Background: Malaria remains a public health problem in spite of the efficacious interventions such as long lasting insecticidal nets (LLINs) and artemisinin-based combination therapy. The Kingdom of Bhutan has achieved notable success in the prevention and control of malaria, and the country is moving towards the malaria elimination phase. For example, in 2011 only 194 malaria cases were registered compared to 5935 cases in 2000. To attain the elimination goal, current efforts need to be reinforced by community-directed interventions in order to empower the community to enhance their health-seeking and other preventive behaviours. Community-directed interventions have proved to be useful in the prevention and control of infectious diseases such as onchocerciasis. This study was conducted to elucidate the effectiveness of the community-directed educational intervention on malaria prevention and control in the malaria-endemic areas of Sarpang District, Bhutan. A quasi-experimental study design was adopted, using both qualitative and quantitative methods (Figure). The study district (Sarpang) was purposively selected from seven malaria endemic districts. The study basic health units (BHU) were Umling and Chuzerganga (intervention arm), and Jigmeling (control arm). These were purposively selected. These BHUs were similar in population size and other relevant contextual criteria. Baseline data was collected during the formative phase using in-depth interviews and focus group discussions (FGDs), household surveys and document/data review. The training tool was developed in collaboration with the BHU staff. Health workers and community action groups (CAGs) were trained on malaria transmission, care and in the use of LLINs, proper use of indoor residual spraying, control of mosquito breeding sites, and the importance of early diagnosis and treatment. The intervention package was implemented in addition to the regular programme activities in the intervention BHUs while in the control BHU, only regular programme activities were conducted. The effectiveness of the intervention was evaluated using household survey, FGDs, in-depth interviews and review meetings. Comparison of the pre- and post-intervention group, showed a significant improvement in knowledge, attitude and practice of the community intervention arm as compared to the control arm.

Conclusion: The quasi-experimental study design was able to elucidate the effectiveness of the community-directed educational intervention on malaria prevention and control in malaria-endemic areas.

Lessons: Quasi-experimental study design is an appropriate approach to establish the impact of a given intervention. However, to ensure reliable results, the intervention and control arms should be as similar as possible in terms of population characteristics and context. The only distinguishing variable should be the intervention in question.

Figure. Schematic diagram of research activities