Background
Despite the progress made, malaria is a significant public health problem. In 2016, an estimated 216 million cases of malaria occurred worldwide claiming 445,000 lives [
1]. About 3.2 billion people in 91 countries are at risk of
Plasmodium infection in the world [
1].
Insecticide-treated bednets or long-lasting insecticidal nets (ITNs/LLINs—henceforth referred to as ITNs) are one of the core interventions recommended by the World Health Organization (WHO) to reduce malaria transmission and prevent malaria in high-risk communities by preventing mosquito bites [
2]. Bednets have been shown to reduce the incidence of uncomplicated malaria cases by 50%, severe malaria by 45% in a variety of settings and malaria mortality by 55% in children [
3].
Myanmar has a high burden of malaria with more than two-thirds of the population at risk [
4]. Myanmar tops in terms of contribution of malaria cases among the countries in the Greater Mekong Sub-region (GMS), which is known for artemisinin resistance [
5].
Myanmar is committed towards eliminating malaria by 2030. In order to accomplish that, the country aims to achieve and maintain 100% access and utilization of ITNs at the household level. Free distribution of ITNs in areas of high malaria transmission is one of the key interventions for malaria elimination in Myanmar. This is carried out mainly by the National Malaria Control Programme (NMCP) and other partners. The NMCP also plans for continuous ITN distribution especially in high-risk population groups. Nearly 11 million ITNs have been distributed free of cost in the last 5 years [
6]. However, there is little information about the actual utilization of ITNs. There were also reports of misuse of ITNs such as use of nets for fishing among migrant plantation workers in Myanmar [
7].
Myanmar has a huge migrant population. In 2014, 9.4 million people were internal migrants (20% of the population) [
8]. Migrants are vulnerable to poor health access and treatment, often leading to worsening of health outcomes. Malaria burden among the migrant population is a big challenge for malaria elimination in the country. This issue is particularly important for mobile migrants working in remote forested areas in Myanmar and in the GMS who face major barriers in accessing malaria diagnosis and treatment services [
9]. The high mobility of this population is one of the main limitations for malaria control and elimination, particularly on the Myanmar-Thai border [
9]. This migration also facilitates the spread of artemisinin-resistant parasites across international borders in the region. There is poor surveillance of malaria and poor uptake of preventive and curative services in these groups [
4]. The NMCP recommends better targeting of these hard-to-reach populations. A strategic framework for artemisinin resistance in Myanmar (MARC) by the Union of Myanmar and the WHO also outlines improving access to and use of malaria care services by the mobile/migrant population as a key objective of the containment framework [
10]. In this context, it is useful to understand the ownership and utilization of ITNs and reasons for its poor utilization among high-risk migrant communities.
There are several studies across the globe reporting the gap between ownership and utilization of ITNs [
4,
11]. Few studies from Myanmar have explored this aspect in the general population and specific migrant occupations, such as plantation workers [
7,
12,
13]. However, there is limited information among migrant populations in high-risk areas of artemisinin resistance. Also, the reasons for poor utilization of ITNs from users’ perspective and barriers to distribution of ITNs from providers’ perspective has little precedence in literature. Those that exist are mostly from African countries which are quite different settings in terms of their demographics and social characteristics, health infrastructure and malaria epidemiology [
14‐
16]. Few studies have looked at net care and repair behaviour of ITNs without actually exploring the utilization aspect of the nets [
17,
18]. The present study was conducted with the following objectives: among the migrant population in the Regional Artemisinin Initiative (RAI) areas of Myanmar, to i) assess the physical condition, ownership and utilization of bed-nets and, ii) explore barriers to distribution and utilization of ITNs.
Results
Household demographic characteristics
Table
1 shows the characteristics of migrant households in RAI areas of Myanmar. Of the 3230 migrant households surveyed, respondents from all households completed the interview (response rate of 100%). Most of them were from Tanintharyi region (27%) and Mon state (26%) followed by Sagaing region (18.3%) and Kayin (12.4%). Nearly 85% of them had no formal education or educated up to primary school level. More than one-third (38%) were either gardeners/farmers/rubber tappers, followed by workers in brick kiln/stone mining company (25%) and daily wage labourers (17.7%). Most of them have migrated to work or in search of jobs (82%).
Table
2 shows the demographic and occupational characteristics of participants of FGDs and KIIs. A total of 17 FGDs (involving 121 participants) with different group of migrants and 17 KIIs with different programme stakeholders were conducted in four selected townships.
