Community engagement approaches for malaria prevention, control and elimination: a scoping review

Abstract

Introduction

Globally malaria programmes have adopted approaches to community engagement (ACE) to design and deliver malaria interventions. This scoping review aimed to understand, map, and synthesise intervention activities guided by ACE and implemented by countries worldwide for the prevention, control and elimination of malaria.

Methods

Three databases (Web of Science, Proquest, and Medline) were searched for peer-reviewed, primary studies, published in English between 1 January 2000 and 31 December 2022. Advanced Google was used to search for grey literature. The five levels of the International Association for Public Participation were used to categorise ACE - (1) Inform, (2) Consult, (3) involve, (4) Collaborate, and (5) Co-lead. Intervention activities were categorised as health education (HE), and/or health services (HS), and/or environmental management (EM). Outcomes were collected as knowledge, attitude, behaviour, help-seeking, health and HS and environment. Enablers and barriers were identified. Malaria intervention phases were categorised as (1) prevention (P), or (2) control (C), or (3) prevention and control (PC) or prevention, control and elimination (PCE).

Results

Seventy-five studies were included in the review. Based on ACE levels, most studies were at the inform (n=37) and involve (n=26) level. HE (n=66) and HS (n=43) were the common intervention activities. HE informed communities about malaria, its prevention and vector control. EM activities were effective when complemented by HE. Community-based HS using locally recruited health workers was well-accepted by the community. Involvement of local leaders and collaboration with local stakeholders can be enablers for malaria intervention activities.

Conclusion

Involving local leaders and community groups in all stages of malaria prevention programmes is vital for successful interventions. Key elements of successful ACE, that is, consult, collaborate, and co-lead were under-represented in the literature and require attention. National programes must consult and collaborate with community stakeholders to develop ownership of the interventions and eventually co-lead them.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The application of the framework International Association for Public Participation and modified by Born, World Health Organization framework for characterising pathway to malaria elimination facilitated the data classification, and the study was guided overall by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review checklist, a strength of this study.

• This scoping review describes and synthesises interventions guided by the levels of ACE for malaria prevention, control, and elimination and captures 22 years of peer-reviewed and grey literature providing a broader scope, a strength of this study.

• The search strategy for the scoping review was developed with the assistance of the University Health Sciences librarian, a strength of this study.

• There were limitations of the study—these included the omission of multicountry studies, studies published in languages other than English and reviews were excluded.

Introduction

Malaria is a global public health challenge causing an estimated 249 million cases and 608 000 deaths worldwide in 2022.¹ Of the total cases, 96% occurred in the World Health Organization Sub-Saharan African region (WHO-SSA) and 2% in the Southeast Asian (SEA) region. Despite significant progress made in the last two decades to decrease the incidence of malaria, the decline since 2015 has slowed.^{2 3} Although malaria incidence decreased from 81 per 1000 population at risk in 2000 to 57 per 1000 population in 2019, the decline since 2019 has remained static with the incidence reported at 68 per 1000 population at risk in 2022.^{1 2} However, the WHO Global Technical Strategy (2016–2030) envisions a malaria-free world by 2030 for which a holistic approach aligned with the Sustainable Developmental Goals (Target 3.3) is required to address the determinants of malaria while delivering malaria intervention activities.^{4 5} This includes enabling round-the-year access to safe, affordable, and quality health services (HS) for malaria diagnosis and treatment and malaria prevention to all population at risk of the disease.⁵ Malaria intervention activities include: promoting and enabling the use of long-lasting insecticidal nets (LLINs), indoor residual spraying(IRS), environmental management (EM) of vectors, for example, larvicidal activities and chemoprophylaxis for prevention; early diagnosis and prompt treatment of positive cases for control and strengthened surveillance and active case detection activities for elimination of malaria.2 3 6 7 Each of these activities are used with varying levels of emphasis for each of the intervention phases: malaria prevention; control; and elimination.

Worldwide, individual countrys’ national malaria programmes have adopted approaches to community engagement (ACE) with the communities at risk of malaria, and affiliated by geographical proximity, specific interests, and similarity of situations that affect their overall well-being.^{4 7 8} The International Association for Public Participation (IAPP) and Born⁹ have categorised ACE into five areas: Inform (to provide balanced information about the disease); Consult (gather feedback from stakeholders on the set goal); Involve (work closely with stakeholders); Collaborate (partner with stakeholders including decision making) and Co-lead (allow the stakeholders to drive decisions and implementation)^{9 10} (see online supplemental figure 1). In essence, malaria programmes that use a community engagement approach should aim to work collaboratively in co-designing and co-leading culturally appropriate interventions to ensure wider acceptance and participation among those at risk, while developing local ownership to increase sustainability.^11–14

ACE that focuses on malaria considers the local context, targets communities to raise awareness and increase knowledge of malaria prevention and ensures year-round access to community-based rapid diagnostic test kits and treatment at the community level, while developing local ownership of the community interventions.^{12 15–17} Furthermore, ACE in malaria can help address health inequalities among disadvantaged and marginalised groups who are confronted by geographical, cultural, financial, and communication barriers.¹⁸ Local access to HS alleviates costs and travel time and makes available diagnostic and treatment services, thereby increasing the ability to identify and manage malaria cases early in at-risk communities.¹⁵ Many projects funded by external development partners and supported by collaboration between non-governmental organisations and national malaria programmes have aimed to sensitise the communities to malaria prevention, control and elimination, initiate partnerships, and build trust in the health system to attain positive health outcomes.^{12 15 16}

To date, no review has investigated or synthesised evidence on intervention activities guided by the ACE for malaria prevention, control, and elimination across countries on different continents. Therefore, this scoping review aimed to understand, map, synthesise, and document the intervention activities guided by the ACE and adopted by malaria programmes implemented across the globe. This understanding will help identify the strategies adopted by countries worldwide for prevention and/or control, and/or elimination of malaria, and identify gaps and areas for future focus.

