title: Pathways to malaria persistence in remote central Vietnam: a mixed-method study of health care and the community.
abstract: BACKGROUND
  There is increasing interest in underlying socio-cultural, economic, environmental and health-system influences on the persistence of malaria. Vietnam is a Mekong regional 'success story' after dramatic declines in malaria incidence following introduction of a national control program providing free bed-nets, diagnosis and treatment. Malaria has largely retreated to pockets near international borders in central Vietnam, where it remains a burden particularly among impoverished ethnic minorities. In these areas commune and village health workers are lynchpins of the program. This study in the central province of Quang Tri aimed to contribute to more effective malaria control in Vietnam by documenting the non-biological pathways to malaria persistence in two districts.
  
  
  METHODS
  Multiple and mixed (qualitative and quantitative) methods were used. The formative stage comprised community meetings, observation of bed-net use, and focus group discussions and semi-structured interviews with health managers, providers and community. Formative results were used to guide development of tools for the assessment stage, which included a provider quiz, structured surveys with 160 community members and 16 village health workers, and quality check of microscopy facilities and health records at district and commune levels. Descriptive statistics and chi-square analysis were used for quantitative data.
  
  
  RESULTS
  The study's key findings were the inadequacy of bed-nets (only 45% of households were fully covered) and sub-optimal diagnosis and treatment at local levels. Bed-net insufficiencies were exacerbated by customary sleeping patterns and population mobility. While care at district level seemed good, about a third of patients reportedly self-discharged early and many were lost to follow-up. Commune and village data suggested that approximately half of febrile patients were treated presumptively, and 10 village health workers did not carry artesunate to treat the potentially deadly and common P. falciparum malaria. Some staff lacked diagnostic skills, time for duties, and quality microscopy equipment. A few gaps were found in community knowledge and reported behaviours.
  
  
  CONCLUSIONS
  Malaria control cannot be achieved through community education alone in this region. Whilst appropriate awareness-raising is needed, it is most urgent to address weaknesses at systems level, including bed-net distribution, health provider staffing and skills, as well as equipment and supplies.
authors.affiliation: Nossal Institute for Global Health, University of Melbourne, Melbourne, Vic 3010, Australia. martham@unimelb.edu.au
authors.forename: Martha
authors.initials: M
authors.lastname: Morrow
authors.forename: Quy A
authors.initials: QA
authors.lastname: Nguyen
authors.forename: Sonia
authors.initials: S
authors.lastname: Caruana
authors.forename: Beverley A
authors.initials: BA
authors.lastname: Biggs
authors.forename: Nhan H
authors.initials: NH
authors.lastname: Doan
authors.forename: Tien T
authors.initials: TT
authors.lastname: Nong
mesh_terms: D000293:Adolescent; D000328:Adult; D001512:Bedding and Linens; D003153:Community Health Services / Q000191:economics / Q000706:statistics & numerical data; D003150:Community Health Workers; D004522:Educational Status; D005260:Female; D006266:Health Education; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008288:Malaria / Q000453:epidemiology / Q000517:prevention & control* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D014744:Vietnam / Q000453:epidemiology; D055815:Young Adult