Based on the analysis sessions, the findings are organized into the following core domains: 1) malaria knowledge, perceptions of healthcare, and other health concerns; and 2) perceptions of anti-malarial MDA, institutional trust, and health messaging.
1. Malaria knowledge, perceptions of healthcare, and other health concerns
Overall, most interview participants (64%) affirmed knowledge of malaria (answered yes to the question, “Do you know what malaria is?”; Supplementary Material 1). In follow-up questions, participants gave a generally accurate description of the disease as transmitted by mosquitos; causing fever, headache, or body aches; and preventable through the use of mosquitos nets, repellant, fumigation, and/or the elimination of breeding sites (criaderos). Research team members remarked that although participants connected malaria with mosquitos, some confused malaria with dengue, another mosquito-transmitted febrile illness common in the Dominican Republic. For example, when asked how malaria is contracted, a 60 year-old woman in Guaricano said: “From mosquitos that reproduce in clean water,” likely recalling health messages about dengue (transmitted by Aedes mosquitoes that favors small containers, tires, or natural holes that fill with rain water for breeding).
In fact, participants appeared more familiar with dengue than they did malaria; in group discussions, this was said to result from greater exposure to health messaging about dengue than malaria and because of heightened fear of dengue. One assistant said that there are likely political reasons underlying the lack of awareness about malaria. The Dominican Republic is a popular tourist destination, and the country’s political leadership and tourism industry have a vested interest in preventing news about malaria from disseminating beyond transmission areas. Simply put, malaria frightens tourists. There was urgent need to control outbreaks, “before people [in the community] start talking to the press,” one assistant half-joked. All of this was said to contribute to poor dissemination of information about malaria.
Knowledge about malaria was generally shaped by 1) personal experience or word-of-mouth in past outbreaks, in which a participant and/or his or her family member or neighbor had contracted the disease and dealt with symptoms, care-seeking, and diagnosis first-hand; and 2) health activities led by community health workers (promotores). In general, there was a positive perception of promotores sponsored by CECOVEZ and the Ministry of Health. Promotores are individuals who live within the community and were sometimes said to be the only source of health-related information or initial point-of-care.
Doctors, too, were trusted, although negative experiences in past malaria outbreaks had sown mistrust. For example, numerous stories recounted how a sick family member or neighbor who had fallen ill was misdiagnosed by a doctor, sent home, and diagnosed later by a health promotora after the patient’s condition had worsened. When malaria was suspected (as opposed to other diseases), people often trusted the CECOVEZ field team and community health workers more than doctors, usually based on past experience or overheard anecdotes in which patients were finally diagnosed by a promotora. One 38-year-old man in Los Tres Brazos said that, “hospitals don’t cure malaria.” Still, many people advised that in general, they would still seek care at hospitals or clinics, likely because they had few options anyway and because medical doctors were still respected for their knowledge: El que sabe es el medico—“he who knows is the doctor,” said an older man in the Simon Bolivar neighborhood. Decisions for seeking healthcare tended to rest with female heads-of-households (amas de casa), such as a mother, wife, or grandmother.
Malaria was linked to trash, contamination, and inadequate sanitation. People cited the nearby canals (cañadas) that were clogged with foul water, emitting a bad odor also said to cause disease (akin to miasma). A few people thought that malaria could be transmitted through water itself. Community residents valued cleanliness, mentioning that prevention of not just malaria but disease in general could be brought about by attention to hygiene (limpieza) of the home and surrounding area. This was in turn linked to environmental contamination in their communities, which surfaced in explanations of disease. “What worries us most is what they will do about this trash here,” said a resident of Las Lila, a particularly marginalized sub-barrio within Los Tres Brazos (Fig. 2). Indeed, upon returning from Las Lila, the research assistants were visibly taken aback by the extent of contamination and abject poverty found there: “there were kids playing in the trash, and people preparing meat to cook [while] standing in trash,” said one team member. “Sometimes, the trash truck won’t come for [up to] two weeks,” a young man in Sabana Perdida was noted to say.
Two-fifths (39%) of interview participants said that asymptomatic malaria infection was possible, usually understood from personal experience or word-of-mouth. For example, one woman in Los Tres Brazos said that, “I heard it said that one neighbor here [had] malaria and [he] said that he didn’t feel anything.” Another woman in Capotillo said that “There are many people who are sick and still go about their day as if nothing is wrong.” In an evocative remark by a young man in Los Guandules, asymptomatic malaria was described as something hidden: Si esta escondido, es algo que esta todavía tapado —“If it is hidden [not causing symptoms], then it must be something that is covered up,” or undetectable.
