Barriers to malaria prevention and chemoprophylaxis use among travelers who visit friends and relatives in Sub-Saharan Africa: A cross-sectional, multi-setting survey addressing behaviors, systems, and comparator populations

Abstract

Despite achievements in the reduction of malaria morbidity and mortality globally, imported malaria cases to the US by travelers continue to grow. Imported malaria occurs disproportionately among individuals who travel to visit friends and relatives (VFRs) in malarious countries. This dissertation examines behavioral and structural barriers to chemoprophylaxis use and malaria prevention among VFR travelers to the African continent. This survey-based study is one component of a broader, multi-methodologic project aimed to reduce malaria in VFR travelers. Barriers are identified through a cross-sectional, three-setting survey of knowledge, attitudes and practices of diagnosed malaria cases, community VFRs, and patients at a specialty travel clinic. Subgroup analyses are performed comparing VFRs traveling to different regions and across survey settings, as well as to non-VFR travelers to generate a deeper understanding of the heterogeneity and breadth of barriers. In all, 489 surveys were completed, 351 among VFRs. VFRs face significant barriers between intending and actualizing malaria prevention; while 95.2% of VFRs planned to take an antimalarial, just 59.4% reported using chemoprophylaxis. Having a primary care provider is strongly positively associated with seeking pre-travel care and improved perceptions of the health care system among VFRs. Compared to VFRs, non-VFR travelers are more successful at preventive approaches including antimalarial use, wearing long clothing, and bed net use. Yet travel clinic VFRs more commonly report certain prevention approaches than VFRs in the community; heterogeneity exists both among VFRs and across traveler populations. A novel conceptual framework is proposed to explain correlations between predictors of malaria illness, integrating concern for malaria, malaria prevention, and travel frequency. Engaging policy leaders in travel medicine is necessary for a deeper understanding of structural barriers to malaria prevention. These findings and call for future partnerships will be central to the development of targeted, evidence-based barrier reduction interventions and policies which may reduce imported malaria over time. A reduction in malaria among VFRs would not only lessen morbidity among the nearly 1,500 travelers with malaria in the US each year, but also decrease health care costs to payers, and reduce risk of local malaria transmission and the subsequent intensive public health response.