Table 2
Socio-demographic details of the participants who were part of focus group discussions and key informant interviews in four townships of Myanmar 2017
Total | 121 | 100 | | 17 | 100 |
Gender | Gender |
Male | 77 | (64) | Male | 14 | (82) |
Female | 44 | (36) | Female | 3 | (18) |
Age group | Age group |
15–24 years | 26 | (21) | 15–24 years | 1 | (6) |
25–44 years | 67 | (55) | 25–44 years | 9 | (53) |
45–64 years | 27 | (22) | 45–64 years | 6 | (35) |
65 years and above | 1 | (1) | 65 years and above | 1 | (6) |
Type of participants | Type of participants |
Bamboo cutters | 15 | (12) | Health assistant | 2 | (12) |
Road construction workers | 15 | (12) | Malaria assistant | 2 | (18) |
Charcoal makers | 11 | (9) | Malaria supervisor | 3 | (12) |
Fisherman | 13 | (10) | Public health supervisor | 2 | (12) |
Gold miners | 16 | (13) | Village health volunteers | 8 | (47) |
Oil diggers | 19 | (15) | | | |
Stone mine workers | 12 | (9) | | | |
Forest workers | 3 | (24) | | | |
Teak plantation workers | 6 | (5) | | | |
Others | 11 | (9) | | | |
Years of service | Years of service |
0–5 years | | | 0–5 years | 8 | (47) |
6–10 years | | | 6–10 years | 2 | (12) |
More than 10 years | | | More than 10 years | 5 | (29) |
Missing | | | Missing | 2 | (12) |
The major themes that emerged from the KIIs and FGDs were (a) barriers in ITN utilization; (b) barriers in ITN distribution; and, (c) suggestions to improve bed net ownership and utilization (Fig.
2).
Household ownership of and access to bed nets
Table
3 shows the household ownership of and access to bed nets among migrants in RAI areas. While almost all households, i.e., 97.8% (95% CI 97.3–98.3%) had at least one bed net, only 63.3% (95% CI 61.5–65.1) had at least one ITN. Similarly, only about 36% (95% CI 34.2–37.8%) of households had sufficient ITNs (at least one ITN per two persons in the household). About half of all household members had access to ITNs. Multivariable analysis showed that households with fewer members (< 6) had higher odds of having sufficient bed-nets. Table
4 shows qualitative analysis revealing that this was probably due to inaccurate mapping as described below. The reasons for poor ownership and access to ITNs have been linked to barriers in ITN distribution in the qualitative interviews.
Table 3
Household ownership and utilization of bed nets among migrant population in Regional Artemisinin-resistance Initiative areas of Myanmar, 2016
Total number of households | 3230 | |
Household ownership of bed nets |
At least one net per household (any type) | 97.8 | (97.3–98.3) |
At least one ITN per household | 63.3 | (61.5–65.1) |
One net per two people (any type) | 69.6 | (67.8–71.4) |
One net per two people (ITN) | 36.0 | (34.2–37.8) |
Total number of household members slept here last night | 11,193 | |
Access and Utilization of bed nets |
Access to ITN | 50.1 | (49.2–51.2) |
Reported sleeping under an ITN the previous night | 52.1 | (51.1–53.1) |
Reported sleeping under an ITN the previous night among pregnant women | 52.8 | (51.0–54.4) |
Reported sleeping under an ITN the previous night among under-five children | 50.8 | (49.0–52.8) |
Table 4
Socio-demographic characteristics associated with household ownership of sufficient ITNs among migrant population in the Regional Artemisinin-resistance Initiative areas of Myanmar, 2016
Migrant settlement type settlementa |
Category 3 | 1251 | 501 | 40.1 | (37.1–43.2) | 1 | | 1 | |
Category 1 | 756 | 299 | 38.5 | (34.8–42.2) | 1.14 (0.57–2.29) | 0.690 | 1.47 (0.76–2.83) | 0.234 |
Category 2 | 982 | 334 | 35.0 | (31.8–38.3) | 1.18 (0.54–2.58) | 0.658 | 1.07 (0.59–1.96) | 0.804 |
Education of head of household |
Up to secondary level | 197 | 387 | 36.4 | (33.1–39.7) | 1 | | 1 | |