Methods

The protocol outlining the full methods for this paper has been published elsewhere,¹⁹ however, a summary is presented below. The review was conducted following the 2017 updated Joanna Briggs Institute (JBI) guide for scoping reviews,^{20 21} using a framework developed by Arksey and O’Malley²² and further refined by Levac et al,²³ and has been registered at JBI. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews has been used to present the review methods and the study results.²⁴

Search strategy

Three databases were searched: Web of Science, Proquest and Medline (OVID) using the keywords “community engagement” OR “community participation” OR “community involvement” OR “public engagement” OR “community mobilisation” OR “social mobilisation” OR “community action” OR “community empowerment” OR “community led” OR “community conversation” AND “prevention” OR “control” OR “elimination” AND “malaria” (online supplemental table 1 shows a Medline search). Grey literature was searched using advanced tools in the Google search engine.²⁵ Only studies published between 1 January 2000 and 31 December 2022 were included in the study.

Selection of sources of evidence

Studies were included if they were: primary studies; in the English language; had quantitative, qualitative or mixed methods designs; were case, programme or project reports and studies that used ACE for malaria prevention, control, and/or elimination. Studies were excluded if they were: secondary studies including reviews (systematic and scoping); study protocols; provided information related to ACE for health issues and diseases other than malaria; multicountry studies; and without a clear study design and methods. One reviewer (KRA) assessed the articles based on title and abstract, applying the inclusion and exclusion criteria, and removing duplicates. The title and the abstracts were then reviewed by two reviewers (JJ and JEL) with any uncertainties discussed until a consensus was reached. Full-text articles were then screened independently by KRA, which were then further reviewed by JEL and JJ for inclusion in the review. The reference lists of included studies were manually searched for any additional articles.

Patients and public involvement statement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Charting the data

Data were extracted and charted in tabular format (KRA) and presented by region and included: author(s), year of publication, country, study aim; study design/methods; level of ACE; intervention activity type; intervention outcomes; intervention phases, barriers and enablers. Two reviewers (JJ) and (JEL) took the first five articles from the data charting table and assessed the data chart for consistency based on the study aims. RR and CG reviewed and edited the data charting table for errors and completeness of information.

Data classification

• The World Bank classification of countries by regions²⁶ was used to categorise studies as SSA, East Asia and Pacific (EAP), SEA and Latin America and the Caribbean (LAC).

• ACE levels were categorised as (1) Inform, (2) Consult, (3) Involve, (4) Collaborate, or (5) Co-lead, based on the framework developed by the IAPP¹⁰ and modified by Born⁹ (see online supplemental figure 1 for the full description of the ACE levels).

• Intervention activity types were categorised as (1) health education (HE), (2) HS and (3) EM.

• Intervention outcomes were classified as (1) knowledge (improved knowledge on malaria), (2) attitude (changes to a way of thinking or feeling that affects an individual’s health behaviour), (3) help-seeking (changes in how an individual accesses formal/informal help related to health), (4) self-efficacy (changes to an individual’s confidence in the ability to complete a task), (5) behaviour (changes in an individual’s actions that can affect their health), (6) environmental (changes to the physical or supporting environment that can affect malaria cases) and (7) health and healthcare (changes in health status of a population, or to health service delivery).^{27 28}

• Malaria intervention phases as per the WHO framework for characterising the pathway to malaria elimination³ were categorised as (1) prevention (P), or (2) control (C), or (3) prevention and control (PC), or prevention, control and elimination (PCE). For example, studies that described, HE, mass drug administration (MDA), vaccines and/or vector control activities were categorised as prevention. Studies that described HS intervention activity types to decrease the disease burden (early diagnosis and prompt treatment) and manage outbreaks were categorised as control, while those with active case detection and surveillance were categorised as elimination. Intervention activity types that crossed phases were categorised as PC or PCE.

• Barriers (obstacles to delivering the intervention activities) were categorised as (1) governance (related to leadership and governance), (2) resources (human and financial), (3) logistics and supply, (4) activity delivery (HE, HS or EM related), (5) sociocultural, (6) geographical, and (7) political. Likewise, enablers (factors that facilitate the proposed implementation of activities)²⁹ identified during the review were categorised as (1) resources (human and financial), (2) activity delivery, and (3) partnerships.

Results

Search and selection of the review

In total, 1878 articles were initially identified from the three databases, and an additional 50 articles/reports were identified from the advanced Google search (figure 1).

Figure 1.

Scoping review selection process flow chart for eligible studies. This figure shows the flow diagram of the selection process of the reviewed articles based on the exclusion and inclusion criteria from the selected databases.

After removing duplicates (n=406), 1472 articles were screened by title and 1194 were excluded. After screening the abstracts, 158 articles were removed and the remaining 120 articles were downloaded for full-text reading. A further 45 articles were excluded (including 13 multicountry studies and 2 full-text papers that could not be retrieved). This resulted in 75 articles (including 3 from the grey literature) being included in the review. A summary of the final 75 articles is provided by 4 regions in tables 1–3, and full details of each study are in online supplemental tables 1–3.

Table 1.

A summary of the approaches to community engagement in the sub-Saharan African region (see online supplemental table 1) for details