The majority (58%) said that malaria could not present asymptomatically. “I think that it isn’t possible to not have symptoms, I think [you] must feel something,” said an older man in Los Guandules.
Finally, common health problems cited by community members included gastrointestinal illnesses (vomiting, diarrhea) as well as infections, such as HIV/AIDS, dengue, the common cold or other viral syndromes known broadly as gripe, and papilloma. Chronic diseases mentioned by participants included diabetes, high blood pressure, and cancer.
2. Perceptions of anti-malarial MDA, institutional trust, and health messaging
No participant (0%) knew what MDA was. After being provided with a definition of MDA (developed prior to the survey by CECOVEZ leadership; see interview guide in Supplementary Material 1), nearly all (92%) participants said that they would agree to participate, whereas 7% stated they would decline MDA entirely (one response was missing).
The overwhelming support for MDA appears attributable to two key factors: concern for one’s personal health and the desire to help the broader community. “We do not know if tomorrow we [will] fall ill,” said a 55-year-old woman in Los Tres Brazos, expressing a need for prevention. In a way, participation in MDA was one way to circumvent malaria’s unpredictability: “I understand that prevention is better than [trying to] cure the disease,” said a 24-year-old woman in Los Tres Brazos.
Participating in potential MDA was also seen as an act of service. “I would take the medicine to prevent malaria in the neighborhood,” said a 28-year-old woman who worked in a banca selling lottery tickets. Connecting individual participation to community-level benefits was widespread across all sampled communities. In essence, participation in MDA communicated a sense of solidarity and care for the community. To illustrate the vocabulary and phrasing that participants used to communicate this sentiment, exemplary quotes (accompanied by original Spanish) are compiled in Table 3.
Table 3
Interview excerpts that express motivation to participate in MDA as a way to support the general community.
Example quotation Original Spanish | Participant background |
It is a contribution to my community. Eso es un aporte a mi comunidad | Female, 40 years old, Capotillo |
It is a social act that deserves support. Una obra social que merece apoyo. | Male, 59 years old, Los Guandules |
For the people of the neighborhood, because they need it. Por las personas del barrio, porque lo necesitan. | Male, 56 years old, Los Tres Brazos |
To help my neighborhood with this evil disease. Para ayudar a mi pueblo con esa enfermedad mala. | Male, 62 years old, Los Tres Brazos |
To cooperate with others. Para cooperar con los demás personas. | Female, 49 years old, Los Tres Brazos |
That way, other people in the community won’t get sick. Así no se enfermarían otras personas aquí en el sector. | Male, 21 years old, Sabana Perdida |
Because what I want for myself, I want for others. Por que lo que quiero para mi, yo quiero para los demás. | Female, 38 years old, Sabana Perdida |
If it benefits the community, I see it as very important. Si es beneficial a la comunidad, lo veo muy importante. | Female, 27 years old, Guaricano |
However, several key reasons emerged for the small proportion of those who would refuse participation in MDA. One reason was feeling unsure if the drug administrator was trained competently or doubting whether the medicine was prescribed by a doctor. In one informal conversation, a resident of Los Tres Brazos said that he or she would take the medicine only, “if the public health [team] is trustworthy.” Another in Capotillo said that, “There are people who won’t take [the medicine], if it isn’t prescribed by a doctor.” An older man in Simon Bolivar said that he would participate, but emphasized that, “I don’t take medicine if [it] is not prescribed by a doctor.”
Another potential reason for declining MDA is that some people would rather decline the MDA in order to observe if others in the community succumb to side-effects. This reflects caution and skepticism towards MDA and underscores the importance people place on their own observations, rather than reassurance by health workers.
Perhaps one of the most obvious hurdles to overcome in a successful MDA is coordinating the MDA with the work schedules of community residents. Work was clearly valued by residents because of precarious economic circumstances. Thus, although they may see participation as a benefit to themselves and their community, their need to earn income may be prioritized above the perceived risk of contracting an otherwise rare disease (Table 4). “I won’t risk a day of [missing] work,” said a 19-year-old man in Los Tres Brazos; “If I am not working, I would participate,” said a 37-year-old woman in Los Tres Brazos. An older man in Simon Bolivar said that “If I have the time to do it, I will.” Similarly, a 60-year-old man in Guaricano said:
Yes, but it depends on the available time [I] have. Many times I am away from the community, but yes, I would take the medicine.
Table 4
Profile of participants who said that they would reject participation in MDA (N = 4).
