TME -related activities consisted of the establishment of a malaria post in each study community, a census to establish the potentially eligible population. ‘Intervention’ villages received three rounds of MDAs, the first and last MDA were preceded and followed by prevalence surveys of the entire community using a highly sensitive uPCR 11 . Malaria posts were established after the initial surveys, prior to MDA and were stocked with basic medical supplies and trained, paid staff. The three rounds of MDA were conducted one month apart, each round consisting of three daily doses of dihydroartemisinin-piperaquine combined with a single low dose primaquine on the first day of each round 4 . All four villages during the TME study periods were asked to participate in 3-monthly surveys to detect submicroscopic malaria by uPCR. Between surveys, villagers were asked to approach their malaria posts if they had fever. Quantitative surveys to study reasons for non participation revealed that the main reason was inadequate understading of the rationale for MDA 13 .

While the region has been in conflict for over six decades, various armed groups are currently engaging in peace discussions with the Myanmar government and armed conflicts are much less frequent. The transportation infrastructure in this part of the Kayin State has long been neglected, with very few all-weather roads. Current development projects are changing this landscape.

Villages were selected based on a screening process using high volume ultrasensitive real time PCR (uPCR) 11 , and a set of eligibility criteria which included high prevalence of submicroscopic malaria (greater than 30% positive for malaria of which 10% was falciparum malaria) and importantly, if the villagers and village leaders expressed willingness to participate in the MDA.

Most villagers were of the Karen ethnic nationality and S’gaw Karen was the most commonly spoken language. Eastern Pwo Karen and Burmese were also spoken in the villages. The majority of villagers were Buddhists, though some were Christians and many simultaneously practice animism.

The distance between KNH, the northernmost study village and TOT, the southernmost is roughly 100km. The two northernmost villages are easiest to access from the Thailand side of the border. Access to TOT, can be difficult during the rainy season. The Shoklo Malaria Research Unit (SMRU) in Mae Sot, Thailand served as the operational headquarters for this TME project.

Between May 2013 and June 2015, a study on TME that included MDA was conducted in four villages of Kayin State (KNH, TOT, TPN and HKT) ( Figure 1 ). In year one, two villages (TOT and KNH) underwent MDA and the other two served as ‘control’ villages (TPN and HKT). After nine months TPN and HKT underwent MDA, and TOT and KNH were ‘controls’. The villages are located in contested areas of Eastern Kayin State, with varying degrees of official government control and several influential armed groups. There have been varying levels of armed conflict in Kayin State since 1949 10 .

Community engagement

The community engagement teams consisted of mainly local people (authors: LK, MMT, SN and SWT) and was led by a senior and respectable member of the Karen community (author: LK), supported by a central team (authors: DT and PYC). Having local and senior members from the Karen community was important so that engagement can be guided by adequate local knowledge and experience in the region, as well as access to target villages.

The following subsections describe the community engagement activities conducted for MDA in the KNH, TOT, TPN and HKT villages. These were based on meeting minutes, field notes, feedback sessions among staff and with community members as well as our own reflections.

Workshops. Two-day training workshops were held with village volunteers and community leaders, including village leaders, village administrative staff, monks, and those responsible for health in the village. These groups consisted of 20 to 50 people. Topics covered in the workshop included those related to malaria, such as drug resistance and treatment for malaria. Villagers were encouraged to visit the malaria posts within 24 hours of experiencing fever or other symptoms that could potentially indicate malaria infection. There were discussions on MDA, its rationale and the related procedures, the reasons for uPCR testing, blood draws, and why participation of the entire population is important. The malaria lifecycle, how malaria is transmitted, the drugs used in MDA, potential adverse events related to the drugs and how to handle them were discussed. A quiz was conducted before and after the workshop to gauge understanding and to reinforce the message. Efforts were made to encourage questions as it is not in the local culture to ask questions in public meetings. These workshops were important as they addressed the fears and misconceptions of the villagers. In addition, village engagement strategies were discussed to specifically address cultural and religious aspects of engagement.

