimination in ethnic minority populations in Vietnam and similar settings.

Why using bed nets is a challenge among minority populations in Central Vietnam

“…In Myanmar, ITN use was limited by the hard material of ITNs, the limited choice in net size to accommodate variable family sizes and sleeping places, and the inadequate height of the net for people to sit comfortably [ 46 ]. In Vietnam, limited ITN use was linked to hard netting [ 41 ], the design of ITNs that was uncomfortable for users who slept on the floor (without a bed), and limited choices for net size for varied family and house size [ 47 , 48 ]. These studies suggest a more appropriate ITN design and features that are better adapted to climatic conditions, variable family structures and sleeping places could increase the acceptance and appropriate use in minority populations.…”

“…In Cambodia and Vietnam, researchers reported a major difference between self-reported net use the night before the survey and observed net use at people’s homes [ 33 , 61 ]. Other mixed methods studies in Southeast Asia, including qualitative methods before conducting a survey, resulted in the inclusion of a series of local factors to measure effective bed net use such as mobility between fields and villages, availability and use of intact bed nets at home and fields, and evening outdoor activities [ 21 , 47 , 62 – 64 ]. In Zanzibar, qualitative methods were used to explore night-time activities and sleeping patterns in one study while another study used a combination of survey research and structured observation to identify the variation in levels of net use [ 65 , 66 ].…”

“…Despite this, the study findings are still relevant for Vietnam. The NMCP has continued to include ITN distribution as an important element of vector control in the elimination strategies to 2030, and recent studies in ethnic minority settings have continued to report on limited uptake of bed nets [ 41 , 47 ].…”

“…Indeed, the study population represents the challenges faced by several minority groups ( e.g. Ra-glai) living in forested areas in Vietnam [ 15 , 47 , 61 ] and in the Greater Mekong Subregion [ 62 , 76 , 77 ], such as a forest-based livelihood, swidden farming, multiple residencies, mobility, the lack of nets, different local housing styles and conditions as well as high illiteracy and animistic beliefs, which are not addressed by the standardized interventions and approaches to malaria elimination.…”

Use of antimicrobials and other medical products in an ethnic minority context of South-Central Vietnam: A qualitative study of vulnerability

“…Health studies found that people of Raglai ethnicity had a higher risk of malaria infection and malnutrition rates among children under 5 years of age in comparison to those who were of Kinh ethnicity [54,[58][59][60].…”