Neighborhood | Gender | Age | Education level | Occupation | Know about malaria | Reason for not participating in MDA |
Los Tres Brazos | M | 19 | Unknown | Barber | No | I work. I must take care of my wife; I cannot risk [losing] a day of work. |
Los Tres Brazos | F | 50 | Unknown | Upholstery | Yes | [I] do not trust taking medicine in that way. |
Simon Bolivar | F | 46 | Primary | Custodian | Yes | I do not have time. |
Guaricano | F | 42 | Primary | Cassava baker | No | I do not like it [the idea of MDA]. |
Some final points regarding potential refusal to participate in MDA include issues of age and socioeconomic status. Based on informal conversations and observations, young people were said to be generally uninformed about health or disease and did not express much interest in MDA. Alternative modes of communication to spread MDA messages would likely be needed to reach this group, which uses popular social media like WhatsApp, Facebook, Instagram, and YouTube.
Older people, too, expressed unique reasons for hesitating or refusing to participate, such as concern about drug-drug interactions and possible side-effects, because they may already be taking prescribed medicines and conceptualize their health as too fragile for MDA. Another interesting point was that those with upper- and middle-class socioeconomic status may be less inclined to participate in MDA because they have generally had little prior exposure to malaria outbreaks and may feel as though malaria is not a problem for them. To note: this point surfaced in a team analysis session after visiting more well-to-do neighborhoods.
Neighborhood associations (juntas de vecinos) are widespread throughout the Dominican Republic and are common entry-points for public health programs to begin community outreach [4, 17]. Presumably, community engagement for a future MDA in Los Tres Brazos would also involve working closely with juntas de vecinos in the transmission focus. However, most people in this study had a negative opinion of local neighborhood associations, which were seen as too political and self-serving. “An evil rat,” said one resident in reference to his junta de vecinos in Los Guandules; ladrones (crooks), said another in the Sabana Perdida neighborhood; “they convene us only when they need something,” said another in Simon Bolivar. Juntas were also said to be overly political; “the junta here resolves problems only for their political party,” said a resident of Simon Bolivar. Finally, the assistants described that some residents seemed to be unsure if their community even had a junta de vecinos, reflecting a lack of community-level organization.
Some hypothetical scenarios in which local politics could adversely affect MDA were raised in team analysis sessions. Some politically aligned neighborhood associations, for example, may seek to capitalize on any large-scale provision of free services in order to gain support among the voting populace and thereby distort MDA campaign messages, such that MDA and ancillary activities appear to be affiliated with a given political party. In contrast, other political parties may seek to undermine MDA activities by spreading misinformation such as, for example, “Political party XYZ is funding the MDA in order to poison this community, because the people here belong to the opposition party.”
However, although trust in juntas de vecinos may have been low, some people mentioned certain key figures in their communities who do help to resolve issues. These individuals were often referred to by their nicknames and were said to be available (dispuesto) for anything (cualquier cosa). Participants also referenced churches as trustworthy sources for information about health and as sources of support in the community. However, sometimes people said that there was simply nobody, or no formal group or organization, in whom they could trust or turn to resolve problems.
Health messaging and health information were closely related to issues of trust as well, carrying additional implications for MDA. Common sources of health information included the promotores, nearby hospitals or clinics, and even 9-1-1 ambulance staff. Some cited mass communication, such as television and radio, although one research assistant observed that few people actually had televisions (due to their economic circumstances); even if they did, electricity in the community was unreliable. In one analysis session, one potential idea for spreading messages was identified: the small gua-guitas (little trucks) that blast announcements (perifoneos) about upcoming events, such as happy hour drink specials at a nearby discotheque or discounted prices for fruits and vegetables.
In addition to spreading information about malaria, word-of-mouth among community members and educative talks (charlas) led by promotores were seen as important ways to learn about health issues in general. An older man in Simon Bolivar neighborhood said:
Well, here, whenever there’s a disease, we know about it from others in the neighborhood talking about it, that’s how it was with dengue.
One woman in Capotillo opined that the best way to get health information was, “from the health promotores, because sometimes the news says fake things.” Social media, especially among young participants, were also mentioned as sources of health information.
However, assistants detected a general disconnect between the content of health information that penetrated these communities and the ways in which community members described malaria or disease in general. This tended to be framed in light of the precarious socioeconomic conditions of the community. For example, although many interview participants cited contaminated water, including the nearby Ozama and Isabela rivers, as responsible for disease, they seemed unsure as to exactly how: “There is a disconnect between information channels [how people obtain information] and their social and economic reality,” wrote one assistant during an analysis session.