No formal education | 260 | 89 | 33.8 | (22.7–40.4) | 1.28 (0.59–2.79) | 0.512 | 1.38 (0.59–3.25) | 0.434 |
Read and write/Primary | 2464 | 538 | 34.1 | (31.6–36.8) | 1.37 (0.8–2.35) | 0.237 | 1.28 (0.76–2.18) | 0.332 |
High school and above | 306 | 150 | 46.2 | (40.1–52.4) | 1.91 (0.97–3.77) | 0.06 | 1.94 (0.8–4.7) | 0.135 |
Occupation of head of household |
Daily wage labourer | 572 | 175 | 28.7 | (24.9–32.8) | 1 | | 1 | |
Farming/gardening/rubber tapper | 1231 | 500 | 43.6 | (40.4–46.7) | 1.55 (0.78–3.08) | 0.199 | 1.26 (0.66–2.38) | 0.462 |
Stone or gold mining work/Oil digger/Brick kiln work | 817 | 236 | 30.2 | (26.8–33.8) | 1.21 (0.59–2.47) | 0.591 | 0.95 (0.52–1.73) | 0.862 |
Merchant | 38 | 28 | 43.6 | (29.3–59.1) | 1.24 (0.61–2.51) | 0.529 | 1.08 (0.51–2.3) | 0.824 |
State/region |
Kayin | 401 | 41 | 10.9 | (7.6–15.4) | 1 | | 1 | |
Tanintharyi | 876 | 164 | 21.9 | (19.1–25.1) | 4.81 (1.64–14.1) | 0.006 | 4.97 (1.79–13.82) | 0.004 |
Shan (East) | 27 | 2 | 1.5 | (0.4–6.0) | 0.18 (0.08–0.38) | < 0.001 | 0.07 (0.05–0.11) | < 0.001 |
Mon | 839 | 455 | 52.0 | (48.6–55.3) | 12.65 (5.25–30.5) | < 0.001 | 11.76 (7.18–19.27) | < 0.001 |
Kachin | 149 | 86 | 34.8 | (29.1–41.0) | 6.12 (2.84–13.23) | < 0.001 | 9.95 (5.77–17.17) | < 0.001 |
Sagaing | 590 | 241 | 38.6 | (34.1–43.3) | 4.74 (1.67–13.47) | 0.006 | 5.72 (2.56–12.78) | < 0.001 |
Bago | 347 | 139 | 60.8 | (54.3–67.0) | 17.7 (8.16–38.44) | < 0.001 | 24.58 (13.19–45.78) | < 0.001 |
Number of household members |
More than 6 | 454 | 15 | 6.4 | (3.6–11.1) | 1 | | 1 | |
1–2 | 1153 | 628 | 56.3 | (52.9–59.6) | 5.75 (2.73–12.12) | < 0.001 | 8.07 (3.87–16.79) | < 0.001 |
3–5 | 1623 | 508 | 27.0 | (24.8–29.3) | 1.56 (0.88–2.77) | 0.12 | 1.51 (0.89–2.55) | 0.116 |
Missed populations during migrant mapping
FGDs with the migrant workers revealed that some migrants who are constantly moving, such as road workers and those working in hard-to-reach areas, are often missed during the mapping exercise and thus are excluded from the list of those eligible for bed-net distribution. Safety and security was also cited as a major concern as most of them work in difficult terrains, forest covered areas and in conflict-affected zones.
Unwillingness to disclose their work site
KIIs with health staff found that some migrant workers, such as wood cutters, did not want to disclose their nature of work and workplace in order to avoid any legal confrontations. They would eventually be missed during the migrant mapping exercise.
Difficulties in transportation
Transportation was the major barrier not only for migrant mapping but also for ITN distribution as the migrant sites are located in remote inaccessible areas, as some of the health staff said,
“Reaching the place is very difficult, sometimes only by walking, need to carry nets and other things on the back. Even motorcycle won’t go that far” (KII: Male, Public Health Supervisor).
“I used my bullock cart for transportation. Some areas cannot be accessed by bullock cart, we have to use an elephant”(KII: Male, Village Health Volunteer).
Inadequate time, manpower and insufficient travel cost to conduct migrant mapping
In KII sessions, basic health staff reported that the time for migrant mapping is inadequate to catch all migrants because they live in remote locations and are often mobile due to the nature of their work. A malaria assistant said,
“We need minimum 6 days for area mapping. For more precise data in migrant communities, even 6 days in not sufficient” (KII: Male, Malaria Assistant).
Some of the KII respondents said that more manpower was required in both migrant mapping and ITN distribution. More micro planning is required in terms of the type of health worker to be employed in different areas considering the terrain, language, mode of transportation to reach the place etc.