Study, country, aim	Study design/Method	Level of approaches to community engagement	Intervention type and activities	Intervention outcomes	Phase(s)
Abuya et al,30 Kenya To assess the implementation and scaling up processes of three PMR programmes	Qualitative FGDs (n=24) with clients (n=12), PMRs (n=12) each group 8–10 participants. In-depth interviews with community volunteers (n=8), trainers (n=6), public health officers (n=5)	Inform PMRs trained	Health services Management of malaria through PMRs	Knowledge Improved and sustained malaria knowledge among PMRs	Control
Aberjirinde et al,100 Rwanda	Qualitative	Involve	EM	Attitude; environment	Prevention
Alegbeleye et al,31 Nigeria	Descriptive	Collaborate	HE	Attitude	PCE
Angwenyi et al,32 Kenya	Mixed methods	Involve	HE; HS	Attitude	Prevention
Asale et al,33 Ethiopia	Quantitative	Involve	HE; EM	Knowledge; help-seeking; behaviour; health and healthcare	Prevention
Banek et al,34 Uganda	Mixed methods	Inform	HS	Attitude	PC
Burke et al,35 Burkina Faso	Qualitative	Inform	HE; HS	Behaviour	PC
Castro et al,36 Tanzania	Quantitative	Involve	HE; EM	Knowledge; behaviour; health and healthcare	Prevention
Chaki et al,37 Tanzania	Mixed methods	Inform	EM	Environment	Prevention
Cox et al,38 South Africa	Quantitative	Involve	HE	Knowledge; attitude	Prevention
de Sousa Pinto da Fonseca et al,39 Mozambique	Qualitative	Collaborate	HE	Knowledge; behaviour	Prevention
Deribew et al,40 Ethiopia	Mixed methods RCT	Inform	HE	Knowledge; behaviour; health and healthcare	Prevention
Elmardi et al,101 Sudan	Mixed methods	Involve	HE; HS	Attitude; health and healthcare	PCE
Goodman et al,41 Kenya	Quantitative	Inform	HS	Health and healthcare	Control
Hamainza et al,42 Zambia	Quantitative	Inform	HE; HS	Health and healthcare	PCE
Ingabire et al,43 Rwanda	Mixed methods	Involve	HE; EM	Knowledge; attitude; behaviour; environment	Prevention
Kaunda-Khangamwa et al,17 Malawi	Qualitative	Inform	HE; HS	Attitude	PC
Kebede et al,45 Ethiopia	Quantitative	Inform	HE	Behaviour	Prevention
Kebede et al,44 Ethiopia	Quantitative	Inform	HE	Knowledge; behaviour; help-seeking	Prevention
Kibe et al,46 Kenya	Qualitative	Involve	HE; EM	Behaviour	Prevention
Kpormegbe et al,47 Ghana	Mixed methods	Inform	HE; HS	Attitude	PC
Ma et al,48 Ghana	Quantitative	Inform	HE; HS	Behaviour; health and healthcare	PC
Malenga et al,50 Malawi	Qualitative	Inform	HE	Knowledge	Prevention
Malenga et al,49 Malawi	Qualitative	Inform	HE	Knowledge; self-efficacy	Prevention
Manana et al,70 South Africa	Mixed methods	Consult	HE	Attitude	Prevention
Matindo et al,71 Tanzania	Mixed methods	Involve	HE; EM	Behaviour	Prevention
Mbalinda et al,51 Uganda	Qualitative	Involve	HE	Attitude; help-seeking	Prevention
Mbonye et al,54 Uganda	Mixed methods	Inform	HE; HS	Health and healthcare	PC
Mbonye et al,56 Uganda	Mixed methods	Inform	HE; HS	Health and healthcare	PC
Mbonye et al,53 Uganda	Mixed methods	Inform	HE; HS	Health and healthcare	PC
Mbonye et al,52 Uganda	Mixed methods	Inform	HE; HS	Attitude; behaviour; help-seeking	PC
Mbonye et al,55 Uganda	Mixed methods	Inform	HE; HS	Health and healthcare	PC
McCann72 Malawi	Quantitative	Involve	HE; EM	Health and healthcare; environment	Prevention
Mlozi et al,57 Tanzania	Descriptive (project report)	Consult	HE	Knowledge	Prevention
Mugisa et al,58 Uganda	Mixed methods	Inform	HE	Knowledge; behaviour; health and healthcare	Prevention
Nakiwala et al,59 Uganda	Qualitative	Involve	HE	Knowledge; attitude; environment	Prevention
Ng'ang'a et al,62 Kenya	Quantitative	Involve	HE	Knowledge	Prevention
Ndira et al,60 Uganda	Qualitative	Inform	HE	Behaviour	Prevention
Ndyomugyenyi et al,61 Uganda	Qualitative	Inform	HE; HS	Behaviour	PC
Nsabagasani et al,63 Uganda	Qualitative	Inform	HE	Attitude	PC
Odero et al, 64 Kenya	Quantitative	Inform	HE; HS	Knowledge; health and healthcare	PCE
Onwujekwe et al,65 Nigeria	Quantitative	Consult	HE; HS	Health and healthcare	PC
Owek et al,66 Kenya	Qualitative	Inform	HE; HS	Attitude	PCE
Tiono et al,67 Burkina Faso	Quantitative	Inform	HS	Health and healthcare	Control
van den Berg et al, 68 Malawi	Descriptive	Involve	HE; EM	Knowledge; environment	Prevention
Wasunna et al,69 Kenya	Quantitative	Inform	HE; HS	Health and healthcare; help-seeking	PC

EM, environmental management; FGD, focus group discussion; HE, health education; HS, health services; PC, prevention and control; PCE, prevention, control and elimination; PMR, private medicine retailer; RCT, randomised controlled trial.

Table 2.

A summary of the approaches to community engagement in East Asia and Pacific region (see online supplemental table 2 for full details)

