Comprehensive evaluation of malaria reactive surveillance and response strategies in Lao Peoples Democratic Republic: a mixed-methods study

Study design and participants

A mixed-methods study was conducted between September and October 2022, and detailed procedures are outlined in online supplemental material 1. Briefly, secondary analysis of an aggregated subset of the routinely collected malaria surveillance data from the provinces in malaria elimination phase, quantitative surveys of malaria programme stakeholders (disease control unit leaders and Vector Borne Disease Control Unit staff from the Provincial and District Health Offices) and malaria service providers (health centre and primary healthcare facility staff and village malaria workers (VMWs)) and qualitative consultations such as focus group discussions (FGDs) with malaria programme stakeholders, malaria service providers and MMPs and semistructured interviews with malaria programme stakeholders, was conducted. Study reporting adhered to the Strengthening the Reporting of Observational Studies in Epidemiology and Standards for Reporting Qualitative Research checklists (online supplemental materials 2A,B).

Study setting

Primary data collections for quantitative surveys and qualitative consultations were conducted in four provinces of Lao PDR—Huaphan (Sopbao district), Khammouane (Boualapha and Thakhek districts), Luangprabang (Phoukhoun district) and Savannakhet (Vilabouli district) provinces (figure 1). These provinces were purposively selected to capture the different stages of elimination across the regions of Lao PDR, such as provinces where all districts (Huaphan and Luanprabang provinces) or most districts (Khammouane province) reported no malaria cases and provinces with several high-burden districts (Savannakhet province) in 2022.

Figure 1

Study areas in Lao PDR*. *Map generated using QGIS application V.3.22.0 using base maps from the Lao PDR Administrative Boundary Common Operational Database developed by the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) downloaded from https://data.laos.opendevelopmentmekong.net/dataset/.

Data collection, management and analyses

For the purpose of secondary data analysis, the Laos Centre of Malariology, Parasitology and Entomology provided secondary datasets containing aggregated data on malaria testing, treatment and surveillance collected through routine malaria surveillance system and performed by staff from health centres as well as district and provincial disease control teams in all 17 provinces in malaria elimination phase between 01 Jan 2018 and 31 Dec 2022. The raw secondary dataset was stored in Microsoft Excel with separate spreadsheets for malaria testing and treatment, malaria case notification and investigation and foci investigation and responses. The Microsoft Excel spreadsheets were imported to Stata V.17.0 (StataCorp, Texas, USA), where they were merged to form a dataset (online supplemental material 3) and analysed to assess the timeliness of case notification and investigation. Timeliness of foci investigation and response activities could not be assessed due to limitations in the secondary dataset.

Quantitative questionnaires in the Lao language were administered to 28 malaria programme stakeholders (Questionnaire one in online supplemental material 4) and 37 malaria service providers (Questionnaire two in online supplemental material 4) to explore their awareness and practice of current malaria RASR strategies and feasibility of implementing these strategies in Lao PDR (online supplemental material 5: additional table 1). Participants were recruited purposively based on their working experience, malaria burden of their responsible geographical area, operational feasibility to collect data and the implementation of malaria elimination strategies at the time of survey. The quantitative data were collected using Research Electronic Data Capture (REDCap) and exported to Microsoft Excel files. Open responses were translated to English and then exported into Stata V.17.0 (Stata Corp, Texas, USA), where the survey data was cleaned and descriptively analysed.

A subset of surveyed malaria programme stakeholders, malaria service providers and MMPs were recruited purposively for qualitative consultations. Four semistructured interviews with malaria programme stakeholders (male: 3; female: 1), five FGDs with 14 malaria programme stakeholders (male: 11; female: 3) (in groups of 2–4), six FGDs with 24 malaria service providers (male: 11; female: 13) (in groups of 3–5) and four FGDs with 20 MMPs (male: 14; female: 6) (in groups of 3–6) were conducted (online supplemental material 5: additional table 2). Interview and FGD guides (online supplemental material 4) were used to explore the perceptions and practices of current malaria RASR strategies and acceptability and feasibility for successful implementation of these strategies in Lao PDR. Malaria programme stakeholders and malaria service providers were purposively recruited based on their roles and experience implementing malaria RASR strategies in Lao PDR. Study participants at the village level such as VMWs and MMPs were purposively recruited if their villages were in the coverage of the selected primary healthcare facility where RASR strategies have been rolled out. Interviews and FGDs were audio recorded, transcribed verbatim and translated into English. They were then organised, managed and analysed thematically (deductive followed by inductive analysis)8 in NVivo (Release 1.7.1) by two researchers who immersed and coded data and then discussed themes and subthemes to reach a consensus on the interpretation.9