“For riverine route, we do not want women as volunteers as the route is dangerous. Some areas need women volunteers, Karen villages need Karen speaking workers to tackle language barrier” (FGD: Male, Village Health Volunteer).
Cost was also a barrier in moving to these locations for migrant mapping and net distribution.
“Some areas can only be reached via riverine route using a boat which costs a lot, around 80 000 kyats per boat” (KII:Male, Malaria Assistant).
Utilization of bed nets
About 52.1% (95% CI 51.1–53.1) reported sleeping under ITNs during the previous night. A similar proportion of pregnant women and children also reported sleeping under ITN the previous night. The reasons for low utilization of bed nets have been explored through qualitative enquiry. Most of the respondents stated that they used ITN if ITNs were available. The main barrier in ITN utilization was insufficient or no ITN in their family. The other reasons were not carrying ITNs to the work site due to overload and dislike of ITNs.
Never received any ITNs
Most of the migrant communities got the distributed ITNs but a few of them didnt, especially road workers/fishermen who were constantly moving.
“I sleep under ordinary bednets but not ITNs because I was not here when ITNs were distributed” (FGD: Male, Fisherman).
“We heard that the government staff deliver the nets, but we never got one, nevertheless, we had an old one that was also provided by health staff” (FGD:Female, Road worker).
Use of old bed nets
Some of the community members reported using old bed nets (more than 1 year old).
“The one we are using now was received more than a year ago. I think the strength to kill the mosquitoes is gone” (FGD: Male, Fisherman).
One of them was still using an old bed net despite having a new one.
“We got two nets within a year, by different groups. The one we are using is one year old which we received first, we keep the new one for the guests” (FGD: Male, Oil digger).
Insufficient ITN for the family
Some migrant households have one ITN for 2 persons, but some family didnot get sufficient numbers of ITNs that they needed. In some households it was difficult to use ITNs for all despite having sufficient nets because of adult males and females in their families of different age groups.
“I am alone and got one net, my son’s family has 7 members but he got only one net which was not sufficient for them” (FGD:Female, Road worker).
Not taking bed nets to their workplace
Most migrants were found not to carry bed nets with them to their workplace, especially the forest-goers or those who work away from home. The reasons cited were: (i) they did not have enough ITN at home; and, (ii) they had so many things to carry.
Do not like to use ITNs
Some FGD respondents reported the reasons for not using bed nets were feeling hot inside the bed net, intolerance to the smell and burning sensation or allergic reaction.
“Bad thing is burning sensation on the contact area, especially face, hot like chilli or as if bitten by ants”(FGD: Male, Fisherman).
“I use ordinary nets because I can’t bear the smell”(FGD: Male, Gold miner).
Characteristics of bed nets, including their physical condition
Table
5 shows the characteristics of surveyed bed nets at the household level. Just over half of all bed nets (54%) were ITNs. Nearly 54% of all bednets were of duration ≥ 5 years. Most of the bed nets were of one and half person size (60.6%). The main source of bed nets was government (91%). Of all nets, 32% had holes or had already undergone repairs. Regarding washing behaviour, nearly 12% of all nets were never washed, whereas another 10% are washed once or less than once a year. Most of the respondents (59.3%) reported drying the bednet under the sun.
