Case study 2: Use of mixed methods to explain malaria persistence in remote Central Viet Nam

Background: Malaria remains a major global threat despite the availability of efficacious tools. Its effective control requires consistent action from both health care systems and community and an understanding of features that precipitate risk. The Viet Nam National Malaria Control Programme (NMCP) introduced in 1991 has controlled malaria through the provision of free anti-malarial drugs, impregnated bed-nets, bi-annual home insecticide spraying and early diagnosis and treatment. Overall, the number of clinical cases declined from 1.2 million and 4646 recorded deaths in 1991 to 185 529 clinical cases and 50 deaths in 2002. However, over 90% of severe cases and deaths occurred in mountainous, forested and largely ethnic minority areas of central Viet Nam, where populations are impoverished, poorly educated, culturally and linguistically distinct and living in dispersed, less accessible settlements. The researchers therefore considered it both instructive and timely to investigate persistent malaria in such settings.

Methods: Mixed methods (qualitative and quantitative) were used to collect data, in order to explore the complex interrelations between the various actors and system elements. Data was collected in two stages. The formative stage used mainly qualitative tools (e.g. community meetings, observation of bed-net use, and focus group discussions/semi-structured interviews) while health managers, providers and the community helped to define and expand thematic areas of enquiry. Outcomes informed the quantitative approaches (e.g. a provider quiz, structured surveys with community members and village health workers, and quality check of microscopy facilities and health records at district and commune levels). The table describes the methods that were used.

Conclusion: Use of the mixed methods informed researchers and the NMCP about the contextual factors that acted as bottlenecks to effective malaria control in the affected region.

Lessons: The complexity of contextual factors coupled with poverty, low education levels, cross-border mobility, and cultural diversity, made it appropriate to use mixed methods.

Table. Summary of mixed methods used during the project
Formative stage
Method Objective Participants
Community meetings To explore beliefs, attitudes, awareness, care seeking/providing and circumstances relevant to malaria exposure and control Malaria control officials, local government, mass organizations, hospitals
Focus group discussion Provincial and district malaria control managers and Commune Health Station staff, village health workers, and community members
Semi-structured interviews Provincial malaria control officials, district malaria control secretaries, district hospital staff, commune health staff, village health workers, community members
Informal group discussion District hospital managers
  • To identify antimalarial drugs on the market
Drug selling points
  • To describe village environment/context
Tests/quiz To obtain an impression of provider knowledge and guidelines adherence District hospital staff
Observation checklists To assess visibility and currency of malaria treatment guidelines
Quality of microscopy
Health service points
Bed-net quality during KAP survey home visits Homes
Review of treatment records/logs Malaria patient records
Structured questionnaire To determine community knowledge, attitudes and practices(KAP) Village health workers
Community members
Source: Morrow M. et al. Pathways to malaria persistence in remote central Vietnam: a mixed-method study of health care and the community. BMC Public Health. 2009; 9(1):1.