Patient and public involvement

This study used non-identified aggregated secondary data extracted from routinely collected national malaria surveillance system database. As such, patients were not engaged nor involved in this research. Village malaria workers and mobile and migrant populations from respective community were involved in data collection. Refer to the Methods section and online supplemental material 1 (Additional methods) for further details.

Awareness and acceptability of RASR activities

All (100%, 28/28) surveyed malaria programme stakeholders reported that the 1-3-7 strategy was the time-bound RASR strategy adopted by the Laos Centre of Malariology, Parasitology and Entomology. However, only 59.5% (22/37) of malaria service providers recalled the 1-3-7 strategy, and 35.1% (13/37) responded that they were not aware of any time-bound RASR strategy. In addition, 5.4% (2/37) of malaria service providers responded that there was another time-bound RASR strategy adopted by the malaria programme, though they were unable to recall what the time frames were.

Interviewees and FGD participants reported that the 1-3-7 strategy was well accepted by malaria programme stakeholders and service providers. Moreover, participants claimed that the 1-3-7 strategy was appropriate and effective because it provided a timely response to interrupt the onward transmission of malaria in their assigned geographical areas. Participants also believed that the 1-3-7 strategy was effective for malaria elimination given that the number of malaria cases had decreased in areas implementing the 1-3-7 RASR strategy, and no new malaria cases were identified for many years in those areas.

… if we follow the 1-3-7 strategy, we can eliminate malaria on time as planned… (A malaria programme stakeholder and FGD participant)

At the grass-roots level, MMPs were not aware of RASR activities such as malaria case notification, case investigation, focus investigation and response as there were no malaria cases in their villages or worksites, although some of them mentioned in FGD that routine malaria prevention, control and diagnosis services such as distribution of mosquito nets and blood testing for malaria were available in their community.

We used to hear that there were some malaria cases in our area before, but we do not hear about it (malaria) anymore… we don’t know what kind of activities are carried out once a malaria patient has been detected. (An MMP and FGD participant)

Implementation and performance of RASR activities

In surveys, malaria programme stakeholders commonly reported electronic reporting system using mobile phones or mobile tablets (89.3%, 25/28) and paper-based reporting (85.7%, 24/28) as methods for reporting malaria cases. Additionally, the majority of malaria service providers reported that they notified malaria cases to the malaria programme stakeholders by direct phone calling (75.7%, 28/37).

After a malaria positive case had been notified, case investigation was mostly led or supervised by the district malaria control unit or district health office (71.4%, 20/28). About half of the surveyed malaria service providers (48.6%, 18/37) responded that they were involved in every case investigation executed within their responsible areas. Among those who were never involved in case investigation before (37.8%, 14/37), almost all of them (92.9%, 13/14) reported that they were willing to be involved in case investigation in the future (online supplemental material 5: additional table 3).

The majority of surveyed malaria programme stakeholders and malaria service providers reported that during a case investigation, the investigator(s) visited the index case (83.1%, 54/65), checked malaria preventive measures used by the index case (84.6%, 55/65), educated the index case on malaria prevention (84.6%, 55/65) and collected travel history of the index case (83.1%, 54/65). In addition, 58.5% (38/65) of the surveyed malaria programme stakeholders and malaria service providers mentioned that the location of the index case was mapped during a case investigation by taking the Global Positioning System coordinates (online supplemental material 5: additional table 4).