Table 5
Physical condition and washing of bed nets in households among migrant population in Regional Artemisinin-resistance Initiative areas of Myanmar, 2016
Total number bed nets | 6088 | | |
Bed net size |
One person size | 429 | 7.0 | (6.3–7.8) |
One and half person size | 3695 | 60.6 | (59.3–62.0) |
Two persons size | 1951 | 32.0 | (30.7–33.3) |
Family size | 2 | 0.0 | (0.0–0.1) |
Bed net condition |
Good (No holes) | 4140 | 68.0 | (66.7–69.1) |
Repaired (No holes) | 1303 | 21.4 | (20.2–22.5) |
Small holes | 645 | 10.6 | (9.5–11.5) |
Type of nets |
Cotton | 279 | 4.6 | (4.0–5.2) |
Nylon | 361 | 5.9 | (5.2–6.6) |
Lace | 1265 | 20.8 | (19.6–21.9) |
CYC | 835 | 13.7 | (12.7–14.7) |
Military net | 41 | 0.7 | (0.4–0.9) |
ITN | 3286 | 53.9 | (52.5–55.3) |
Don’t know | 21 | 0.4 | (0.2–0.5) |
Ever been soaked in insecticide |
Yes | 161.9 | 2.7 | (2.2–3.1) |
Frequency of washing |
Never washed | 735 | 12.4 | (11.5–13.3) |
Weekly once | 187 | 3.2 | (2.6–3.7) |
Once in 2–3 weeks | 577 | 9.8 | (8.9–10.6) |
Once a month | 1290 | 21.8 | (20.6–23.1) |
Once in 2–3 months | 1430 | 24.2 | (23.0–25.4) |
Twice a year | 1110 | 18.8 | (17.7–19.9) |
Once a year | 530 | 9.0 | (8.1–9.8) |
Less than once a year | 50 | 0.9 | (0.6–1.1) |
Washing behaviour (N = 5349) |
Material used in bed net washing |
Soap | 738 | 13.8 | (12.8–14.8) |
Soap powder/liquid/cream | 4250 | 79.5 | (78.2–80.7) |
Missing | 361 | 6.8 | (5.9–7.6) |
Ways of drying bed net |
In shade | 2108 | 39.4 | (37.9–40.9) |
In sun | 3174 | 59.3 | (57.8–60.8) |
Not sure | 57 | 1.06 | (0.7–1.3) |
Washing technique |
Hand | 4345 | 81.2 | (80.0–82.5) |
Foot | 111 | 2.1 | (1.6–2.5) |
Stick | 521 | 9.7 | (8.9–10.6) |
Missing | 372 | 7.0 | (6.1–7.8) |
Source of bed net |
Gift | 55 | 1.8 | (1.2–2.4) |
Government | 2804 | 91.0 | (90.0–92.1) |
NGO | 179 | 5.8 | (5.0–6.7) |
Pharmacy/market | 17 | 0.5 | (0.2–0.8) |
Others | 3 | 0.1 | (0.0–0.1) |
Don’t know | 23 | 0.8 | (0.5–1.0) |
Duration of bed net |
Less than 6 months | 279 | 4.5 | (3.9–5.1) |
6 months–1 year | 361 | 5.9 | (5.2–6.5) |
1–2 years | 1265 | 20.8 | (19.5–21.9) |
2–3 years | 835 | 13.7 | (12.7–14.7) |
3–5 years | 41 | 0.7 | (0.4–0.9) |
≥5 years | 3286 | 53.9 | (52.5–55.3) |
Don’t know | 21 | 0.3 | (0.2–0.5) |
Missing | 5 | 0.1 | (0.0–0.1) |
Suggestions to improve bed net utilization
The qualitative study also explored feasible solutions to improve bed net distribution and utilization: 1) NMCP staff suggested more time, manpower and money (transportation costs) for precise migrant mapping and effective distribution of ITNs; 2) migrants who travel to hard-to-reach areas for work suggested to leave the bed nets at a nearby common place so that they can get it later; 3) migrants also requested to give ITNs to their local group leader or work site manager when they are busy with their work or not present at the time of distribution; 4) some suggested to consider gender difference especially for the reproductive age group while mapping the population because of they cannot sleep under one net together; 5) they also proposed IT clothing for more effective prevention method of mosquito bites especially at the time of working in forests.
Discussion
This mixed methods study among the migrants in RAI areas of Myanmar had some interesting findings. Firstly, about two-thirds of all households had at least one ITN, which is similar to another study among migrants in Bago region of Myanmar in 2014 [
22]. Another study among migrant plantation workers in two regions of Myanmar showed that more than nearly 80% of households had at least one ITN [
7]. This was probably because free and mass distributions of ITNs were done in both the study sites as one of the activities of the MARC Programme. This study also showed that only one-third of the migrant households had sufficient ITNs (1 ITN/2 persons) which is similar to that of another nationwide community-based study conducted in MARC areas in 2014 with 30% [
23]. This is far below the desired target of 100%, suggesting the need for innovative models of ITN distribution suited to such mobile populations, some of which have been suggested by the migrants themselves in this study.
The qualitative component of this study explored barriers to distribution of ITNs, which possibly explains poor ownership of bed nets. One of them was incomplete migrant mapping due to remote locations of migrant sites, inadequate time, costs of transportation and non-availability of migrants during household visits, etc. To improve ITN distribution, accurate and detailed migrant mapping is essential because it produces a master list of migrant households eligible for ITNs. This requires more programmatic resources such as time, manpower and costs to cover transportation to reach these migrant sites.