Study, country, aim	Study design/Methods	Level of approaches to community engagement	Intervention type and activities	Intervention outcomes	Phase(s)
Adhikari et al,14 Laos To describe the various components of the CE intervention for MDA	Qualitative In-depth interviews (n=7) with field staff. Content analysis of field notes (n=125), meeting minutes and photographs	Collaborate Team consisting of community and leaders. Training of community for education training and co-ordination of intervention	Health education Community awareness using village volunteers Health services Blood survey and MDA conducted	Knowledge Improved knowledge of malaria and MDA in the community	PCE
Adhikari et al,73 Laos	Quantitative	Collaborate	HE; HS	Knowledge; health and healthcare	PCE
Callery et al,74 Cambodia	Qualitative	Involve	HE	Knowledge; attitude; self-efficacy	Prevention
Canavati et al,75 Cambodia	Mixed methods	Involve	HE; HS	Behaviour	PCE
Ean et al,76 Cambodia	Qualitative	Inform	HE	Knowledge; self-efficacy	Prevention
Fitzpatrick et al,77 Papua New Guniea	Descriptive	Involve	HE	Behaviour; health and healthcare	Prevention
Kajeechiwa et al,78 Myanmar	Quantitative	Collaborate	HE; HS; EM	Health and healthcare	PCE
Kaneko et al, 79 Vanuatu	Descriptive	Inform	HS; EM	Health and healthcare	PCE
König et al,80 Myanmar	Qualitative (case study)	Involve	HE; HS	Knowledge; health and healthcare	PCE
Lee et al,81 Myanmar	Descriptive	Inform	HE; HS	Attitude	PCE
Lim et al,83 Cambodia	Quantitative	Inform	HS	Attitude; health and healthcare	Control
Lim et al,82 Cambodia	Qualitative	Involve	HE	Attitude	Prevention
Matsumoto-Takahashi et al,85 Philippines	Quantitative	Inform	HE; HS	Knowledge; behaviour	PC
Matsumoto-Takahashi et al,84 Philippines	Quantitative	Inform	HE; HS	Health and healthcare	PC
Maung et al, 86 Myanmar	Mixed methods	Involve	HE; HS	Knowledge; behaviour; help-seeking	PCE
Nay Yi Yi et al, 95 Myanmar	Mixed method	Inform	HE; HS	Health and healthcare	PCE
Nguon et al,87 Cambodia	Qualitative	Involve	HE	Attitude	Prevention
Nyunt et al,88 Myanmar	Mixed methods	Inform	HE	Knowledge; help-seeking	Prevention
Oo et al,89 Myanmar	Qualitative	Co-lead	HE; HS	Attitude	PCE
Peto et al,90 Cambodia	Mixed methods	Involve	HE; HS	Knowledge	Prevention
Pratt et al,91 Myanmar	Qualitative	Involve	HE; HS	Knowledge; health and healthcare	PC
Reeder et al,92 Papua New Guinea	Observational (descriptive)	Collaborate	HE	Behaviour	Prevention
Sahan et al,93 Myanmar	Qualitative	Consult	HE; HS	Help-seeking	PCE
Tangseefa et al,94 Myanmar	Qualitative (descriptive)	Collaborate	HE; HS	Attitude	PCE

CE, community engagement; EM, environmental management; HE, health education; HS, health services; MDA, mass drug administration; PC, prevention and control; PCE, prevention, control and elimination.

Table 3.

A summary of the approaches to community engagement in Southeast Asia and the Latin America and Caribbean region (see online supplemental table 3 for full details)

Study, country, aim	Study design/Methods	Level of approaches to community engagement	Intervention type and activities	Intervention outcomes	Phase(s)
Southeast Asia region
Das et al,96 India   To assess the effectiveness of two community-based interventions: (i) community mobilisation promoting appropriate malaria-related behaviour and (ii) community mobilisation together with supportive supervision of community health workers	Quantitative 40 villages (each with n=900) were randomly assigned to each arm Arm A: supportive supervision of ASHA and community mobilisation support Arm B: only community mobilisation activities, and control arm-only regular national programme activities	Involve Community members assisted in planning and refining intervention strategies	Health education Community-level meetings, street performance and regular distribution of resources Health services ASHA door-to-door malaria case management (testing and treatment)	Behaviour Higher proportion of people (84.5% and 82.4% vs 78.7%) and children (96.8% and 94.3% vs 90.7%) slept under the net in the intervention areas compared with control Health and healthcare Timely case management by ASHA in the intervention arm was higher compared with control (82.1% vs 67.1%)	Prevention and control
Kishore et al,97 India	Quantitative	Inform	HE; HS	Knowledge; help-seeking	PC
Togbay et al,98 Bhutan	Mixed methods	Involve	HE; EM	Knowledge; attitude; behaviour; environment	Prevention
Latin America and Caribbean region
Prat et al,102 Brazil	Descriptive	Involve	HE; HS	Health and healthcare	PC
Valdez et al,99 Dominican Republic	Qualitative	Inform	HS	Health and healthcare	Control

ASHA, Accredited Social Health Activists; EM, environmental management; HE, health education; HS, health services; PC, prevention and control; PCE, prevention, control and elimination.

Study region, year of delivery and study design

Using the World Bank classification of countries by regions (online supplemental figure 2a), the majority of the studies were conducted in SSA (n=46)^{17 30–72} (table 1) followed by EAP (n=24)^{14 73–95} (table 2), SEA (n=3),^96–98 and LAC (n=2)^{91 99} regions (table 3). More than half of the SSA studies were conducted in three countries: Uganda (n=12);34 51–56 58–61 63 Kenya (n=8);30 32 41 46 62 64 66 69 and Malawi (n=5).17 49 50 68 70 72 Similarly, two-thirds of the EAP studies were conducted in Myanmar (n=10)78 80 81 86 88 89 91 93–95 and Cambodia (n=7).74–76 82 83 87 90 The study designs were: qualitative studies (n=25);17 30 35 39 46 49–51 59–61 63 66 73 74 76 80 82 87 89 91 93 94 99 100 quantitative studies (n=21);14 33 36 38 41 42 44 45 48 62 64 65 67 69 72 78 83–85 96 97 and mixed methods studies (n=21).32 34 37 40 43 47 52–56 58 70 71 75 86 88 90 95 98 101 Of the remaining eight studies, five were descriptive case studies,57 68 81 92 102 and three were project reviews/reports^{31 77 79} (online supplemental figure 2b). Twenty studies were conducted before 2010, and the remaining studies (n=55) were conducted between 2011 and 2022, with two-thirds (n=37) being undertaken since 2016 (online supplemental figure 2c).

Level of community engagement

Based on the IAPP framework categories, the majority of the studies (n=37) were categorised as the Inform level, with most being from SSA (n=27)17 30 34 35 37 40–42 44 45 47–50 52–56 58 60 61 63 64 66 67 69 and EAP (n=8),76 79 81 82 84 85 88 95 while there was one study each from SSA⁹⁷ and LAC.⁹⁹ Twenty-six studies were categorised at the involve level (n=26), with SSA contributing the most studies (n=14)32 33 36 38 43 46 51 59 62 68 71 72 100 101 followed by EAP (n=9),74 75 77 80 82 86 87 90 103 SEA (n=2),^{96 97} and LAC (n=1).¹⁰² Four studies were categorised as consult, of which three were from SSA^{57 65 70} and one from EAP.⁹³ Lastly, among the seven studies categorised at the collaborate level, two were from SSA^{31 39} and five were from EAP.14 73 78 92 94 One study from EAP⁸⁹ was classified as co-lead.