During qualitative consultations, malaria programme stakeholders mentioned that after investigating and classifying malaria cases according to the National Guidelines, the responsible team which was comprised of district disease control team and designated health facility staff conducted reactive case detection (RACD) as part of the foci investigation and responses. In surveys, malaria programme stakeholders and service providers responded that RACD was triggered either by local cases only (40.0%, 26/65) or by both local and imported cases (46.2%, 30/65). The majority of survey participants (86.2%, 56/65) mentioned that household members of the index case were screened during RACD. All malaria programme stakeholders (100%, 28/28) stated that neighbours of the index case need to be screened during RACD; however, only 62.2% (23/37) of the malaria service providers mentioned that they did so (table 1).

Surveyed participants reported that there were no standardised procedures for conducting RACD. Almost all malaria programme stakeholders (92.9%, 26/28) reported that all household members should be screened during RACD whether they had a fever or not. However, about half (51.4%, 19/37) of the malaria service providers reported that they screened all household members regardless of fever, and 35.1% (13/37) mentioned that only the febrile cases were screened. The majority of malaria programme stakeholders (71.4%, 20/28) reported that all neighbours of the index case should be screened regardless of fever, and 28.6% (8/28) mentioned that only the febrile cases should be screened. About half of the surveyed malaria service providers (48.6%, 18/37) reported that all neighbours were screened during RACD regardless of fever, and approximately one-quarter (24.3%, 9/37) mentioned that only febrile cases were screened. Survey respondents also reported variations in the median number of neighbours (13, IQR: 5, 50), households (10, IQR: 5, 24) and geographical parameter (radius in metres; 125, IQR: 50, 500) around the index case screened during an RACD (table 1).

During FGD, malaria service providers mentioned that they did not understand the process of RACD because there were no malaria cases in their geographical areas, or they were not aware of any specific guidelines or instructions for RACD. Malaria programme stakeholders also highlighted during interviews that there were human resource and financial challenges in doing RACD as part of the RASR strategy.

Apart from RACD, other commonly conducted focus response activities as reported in surveys included awareness raising among community members on malaria transmission, malaria prevention and vector control measures if needed, entomological surveillance, and spot checks for mosquito breeding places if proper entomological surveillance was not feasible (online supplemental material 5: additional table 5).

Timeliness of RASR activities in Lao PDR

Secondary analysis of malaria data from the districts in the elimination phase revealed that the total number of malaria cases per year ranged between 77 (in 2019) and 257 (in 2018). Among 17 reporting units, Khammouan province consistently held the largest number of malaria cases every year, making up 54%–88% of total cases except for the year 2022 (online supplemental material 5: additional table 6).

In 2018, none of the included provinces achieved timely case notification within 1 day. Of the total cases, only 1.3% in 2019 and 0.5% in 2020 achieved timely case notification within 1 day. However, from 2021 onwards, >95% of cases were reported in 1 day, with eight out of 10 provinces achieving 100% timeliness in case notification in 2022. Overall, timely case investigation significantly increased from 15.6% in 2018 to 74.0% (57/77) in 2019, 82.1% (170/207) in 2020 and increasing further to 97.2% (105/108) in 2021 and 98.6% (145/147) in 2022. In 2022, 100% timeliness in case investigation was noted for eight out of 10 provinces (figure 2; online supplemental material 5: additional table 6).

Figure 2

Overall timeliness of case notification and investigation in malaria elimination provinces of Lao PDR during 2018–2022 (source: secondary data analysis).

Enablers of RASR activities in Lao PDR

An enabler of RASR activities in Lao PDR was the strong perception of malaria programme stakeholders that the 1-3-7 strategy was an effective approach to achieve malaria elimination if carried out in a timely manner. They also reported that the 1-3-7 strategy was appropriate for their areas, and they already introduced and advocated its use for malaria elimination across all the districts in their provinces.

Malaria service providers reported in FGDs and interviews that the 1-3-7 strategy was feasible to implement in their geographical areas because they believed that the health centre staff and VMWs were knowledgeable about their local context and could approach target populations well. Malaria programme stakeholders also reported that health staff and VMWs could participate in different RASR activities such as case notification, investigation and response. Furthermore, malaria service providers reported that although many community members did not understand the objective and goals of such activities, there was good community participation in RASR activities because they believed in service providers.