Meetings. Meetings were held with groups of children, homemakers and youth groups. These meetings took place in village community halls, schools, temples and other places where groups of people routinely gather such as tea shops, farms and private homes.

In addition to these relatively formal meetings, the community engagement team regularly sought out ad hoc events with pre-existing social groups to talk about the TME project. One example for such spontaneous contact was a ladies social group at the TPN village who met at midday every day.

The community engagement activities were iterative. “Feedback meetings” were held by the team and village leaders with the goal of addressing queries from villagers about topics such as MDA-related rumours and adverse events. As the TME team consisted of healthcare providers, these small meetings also involved discussions about non-TME related everyday health problems, like seasonal illness and tiredness. Outsider groups were also asked to participate in the drug administrations and targeted with community engagement communications. These groups include armed forces, visitors, loggers or anyone who did not permanently stay in the village but visits it regularly.

House-to-house calls were made based on the census using house numbers. They were conducted seven days after MDA, and every two weeks for the entirety of the two-year project to take account of villager mobility and migrations, and to coincide with clinical case sessions at the malaria post. House calls were made by senior members of the team to people who declined to participate in the MDA in the evening when villagers had returned to their homes to talk about their concerns, worries and reasons why they would not or could not participate in the drug administration.

Exhibitions. Maps, posters created by staff and displays of artwork that children created during engagement activities were exhibited in the space were villagers waited during the drug administration (Figure 2). Topics covered included in these exhibits: impact of malaria, earlier spread of drug resistance to Africa such as chloroquine resistance; how malaria affects people, why uPCR is used versus rapid drug tests or microscopy, the MDA rationale, the Plasmodium lifecycle, how malaria transmits, drugs used and how blood samples are processed. Presentations were done using slide shows where possible, posters, drawings and discussions. In addition, locally available samples of antimalarial drugs, familiar to villagers were laid out and discussed.

Activities for children and young people. Activities with children included colouring competitions, singing and acting with topics that were related to the malaria such as the Plasmodium life cycle, the blood volumes needed and the uPCR survey. Colouring was found to be very popular as it was difficult to get colour pencils in these villages. Singing, chanting and acting was also popular as this was entertaining and pleasurable for both children and their parents. There were also spontaneous sessions of games and activities for children unrelated to malaria.

Incentives and ancillary care. While not really an incentive, community members did see the malaria posts as a benefit of being part of the project. Furthermore, water catchment and distribution systems and public latrines were built in each of the study villages. In meetings with the village leaders, water supply was identified as a priority by all four villages. These village-level benefits help build trust and ownership without the coercive element of individual incentives.

Health education unrelated to MDA was provided by the TME community engagement team to villagers at their request, for example family planning, nutrition and vaccination. Youth and healthcare staff benefited from health education and capacity building. Some young people were offered nursing and midwifery training and attachment at the Shoklo Malaria Research Unit so they can go back to work in their own villages more efficiently. Small gifts such as food bundles and household items (e.g. instant noodles, cooking oil, soap) were also given to villagers during MDA visits. No individual monetary incentives were provided.

General rapport building activities. The community engagement team members embedded themselves in the community and engaged in general rapport building activities, frequently joining in village religious ceremonies such as the wrist tying ceremony, as well as rice planting and harvesting. The teams were hosted by villagers in their homes during the intensive MDA and survey days. Social activities with villagers allowed the team to learn more deeply about the realities of village life, seasonal work and obligations, and villagers’ priorities. This knowledge allowed us to plan community based events which were better attended when they did not conflict with villager commitments to their land, religious ceremonies or holidays.

Furthermore, these casual settings provided further opportunities to chat about the TME project, to hear villager comments and suggestions outside of formal settings or in front of the entire community. The makeup of the community engagement team allowed them to integrate themselves more deeply into normal villager life. Through these actions the team was not only able to gain deep insight into the communities, but they were also able to create a strong rapport with community members.