Intervention type and activities

In SSA, the majority of the studies included an intervention activity related to HE (n=15),39 40 44 45 49–51 57–60 62 70 and a combination of HE and HS (n=18).17 31 32 35 42 47 48 52–56 61 64–66 69 101 Some studies (n=7) focused on HE and EM,33 36 43 46 68 71 72 while some were standalone HS (n=5)30 34 41 63 67 or EM (n=2)^{37 100} intervention activities. In the EAP region, most of the intervention activities focused on HE and HS (n=14),14 73 75 80 81 84–86 89–91 93–95 followed by HE (n=7),74 76 77 82 87 88 92 HS and EM (n=1),⁷⁹ and all three areas (HE, HS and HM) (n=1).⁷⁸ Likewise, in SEA, two studies focused on HE and HS,^{96 97} while one included intervention activities for HE and EM.⁹⁸ Of the two studies, in the LAC region, one had HE and HS¹⁰² intervention activities, and the other had HS-related activities only (n=1).⁹⁹

Intervention outcomes

Health and healthcare outcomes were reported in 30 studies33 36 40–42 48 52–56 64 65 67–69 72 73 77–80 83 84 91 95 96 99 101 102 of which almost half of the studies (n=14) reported a decrease in cases.33 36 40–42 52–56 72 99 101 102 However, Ma et al⁴⁸ reported no significant difference in malaria prevention postintervention. Thirty studies also reported changes in knowledge of malaria prevention (n=30),14 30 33 36 38–40 43 44 49 50 57–59 62 64 68 73 74 76 80 84–88 90 91 97 98 including improvement in the overall knowledge for malaria transmission, signs and symptoms, prevention using LLINs,14 38–40 44 57–59 64 73 74 85 86 88 90 91 97 98 vector control,^{36 43 98} and MDA.^{14 90} Behaviour outcomes were reported by 23 studies35 36 39 40 43–46 48 51 52 58 60 61 71 75 77 85 86 92 96 98 of which most of the studies reported improved use of LLIN (n=12)33 36 40 44 45 48 58 60 75 77 85 96 followed by treatment-seeking behaviour for malaria (n=7).44 45 51 52 58 61 86 Although improved participation in vector control activities were reported by some studies (n=3),^{43 44 46} low participation was observed by one study⁷¹ despite the community having a good vector knowledge. Change in attitude was reported in 22 studies17 31 32 34 38 43 47 51 52 59 63 66 70 74 81–83 87 89 92 94 98 101 of which 17 studies17 31 32 38 43 47 51 66 70 74 83 87 89 92 94 100 101 reported acceptance of the intervention activity while some studies reported concerns regarding technical ability of the community health workers (CHWs),^{34 81} quality of the antimalarial drugs,⁶³ the use of children to deliver malaria prevention messages,⁵⁹ and the range of services provided by the CHWs.⁵² The other reported outcomes were help-seeking for healthcare (n=8),33 44 51 52 69 86 88 97 environmental improvements for vector control (n=7),37 43 59 68 72 98 100 and improved self-efficacy (n=3).^{49 74 76}

Twenty-three studies identified barriers faced in implementing the intervention activities,17 30 34 37 39 43 46 49 51 52 62–64 69 75 76 78 80–82 88 94 100 however, enablers for implementing intervention activities were also identified (n=15)14 17 30 31 34 35 49 64 68 76–78 82 86 94 (see table 4). Most barriers were related to activity delivery (n=13),30 37 49 51 52 75 76 80–82 88 94 followed by resources (n=8),30 34 37 46 49 51 63 81 logistics and supply (n=6),17 30 62 64 69 78 sociocultural (n=4),49 51 80 94 geographical (n=4),43 76 78 80 political (n=3),^{64 78 80} and governance (n=2).^{39 78} Likewise, enablers for activity delivery (n=8),14 49 68 76 78 82 94 101 managing resources (n=5)17 31 34 35 86 (i.e., human resources retention and identifying financial resources) and developing partnerships (n=2)^{30 64} were also unearthed during the review.

Table 4.

Barriers and enablers for facilitating intervention activities

	Sub-Saharan African region	East Asia Pacific region
Barriers
Governance	Leadership and quality control of the intervention (Mozambique)39	Poor networking and telecommunication facilities (Myanmar)78
Resources	Human Increased workload of CHWs in recruitment and training of volunteers (Tanzania)37 81 Demotivated staff due to lack of recognition (Uganda)63 Frequent staff turnover (Kenya),30 46 (Uganda),34 (Tanzania)37 Financial Participants driven by incentives to attend activities (Malawi),49 (Uganda)51 Scarcity of funds for intervention activities (Tanzania),37 (Kenya)46	Human Frequent staff turnover (Myanmar)81
Logistics and supply	Shortage of nets based on household size (elder males prioritised); nets had wear and tear (Kenya)62 Low stock of commodities (Kenya),30 64 69 (Malawi)17	Low stock of commodities (Myanmar)78
Activity delivery	Health education related Decreased interest due to repeated content (Malawi)17 Community resistance towards HAs (Malawi)49 Health services related Community preference for commercial nets over locally produced nets (Tanzania)46 Access to ANC at health units (time and distance) (Uganda)52 Poor communication between stakeholders (Kenya),30 (Malawi)17 Environmental management related Travel distance to identify conduct Larval Source Management activities (Tanzania)37 Poor access to private water reservoirs (eg, ponds) (Tanzania)37	Health education related Low literacy rates, non-cohesive communities, expectations of services beyond malaria (Myanmar)78 Language barriers (Myanmar)88 Children’s TV viewing times influenced programme selection (Cambodia)75 Conflicting health education activity (radio and drama) and working times (Cambodia)75 82 Limited days in between drama events for travel and preparation (Cambodia)76 Health services related Preference for private sector providers (Myanmar)88 Overprescription of drugs by CHWs (Myanmar)81
Sociocultural	Mobile population (eg, seasonal migrant workers) (Uganda)51 Self-medication, reliance on traditional healers (Malawi)49	Traditional beliefs of communities (Myanmar)80 94 Self-medication, reliance on traditional healers (Myanmar)94
Geographical	Heavy rainfall, slippery roads and deep marshlands (Rwanda)43	Remoteness (Myanmar)80 Road access and lack of transportation facility (Cambodia),76 (Myanmar)78
Political	Armed conflict affecting movement and supplies (Kenya)64	Armed conflict affecting movement and supplies (Myanmar)78 80
Enablers
Resources	Human Acknowledgement of volunteers from traditional and religious leaders (Nigeria),31 (Uganda),34 (Malawi)17 Gender diversity during volunteer selection (Burkina Faso)35 Financial Local fundraising/microfinancing schemes for project sustainability (Nigeria)31 Materialistic incentives (eg, hats, caps, t-shirts and bicycle) to HAs (Malawi)17	Financial Local fundraising/microfinancing schemes for project sustainability (Myanmar)86
Activity delivery	Health education related Involvement/Participation of elders, local leaders, village chiefs and children in the intervention activities (Malawi)49 Health services related Accessible and inexpensive service from skilled volunteers (Sudan)101 Environmental management related Promotion of locally produced materials (eg, tools and wire mesh)68	Health education related Involvement/participation of elders, local leaders, village chiefs, monks and children in the intervention (Cambodia),76 82 (Myanmar)78 94 Involvement of village leaders during recruitment of CHWs (Lao PDR)14
Partnerships	Partnerships with multiple stakeholders (Kenya)30 64

