RESUMO
BACKGROUND: The National Malaria Control Programme (NMCP) in Myanmar trained health staff at the township level starting in mid-2016 in order to achieve the Plasmodium falciparum malaria elimination target by 2020. This study aimed to evaluate the knowledge and perception of Basic Health Staff (BHS) and Vector-borne Diseases Control (VBDC) teams exposed to a short training course on malaria elimination in six targeted townships which included two conflict-affected townships between 2016 and 2017. METHODS: This was a cross-sectional mixed-methods study using quantitative and qualitative data extracted from one survey database conducted between October 2018 and March 2019. Modified Poisson regression analysis was performed to ascertain the determinants of low knowledge scores after the training programme. RESULTS: Altogether, 544 trained frontline health workers involved in malaria elimination at the time of the survey were recruited and 56% (302/544) were stationed at sub-Rural Health Centers. More than half of the respondents had correct knowledge of malaria case categories although relapse and recrudescent cases (39% and 37% respectively) were less well known. Over two-thirds of respondents could mention those eligible for malaria testing. Less than 30% knew the foci classification. The overall knowledge scores ranged from 10 to 31. The significant predictors of low level of knowledge [the cut-off point was set at the median value of 21 (IQR 12-30)] in multivariate analysis were the younger age group (18-29 years) and health staff who had attended malaria elimination training in 2017, [(APR = 1.6, 95% CI 1.2-2.2)]; and (APR = 1.5, 95%CI 1.2-1.8)]. Qualitative data from 10 key informants identified perceived challenges in conflict-affected areas as well as in areas of high population mobility with further implications for case surveillance. In addition, the low level of education of community members was noted as one of the barriers that hampered public readiness in the elimination scenario. CONCLUSION: A significant impact on knowledge improvement after the training programme was not visible especially for correct notification of malaria cases and treatment according to National Malaria Elimination Guidelines. Regular monitoring and continuing guidance by the higher level management is critical to support the field staff.
RESUMO
BACKGROUND: The National Plan for Malaria Elimination (NPME) in Myanmar (2016-2030) aims to eliminate indigenous Plasmodium falciparum malaria in six states/regions of low endemicity by 2020 and countrywide by 2030. To achieve this goal, in 2016 the National Malaria Control Program (NMCP) implemented the "1-3-7" surveillance and response strategy. This study aims to identify the barriers to successful implementation of the NPME which emerged during the early phase of the "1-3-7" approach deployment. METHODS: A mixed-methods study was conducted with basic health staff (BHS) and Vector Born Disease Control Program (VBDC) staff between 2017 and 2018 in six townships of six states/regions targeted for sub-national elimination by 2020. A self-administered questionnaire, designed to assess the knowledge required to implement the "1-3-7" approach, was completed by 544 respondents. Bivariate analysis was performed for quantitative findings and thematic analysis was conducted for qualitative findings using Atals.ti software. RESULTS: Although 83% of participants reported performing the key activities in the "1-3-7" surveillance and response approach, less than half could report performing those activities within 3 days and 7 days (40 and 43%, respectively). Low proportion of BHS correctly identified six categories of malaria cases and three types of foci (22 and 26%, respectively). In contrast, nearly 80% of respondents correctly named three types of case detection methods. Most cited challenges included 'low community knowledge on health' (43%), 'inadequate supplies' (22%), and 'transportation difficulty' (21%). Qualitative data identified poor knowledge of key surveillance activities, delays in reporting, and differences in reporting systems as the primary challenges. The dominant perceived barrier to success was inability to control the influx of migrant workers into target jurisdictions especially in hard-to-reach areas. Interviews with township medical officers and the NMCP team leaders further highlighted the necessity of refresher training for every step in the "1-3-7" surveillance and response approach. CONCLUSIONS: The performance of the "1-3-7" surveillance and response approach in Myanmar delivers promising results. However, numerous challenges are likely to slow down malaria elimination progress in accordance with the NPME. Multi-stakeholder engagement and health system readiness is critical for malaria elimination at the sub-national level.