Almost all the health staff are from the local community so that they are well familiar with location and context … they can participate in different activities like giving health education, notifying, reporting and investigating malaria cases, and assisting response activities. (Interview with a malaria programme stakeholder)

Barriers for RASR activities in Lao PDR

Survey results showed that about half of the participants believed there were no barriers in conducting case notification within 1 day (44.6%, 29/65), case investigation within 3 days (50.8%, 33/65) or foci investigation and response activities within 7 days (40.0%, 26/65) (online supplemental material 5: additional table 7). However, some operational and health system-related barriers were identified during interviews and FGD.

Operational barriers for RASR activities in Lao PDR

Having many MMPs in an area was identified as an operational barrier for the successful implementation of RASR activities in Lao PDR because of their mobility patterns and the nature of their workplaces. MMPs in some villages and districts were travelling from one place to another in a relatively short period of time, which made the completion of all steps of RASR activities difficult for malaria service providers to achieve. Malaria service providers perceived that the completeness of RASR activities was undermined by MMPs working in remote rubber plantation sites, which are not easily accessible. Further, owners of rubber plantation sites did not cooperate well with the health sector in performing RASR activities among MMPs. Malaria service providers suggested that a strategy such as cooperation with relevant authorities from labour offices and business owners should be developed to improve access to MMPs and strengthen RASR strategies.

Data collection (for RASR) among this group of population (MMP) is challenging because almost every migrant comes and sells the goods in the village and district for a short period like one or two days. And then they move on to other places. (A malaria programme stakeholder and FGD participant)

Another operational barrier for the successful implementation of RASR activities in Lao PDR was inaccessibility to at-risk populations in the community. Malaria programme stakeholders and malaria service providers reported that some villages were far away from the health centres and were difficult to access, preventing timely implementation of RASR activities, especially in the rainy season. Additionally, it was reported that some villages at risk of malaria did not have mobile phone network or internet access, resulting in delays to every step of RASR activities. Malaria programme stakeholders and malaria service providers reported that there were telecommunication barriers to conduct case notification within 1 day (36.9%, 24/65) (online supplemental material 5: additional table 8). Consistent with the quantitative finding, malaria programme stakeholders also reported during semistructured interviews and FGDs that the timing of RASR activities was negatively impacted by transportation and telecommunication difficulties. Suggested approaches to improve timely notification of malaria cases and subsequent RASR activities included the provision of mobile top-up cards and transportation to hospitals and health centres in remote areas.

RASR activities cannot be carried out in some areas according to the 1-3-7. Especially in remote and hard-to-reach areas where the road is cut off and there is no phone signal. It is the main obstacle for implementation (of 1-3-7 strategy). (A malaria programme stakeholder and FGD participant)

Strengths and limitations of the study

This was the first mixed-method study to comprehensively evaluate the performance and operational feasibility of RASR strategies and activities in Lao PDR. The study has used diverse data collection methods and included participants from different levels ranging from MMPs and frontline malaria service providers to higher-level malaria programme stakeholders. Moreover, findings from different methods were triangulated to increase the breadth and depth of understanding of the study findings.

Completeness and effectiveness, essential parameters for measuring the success of RASR strategy could not be assessed due to limitations in the secondary dataset, which provided no more than the provincial-level aggregated data with a limited number of variables (online supplemental material 3). Due to this limitation, completeness of each step of RASR strategy and effectiveness of RACD could not be calculated (online supplemental material 1: section 3).

Recommendations and conclusion

Overall, the implementation of RASR strategy for malaria elimination is on the right track in Lao PDR. The timeliness of case notification and investigation was found to be satisfactory after 3 years of implementation, and the opinions and perception of malaria programme stakeholders and malaria service providers towards RASR strategies were encouraging. However, this study highlighted the important barriers to effective implementation of RASR strategies in Lao PDR. To further strengthen RASR strategies in accelerating towards malaria elimination in Lao PDR, this study provides a set of recommendations in table 2. Optimisation of RASR strategy by following these recommendations will accelerate malaria elimination in Lao PDR, which in turn will contribute to the malaria elimination in the GMS by 2030.