It is reported in this study that the migrant workers were sometimes not present in the household during migrant mapping or ITN distribution due to their mobile nature of work. To tackle this, the migrants in an FGD have suggested leaving the bed nets at a nearby common place or to giving it to their local group leader or work site manager when they were not present at the time of distribution.
Secondly, only about half of all household members reported sleeping under an ITNthe previous night similar to other studies which reported a proportion ranging from 39 to 56% [
22,
24,
25]. The qualitative component in this mixed methods study has tried to explore the reasons for this gap. Poor utilization of bed nets has among those who had bed nets has been ascribed to dislike of ITNs due to intolerance to the smell, allergic reaction and feeling hot inside the bed net [
26]. This requires behaviour change communication (BCC) strategies through effective health messaging explaining about ITN, misconceptions around it, their minor side effects and its temporary nature. Due to the mobile and hard-to-reach nature of this population, BCC strategies could be tailor-made. A report by the WHO on BCC strategies among mobile migrant populations showed that engagement of the employers and the community is crucial in maximizing the reach of BCC programmes. It is also important to develop culturally appropriate bilingual Information Education Communication (IEC) materials [
27]. BCC campaigns could be integrated with the ITN mapping and distribution activity. These messages could be reinforced during home visits by the VHVs.
BCC campaigns have been found to be effective in closing the gap between ownership and use [
28,
29]. A Cochrane review on strategies to improve bed net use found that educational interventions regarding ITN use may increase the number of adults and children using them. The review also found that incentives lead to little or no difference in ownership or use of ITNs [
30].
Thirdly, the qualitative enquiry reported some innovative ways of distribution of ITNs especially in such migrant/mobile populations when nobody is found at home. These may be considered by the national programme in subsequent ITN distribution campaigns. Insecticide Treated (IT) clothing was also suggested for avoiding mosquito bites for those who work in the forests. Similarly, other interventions such as insecticide-treated plastic sheeting for constructing temporary shelters, insecticide impregnated tents, insecticide-treated hammock nets, long-lasting impregnated blankets, and top sheets have been tried among refugee settlements, internally displaced populations and other complex emergencies with good success. These needs to be explored further in this setting [
31].
Finally, around half of those at particular risk of malaria (children under five years and pregnant women) reported having slept under an ITN the previous night. There is no targeted strategy to distribute ITNs to these high-risk groups. A major reason is that during the migrant household mapping, the households with children and pregnant women are not listed separately. The overall target is to distribute one ITN per two people regardless of the high-risk group. This is of particular concern as malaria-related morbidity and mortality is the highest in these groups. The NMCP needs to prioritize these sub-groups to ensure they receive 100% access to ITNs.
The major strengths of the study were that the data were obtained from a large survey among migrant population in RAI areas; the response rate was high; the interviewers were well trained and supervised. Data quality was ensured through double data entry and validation using EpiData entry software and a weighted analysis was carried out to account for the multi-stage sampling design in the survey. Secondly, a mixed methods approach enabled an understanding of the challenges in distribution and utilization of bed nets in this high-risk community and also come up with feasible solutions to mitigate these challenges, both from a users and providers. Thirdly, the study also adhered to STrengthening the Reporting of OBservational Studies in Epidemiology [
32] and COREQ guidelines to report the study findings [
21]. Fourthly, because the survey analysed a representative sample of migrants, the results could be generalizable to this high-risk group.
A limitation of the study was that the study represents migrant population covered by migrant mapping, however, there is no information on bednet ownership and use in other hard-to-reach areas where migrant mapping could not be performed. The populations in those areas might be having poorer bed net ownership and utilization due to inaccessible locations. Another limitation might be due to the fact that the interviewers were from the malaria control programme, and healthcare workers may have been reluctant to criticize the programme.
Acknowledgements
We would like to thanks the NMCP for sharing and giving permission to use the dataset used in this study. This research was conducted through the Structured Operational Research and Training Initiative (SORT IT), a global partnership led by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR). The model is based on a course developed jointly by the International Union Against Tuberculosis and Lung Disease (The Union) and Medécins sans Frontières (MSF/Doctors Without Borders). The specific SORT IT program which resulted in this publication was jointly organized and implemented by The Centre for Operational Research, The Union, Paris, France; The Department of Medical Research, Ministry of Health and Sports, Myanmar; The Department of Public Health, Ministry of Health and Sports, Myanmar; The Union Country Office, Mandalay, Myanmar; The Union South-East Asia Office, New Delhi, India; and Burnet Institute, Australia.
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