ANC, antenatal care; CHW, community health worker; HA, health animators.

Phases (prevention, control, elimination)

Nearly one-third (n=33) of the studies focused on prevention of which the majority were from SSA (n=24),32 33 36–40 43–46 49–51 57–60 62 68 70–72 100 followed by EAP (n=8)74 76 77 82 87 88 90 92 and one study⁹⁸ from SEA. Among the five studies36 41 67 83 99 under the control phase, three^{30 41 67} were from SSA, while one study was from EAP⁸³ and LAC.⁹⁹ The remaining studies addressed a combination of phases: PC (n=21), where 15 studies were from SSA,17 34 35 42 47 48 52–56 61 63 65 69 3 from EAP,^{84 85 102} 2 from SEA^{96 97} and 1 from LAC¹⁰²; and under PCE (n=16) the majority were from EAP (n=12),14 73 75 78–81 86 89 93–95 while 4 were from SSA.42 64 66 101

Discussion

This review aimed to understand, map, synthesise and document the malaria prevention intervention activities in the SSA, EAP, SEA and LAC regions guided by the five levels of ACE for the prevention, control and elimination of malaria. A total of 75 studies from 4 regions and 24 countries published between 2000 and 2022 based on ACE were identified during the review. The discussion below will explore the intervention activity types, that is, HE, HS and EM, their outcomes and how they are guided by the levels of ACE.

Prevention

Health education

The review identified HE interventions as an important component of malaria prevention, with educational activities being implemented in a variety of ways. Locally recruited CHWs and volunteers were most frequently used to provide HE and inform communities on malaria prevention (n=35).14 17 35 38 47–50 52–56 61 65 66 68 69 71–73 75 81 84–86 89 91 94–97 99 101 102 Although using local CHWs facilitates communication and understanding of the messages conveyed,^{31 66} their limited technical knowledge and skills can be a barrier to community acceptance.^{34 81} To enhance technical capabilities, CHWs should be provided with regular training and skills development workshops, and their work should be monitored periodically by the experts in the field.⁴ In addition, providing CHWs with supervision by malaria experts will help build the CHWs’ capacity and expertise, and in turn, improve community acceptance of the CHWs.¹ The involvement of local leaders, elders, and village chiefs during the recruitment of the CHWs and implementation of the HE sessions can improve community acceptance and participation.14 49 50 76 82 94 Retention of locally recruited CHWs and volunteers can also be a barrier due to inadequate remuneration.34 37 51 63 81

The review identified that besides remuneration,34 37 51 63 81 other factors such as long, poorly defined working hours,⁸¹ and a lack of recognition⁶³ can lead to demotivation and frequent turnover of the CHWs.30 34 37 46 81 This can be costly and challenging while delivering an intervention as training of new recruits is time-consuming, and an added burden on the existing health staff and resources.⁸¹ It was found that CHW motivation can be enhanced through the provision of incentives (eg, bicycles, bags, caps, t-shirts)¹⁷ and recognition by local leaders during events.^{17 31 34} We also found that CHWs can be supported and retained through local fundraising (eg, selling harvests and establishing microfinancing schemes). This was achieved in Nigeria and Myanmar to ensure that the CHWs were retained.^{31 86} Likewise, the review found recruiting retired and respected elders (teachers, health workers, public servants) in the community as CHWs can address this problem.35 49 92 96 Of interest, in India, volunteers staffed under the national healthcare system, such as Accredited Social Health Activists (ASHA), were used to inform the communities and improve their knowledge of malaria prevention.⁹⁶ As ASHA volunteers are community-level staff under the primary public healthcare system, these volunteers can be suitable and sustainable alternatives to the CHWs.¹⁰⁴

Non-health personnel and peers can be used for HE intervention activities to inform the communities about malaria prevention. For example, in Thailand taxi drivers were used to inform at-risk groups, such as seasonal migrant workers,⁷⁵ while in Uganda,⁵¹ Ethiopia,^{44 45} and Mozambique³⁹ school children were used to educate their families and communities on malaria prevention. Furthermore, students are effective and successful in improving knowledge when used among peers and colleagues39 44 45 59 having the capacity to inform a broad population in a short period. However, acceptance of information from young students by elders can be a barrier,⁵⁹ therefore, in such instances, conducting HE activities in culturally acceptable ways or being supported by respected members of the communities including stakeholders might be beneficial.14 49 76 82 94 Likewise, empowering individuals and communities using various behavioural change communication strategies can also be pivotal in removing such barriers.⁴ Conveying key malaria prevention messages by children and youth through street dramas using traditional costumes was found to be acceptable to participants across all age groups including the elderly in Cambodia.^{74 76} This review found two studies where local faith-based organisations in Nigeria³¹ and schoolteachers in Mozambique³⁹ collaborated to support the volunteers in conducting the education sessions to empower specific target groups such as the elderly on malaria prevention.⁴ Hence, the opportunity to partner with health professionals, peers, students, religious and local leaders from across the community enhances community acceptance and participation and is integral to the success of HE interventions.

