Malaria control and cultural acceptance of prevention methods. The case study of Democratic Republic of Congo and Vietnam
Résumé (anglais)
This study falls within SDG Focus Goal 3: Good Health and Well-Being — Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases; Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. This study examines malaria control and cultural acceptance of prevention methods in the Democratic Republic of Congo (DRC) and Vietnam, two countries with different malaria transmission patterns, health system capacities, and cultural contexts affecting prevention uptake. The DRC has one of the highest malaria burdens globally (approximately 12-15% of global cases), with high transmission intensity, weak health infrastructure, and community-based prevention delivery through community health workers (CHWs) for intermittent preventive treatment in pregnancy (IPTp). Vietnam has successfully reduced malaria incidence dramatically over recent decades and is moving toward elimination, but malaria persists in forested areas among ethnic minority populations (Ra-glai, other groups) where traditional livelihoods (slash-and-burn agriculture, forest work) and cultural beliefs affect acceptance of vector control measures (bed nets, indoor residual spraying) and treatment-seeking behaviors. The research analyzes how each country's cultural context (social norms, traditional beliefs, trust in health workers, mobility patterns) affects acceptance of malaria prevention methods, the effectiveness of community-based delivery strategies, and the lessons for other countries. A comparative analysis was conducted examining primary and secondary sources including WHO malaria reports, national malaria strategic plans, academic research, program evaluations, and policy documentation covering recent decades to 2025. The DRC presents a context where malaria control relies heavily on community-based delivery of prevention methods. Key features include high malaria burden (approximately 12-15% of global malaria cases, high transmission intensity, children under 5 and pregnant women most vulnerable). Control strategies include insecticide-treated nets (ITNs), indoor residual spraying (IRS) in targeted areas, intermittent preventive treatment in pregnancy (IPTp-SP) traditionally delivered at antenatal care (ANC) visits, and community-based IPTp (C-IPTp) through community health workers (CHWs). A large-scale anthropological study (2018-2021, 796 in-depth interviews, 265 focus group discussions, 388 direct observations) across four sub-Saharan African countries including DRC examined factors influencing C-IPTp acceptability. Key findings: alignment of C-IPTp with existing social norms surrounding pregnancy and maternal health-seeking practices; active involvement of influential and trusted actors (husbands, relatives, community leaders) in implementation; existing and sustained trust in CHWs as critical for acceptability; influence of husbands and other relatives in pregnant women's care-seeking decision-making; pregnant women's perceptions of SP (sulphadoxine-pyrimethamine) for IPTp; and persistent barriers to facility-based ANC access. CHWs were authorized to administer all doses of IPTp-SP, including the first dose, in DRC and Nigeria. Key challenges include working conditions of CHWs (volunteer status, workload), perceptions of SP (side effects concerns, efficacy doubts), and persistent barriers to facility-based ANC access (distance, cost, quality). Key outcomes include reported acceptability of C-IPTp among targeted communities, supporting the public health value of community-based interventions. Vietnam presents a context where malaria has been reduced dramatically (from high incidence in 1990s to elimination phase), but malaria persists in forested and mountainous areas of central and southern provinces, home to ethnic minority populations (Ra-glai, others). Key features include progressive confinement of malaria to ethnic minority groups in remote forested areas. Control strategies include ITNs (distributed free by national malaria control programme), indoor residual spraying, active surveillance, and health information campaigns. Cultural and behavioral factors limiting effectiveness include territorial arrangements and mobility between "new villages" (government resettlement areas with brick houses, sufficient bednets) and "old villages" (forest fields where slash-and-burn agriculture occurs). A mixed-methods study among Ra-glai ethnic minority in Bac Ai district, Ninh Thuan province (households n=410) found: 97.6% of households went back to their "old villages" to continue slash-and-burn agriculture; in the old village, 48.5% of households lived in open-structured plot huts and only 5.7% had sufficient bednet coverage. Bed net use was 84.6% in the villages but only 52.9% at the forest fields; 20.6% of respondents slept unprotected in both places. Low perception of malaria risk among forest farmers: only 15.6% acknowledged the higher risk of contracting malaria in the forest than in the village; perceived mosquito biting times only partially coincided with Anopheles dirus and Anopheles minimus true biting times; the disease locally identified as 'malaria' was hardly perceived as having an impact on forest farmers' daily lives. Household representatives believed malaria could be cured with medicines (57.8%), but also perceived non-malarial medicines, rituals, and vitamin supplements to be effective against malaria. Use of public health services for most recent illness was 62.9%, but low-cost medicines were also purchased in private sector as perceived cost-effective option for slash-and-burn farmers. Key challenges include mobility between villages and forest fields (undermining fixed interventions like IRS, ITNs), low risk perception, pluralistic health-seeking (public + private + traditional), and cultural beliefs about malaria causation and treatment. Key outcomes include identification of factors limiting effectiveness of national malaria elimination strategy in local settings, with call for adaptive, reflexive strategies responsive to socio-ecological diversity. Both countries demonstrate that malaria control requires community engagement and trust in CHWs (DRC's C-IPTp acceptability, Vietnam's CHW role). Social norms and cultural beliefs (DRC's pregnancy social norms, Vietnam's low risk perception) affect prevention uptake. Mobility and territorial arrangements (Vietnam's mobility between new and old villages, DRC's access barriers) affect intervention effectiveness. Pluralistic health-seeking (public, private, traditional) must be addressed. Adaptive, context-specific strategies are needed for elimination. The transferability of DRC's C-IPTp community-based delivery model to Vietnam's ethnic minority areas is relevant for malaria elimination (reaching remote populations). The transferability of Vietnam's active surveillance and elimination-focused strategies to DRC could inform DRC's transition from control to elimination in low-transmission areas.
Mots-clés: malaria control, cultural acceptance, DRC, Vietnam, SDG 3, community health workers, IPTp, bed net use, ethnic minorities, forest malaria, elimination
Résumé (français)
Cette étude examine la lutte contre le paludisme et l'acceptation culturelle des méthodes de prévention en République Démocratique du Congo (RDC) et au Vietnam, deux pays avec différents schémas de transmission du paludisme, capacités de système de santé et contextes culturels affectant l'adoption des mesures de prévention. La RDC présente l'une des plus lourdes charges de paludisme au monde. Une étude anthropologique à grande échelle a examiné l'acceptabilité de la livraison communautaire du traitement préventif intermittent chez la femme enceinte (TPI) par les agents de santé communautaires. Le Vietnam a considérablement réduit l'incidence du paludisme, mais la maladie persiste dans les zones forestières parmi les minorités ethniques. La mobilité entre les villages et les champs forestiers, la faible perception du risque et les croyances culturelles limitent l'efficacité des stratégies de contrôle. Les deux pays démontrent que la lutte contre le paludisme nécessite l'engagement communautaire, l'adaptation aux croyances culturelles, et la prise en compte des schémas de mobilité et des comportements de recherche de soins.
Mots-clés: lutte contre le paludisme, acceptation culturelle, RDC, Vietnam, ODD 3