Community patient follow-up as a part of P. vivax case management in Cambodia: a mixed methods study

Background Community health workers have been key to improvements in global health. In Cambodia, a malaria-endemic country, village malaria workers (VMWs) have helped reduce the malaria burden over the last two decades. In 2021, VMWs were tasked to support health facility workers (HFWs) in conducting follow-up of patients with Plasmodium vivax malaria to ensure adherence to treatment and patient safety. Implementing routine safety monitoring at the community level for malaria treatment has yet to be studied. Methods Mixed methods were employed with a period of analysis between January 2021 and March 2023. Qualitative data were collected from policymakers, sub-national program officials, HFWs, VMWs, and patients. Patient-specific quantitative surveillance data were gathered from nine study sites and complemented with national aggregate data. A thematic analysis of the qualitative data was conducted, and key proportions were derived from quantitative data. All data were interpreted together with an interpretivist theoretical framework of implementation, combining existing frameworks’ components, such as expectation, coherence, adoption, and fidelity. Results Overall, 2,169 patients with P. vivax malaria received primaquine in 2021 and 2022, of whom 60% received follow-up visits in 2021 and 90% in 2022; more than half of these visits happened at the community level. Qualitative data indicated that the way and extent to which follow-up was implemented varied depending on the strategies VMWs adopted to ensure that the intervention was ‘doable’. These strategies included calling patients to make an appointment, flexibility on which days patients were visited, and reaching patients through their families. VMWs aimed to achieve the intervention’s purpose as per the guidelines, which is to enhance adherence and treatment safety. They also sought to achieve additional value attributed to the intervention, including comforting patients or conducting health education. Conclusions Follow-up visits were well embedded into VMW’s role and responsibilities. This was supported by VMWs’ understanding of the intended purpose and added value they attributed to the intervention, as well as their adaptive implementation strategies to make the intervention ‘doable’. These strategies should be integrated into policy and existing infrastructure while encouraging and resourcing problem-solving to achieve the intervention’s intended purpose and added value.