This review highlighted the importance to Inform,^{44 45 58} Consult,^{57 65 70} Involve33 36 38 43 46 59 62 and/or Collaborate^{31 39} with multiple stakeholders and community groups at the local level, while designing and implementing malaria prevention activities. However, initially, stakeholders need to be informed of the importance of malaria prevention before designing any intervention. For example, community leaders and malaria control managers in Nigeria,⁶⁵ and government officials, political party affiliate ward chairs, and officials from agricultural and livestock departments in Tanzania⁵⁷ were informed and consulted on malaria prevention by research experts before implementing HE and other prevention activities in the community.

Community groups and the establishment of local committees (eg, task forces, community action groups) can support HE intervention activities to improve malaria prevention knowledge in the communities.68 78 80 90–92 94 For a country to achieve malaria elimination, it is essential to collaborate and develop partnerships with multiple stakeholders at the community, state and federal levels.^{4 7} Groups at these different levels can share resources and provide oversight and accountability for activities.⁴ For example, in Malawi⁶⁸ and Myanmar,^{80 93 94} task forces were formed at the community level, which comprised local leaders, health workers, government officials and other stakeholders (eg, community-based health projects, army, local faith and community organisations and religious groups) to support the implementation of the intervention activities and inform communities on malaria prevention. As sociocultural barriers exist in communities,^{80 94} these can be traversed by involving religious leaders in the delivery of the intervention activities.

HE interventions can use alternative strategies such as mass media (radio/television),^{39 58 64} street dramas, and exhibitions58 59 62 74 76 82 87 to inform a larger audience. However, higher costs for radio and television messages during peak hours, limited electricity supply in remote areas, availability of televisions in households, and the choice of channels among household members can act as barriers.⁷⁵ This review found that street drama was popular and well-accepted by communities as it was entertaining, relatable and delivered using culturally and locally relevant malaria prevention messages.74 76 82 83 For example, in Cambodia, street dramas were performed by professional artists along with children and youth wearing traditional costumes, with key malaria prevention messages delivered in the local language.74 76 82 87 These activities improved self-efficacy among younger people building their self-confidence in public speaking and promoting cultural connectedness in communities.^{74 76} Key messages delivered in the local language can generate interest in the participants as it removes any language barriers and is understandable and relatable.^{97 98} Noteworthy, over time, unchanged content or delivery methods can become monotonous, decrease interest and can adversely affect engagement.¹⁷ Therefore, all HE content should be regularly modified and updated, and delivery methods restructured to bolster interest and impact for the target audiences.

Environmental management

EM interventions target environmental improvements and positive behaviour change in communities for vector control, an important component of malaria prevention. The review found that EM intervention activities were most effective when preceded by HE so that communities can build their knowledge and understand the importance of the environmental strategies.⁴⁶ Likewise, it is important that the EM activities are conducted periodically and are not a standalone activity.⁹⁸ Some examples include, repeated monthly EM activities in the form of larval source management (LSM) and structural house improvements in Malawi,⁶⁸ and the filling of potholes and ditches in Ethiopia³³ and Bhutan.⁹⁸ Similarly, in Myanmar, latrines and the water supply system were improved to minimise vector breeding sites,⁷⁸ and in Vanuatu LSM activities released larvivore fishes in ponds near human settlements.⁷⁹ Fishes such as guppies, bass, bluegill and catfish feed on mosquito larvae and can be used by National Malaria Programs (NMPs) as a natural vector control measure for malaria prevention and control.¹⁰⁵

The review also found that EM interventions can be used to provide employment opportunities and generate income for communities.⁴⁶ For example, in Kenya, mosquito repellent soaps and liquids were made from local herbs such as neem plants and sold by the villagers in the local market,⁴⁶ while in Malawi hand tools and wire meshes used for house improvements were produced locally.⁶⁸ Such local products are affordable, culturally acceptable and can be positive enablers for EM interventions targeting malaria prevention.⁶⁸ Hence, national programmes can implement similar activities to engage and promote malaria prevention activities aligned with cultural beliefs and traditions, a potential economic boost for the local community and provide employment opportunities for income generation.

The community engagement literature supports the involvement of elders and respected members of the community in the designing and implementation of activities, as they can be influential in encouraging communities to participate.⁹⁸ Like HE, we found that EM intervention activities were conducted by a variety of personnel including CHWs,37 68 71 72 community groups, and task forces33 98 100 102 or experts from the Ministries.⁴⁶ For future consideration, involving community-based groups, such as parent groups, farmers, youth, local leaders, teachers and children may make EM activities more effective in malaria prevention.^{100 106}

Health services

The review identified HS intervention activities that informed and involved the communities while providing them services such as MDA,14 73 93 94 and vaccines³² for malaria prevention. Along with chemoprevention, malaria vaccines are a potential solution to prevent malaria in highly endemic countries.¹⁰⁷ Recently, WHO approved the use of a first-generation vaccine¹⁰⁷ and this review identified one study in Kenya where ACE was used to educate the caregivers of children of the vaccine’s benefits and to deliver malaria vaccination at health facilities.³² Likewise, WHO recommends MDA (using artemisinin and piperaquine combination) as a prevention measure to accelerate malaria elimination in countries with moderate transmission rates and confined transmission settings, such as islands.¹⁰⁸ Often these HS interventions also include HE on MDA to inform communities of its role in malaria prevention and control.^{14 73} Our review found higher MDA participation rates in communities where HS activities were combined with HE,^{14 73} and involved local community leaders.⁹⁰

Chemoprevention activities targeted at high-risk groups such as pregnant women and children are key to malaria prevention in high transmission areas. In Burkina Faso, Ghana, and Uganda, CHWs conducted Intermittent Preventive Treatment (IPT) interventions for pregnant women^{35 52–56} and children⁴⁷ for malaria prevention. This is of particular importance, for children and pregnant women,³ as globally, an estimated 75% of malaria infected children under the age of five years die every year^{1 3} and in 2021, 32% of the total 40 million pregnancies worldwide were exposed to malaria, with the exposure in the SSA region even higher, at 40%. Chemoprevention during pregnancy and early childhood are important to prevent low birth weight (LBW) and child mortalities.¹ An estimated 457 000 LBW deliveries were averted in 2021 due to targeted IPT interventions conducted across 33 countries.¹ CHWs can conduct IPT and are preferred by caregivers as travel and waiting times at health facilities is avoided.^{35 47} Therefore, such community-based services can improve healthcare and the help-seeking behaviour in malaria-risk communities.

Control and elimination

Health services

HS interventions are crucial for control (early diagnosis and prompt treatment) and elimination (surveillance and active case detection) of malaria. As in HE interventions for malaria prevention, locally recruited and trained CHWs14 17 31 35 42 47 48 52–56 64–67 69 73 75 78–81 83–86 89–91 93–95 97 99 101 102 were used to conduct HS activities in the community; an approach that can diagnose a high proportion of malaria cases early and relieve the stress on health facilities. For example, in Zambia, 84.1% of the total malaria cases were identified by the CHWs in the community.⁴² However, it is important to regularly supervise and monitor the quality of testing undertaken by the volunteers in the community by using clinical staff from nearby public health facilities.⁴² The range of activities conducted by CHWs included community-based testing,14 17 31 35 42 47 48 52–56 64–67 69 73 75 78–81 83–86 89–91 93–95 97 99 101 102 surveillance activities,31 42 64 66 101 referral of febrile cases,^{17 47 48} and case management in communities^{67 69} to control and eliminate malaria. CHWs can therefore be a successful healthcare resource for malaria prevention, control and elimination, especially in remote communities.

The private sector plays an important role in the delivery of HS interventions for the management of malaria in multiple countries⁹⁸ as public health facilities in low-income and middle-income countries often have limited or no medical supplies, including essential malaria test kits.⁶⁹ The limited opening hours of outpatient services at public facilities, costs incurred to travel to a public health facility and the proximity of a private sector provider to the community can all influence the choice of healthcare provider.^109–111 In such conditions, private sector providers can become the preferred option for malaria control by providing HS in communities, especially for children and older people, as they can bridge the gaps in the existing healthcare system,^{109 111 112} and minimise self-treatment rates.⁵⁵ The review found private medicine retailers and community-based drug sellers/pharmacists were used in Kenya^{3 30 41} and Uganda^{34 63} to provide healthcare to control malaria in communities. Going forward, the national programmes should involve and engage private health providers in the community to ensure wider population coverage of malaria control activities.

Finally, locally led HS interventions can improve acceptance and develop ownership, a key factor for long-term sustainability,¹¹¹ however, to control and eliminate malaria it is important to collaborate with multiple stakeholders at the community, state, and federal levels.^{4 7} For example, we identified a scarcity of malaria commodities (including test kits and antimalarials), especially in remote and conflict-affected areas.17 30 64 69 78 This is where involving the communities to express their needs and concerns^{77 109} and collaborating with authorities and government officials can be crucial.⁷⁸ To overcome logistics-related barriers, strong political commitment should be sought from the national programmes to ensure a continued supply of essential malaria testing and treatment commodities to remote and conflict-affected areas.^{4 113} The review found the army in Myanmar was integral to the continuation and success of HS intervention activities, as they facilitated the transportation of malaria testing supplies and LLINs in conflict-affected areas.⁸⁰ Partnerships with stakeholders at different tiers of the government and the community and their involvement in the implementation of activities can be pivotal for national programmes in their effort to control malaria, develop local leadership and hence pave the way to elimination.

Strengths and limitations

This review employed a comprehensive search strategy across multiple databases and a grey literature search to identify studies that used ACE for PCE of malaria. To our knowledge, this review on ACE and malaria is the most comprehensive one to date. The review used a widely popular framework devised by the IAPP¹⁰ and modified by Born,⁹ and the WHO framework for characterising the pathway to malaria elimination⁴ during the classification of the study. Likewise, the whole review was guided by the PRISMA scoping review checklist adding further strength to the methods. The WHO Global Technical Strategy 2016–2030 highlights community engagement as a critical strategy for malaria elimination⁴ and in recent years has become a widely used strategy by national programmes worldwide. However, we captured 22 years of peer-reviewed and grey literature to provide a broader scope and ACE that have been used during the period.

In terms of the limitations, the quality of the studies was not assessed. This reviewonly focused on primary sources that were published in English which might have biased the selection. Malaria predominantly occurs in the SSA region and most countries in this region use French as an official language.¹¹⁴ Hence, some important studies published in Francophone journals, or any other languages may have been missed during the review. Likewise, the classification of the studies based on the phases, that is, prevention, control and elimination was a challenge. As most studies did not indicate the phases their ACE was focused on, errors might have occurred during the classification of interventions based on phases. Nonetheless, we have tried our best to align the classification based on the WHO definition of PCE of malaria. Lastly, reviews (scoping and systematic) and multicountry studies were excluded, a limitation of the study. However, since we synthesised 75 studies in this review, most interventions reported in reviews and multicountry studies had already been identified and reported. Despite all the limitations, this review provides a comprehensive overview of the various ACEs for malaria PCE.

Conclusion

We identified that over the last two decades, HE, HS, and EM intervention activities have been guided by the five levels of ACE to prevent, control, and eliminate malaria worldwide. Based on our review, interventions were predominantly at the inform and involve levels of ACE which included informing a diverse range of stakeholders, such as local leaders, people of faith, government officials and extending to school children. These stakeholders were involved in a variety of activities, such as street theatre to improve the knowledge of communities on malaria prevention through HE. While Consult, Collaborate and Co-lead are described as key elements of successful ACE, their presence was limited in the literature. The review findings suggest consulting with community members on the design, cultural appropriateness of the content and methods of delivery are key factors to consider when engaging the community in prevention and control interventions and may improve participation and acceptance of malaria activities conducted. Likewise, for countries to reach elimination, the national programmes must work with community members, private stakeholders, religious and faith-based organisations, researchers and civil society partners, and form community-based committees to develop ownership of the interventions and eventually co-lead with them.

Data availability statement

No data are available.

Ethics statements

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