Background: This study evaluates the impact of a community-based primary healthcare system strengthening program on the uptake of selected maternal and child health services in two rural regions of Ghana. Methods: This study evaluates the health system strengthening (HSS) innovations, known as CHPS+, instituted in eight non-randomly selected districts and six comparison districts. We used repeated cross-sectional cluster surveys to collected data from women of reproductive age (15-49 years) at baseline (April to October 2017) and follow-up endline (August to December 2020). Samples were collected in the Northern and Volta Regions where poverty and health adversity is pervasive. A difference-in-differences (DiD) analytical framework was used to estimate CHPS+ impact by estimating logistic regression models for maternal and child healthcare services outcomes (antenatal care, skilled birth and childhood immunization), utilizing weighting procedures to adjust for unequal probabilities of sample selection. Findings: The results show that women in the CHPS+ saw significantly higher likelihood of completing the World Health Organization (WHO) recommended minimum number of ANC visits between baseline and endline compared with their counterpart in the comparison areas (0R: 1.624, 95% CI: 1.044-2.525). Likewise, the odds that children were receiving diphtheria, tetanus and pertussis (DPT) (OR: 1.292, 95% CI: 0.790 - 2.111) and measles (OR: 1.536, 95% CI: 0.986 - 2.393) immunization were elevated among the intervention group relative to children resident in comparison areas. Interpretation: HSS using the CHPS+ model will accelerate Ghana’s effort to achieve SDG 3.2 and improve prospects that Ghana will progress toward universal health care.

Community-based diabetes prevention and control programs are effective but limited in West Africa. We assess adoption and effectiveness of a contextually adapted Diabetes Prevention Program "Power to Prevent" (DPP-P2P) in Bamako, Mali. Guided by implementation science principles, we adapted the DPP-P2P to align with Malian culture, integrating dietary and exercise modifications. Local audiovisuals and photo guides were created for healthy food preparation and exercises. Six community health centers with high diabetes rates were randomly assigned to intervention or comparison, and 429 individuals (≥ 25 years old with diabetes, hypertension, or obesity) consented to participate (intervention = 282; control = 147). Diabetes peer educators facilitated 14 bi-weekly sessions over six months. We assessed Hemoglobin A1c (HbA1c) and blood pressure and surveyed 15 key healthy lifestyle behaviors pre-and post-intervention. Retention was 77.1%, and groups especially liked the role plays, African audio-visuals, peer educator success stories, and demonstrations. In the intervention group, individuals wanting to weigh less increased from 31.5 to 58.9% (p < 0.001), exercise days rose from 3.5 to 5.6 (p < 0.001), and the desire for a healthier diet rose by 0.64 points. Average HbA1c in the intervention group dropped from 6.5% to 5.4% (p = 0.001). The intervention increased the odds of lowering blood glucose below 6.5% by 2.31 times (p = 0.020) and blood pressure below the hypertension threshold by 2.67 times (p = 0.060). The Malian-adapted DPP-P2P was well accepted by the community, increasing the adoption of healthy behaviors and reducing blood glucose and hypertension. This program could benefit Mali and Sahelian countries in tackling diabetes and hypertension. Trial Registration:ClinicalTrials.gov #NCT05260879. Registered 6 December 2021-Retrospectively registered (registration link: https://clinicaltrials.gov/study/NCT05260879).

Abstract Background Community health workers (CHWs) are central to universal health coverage strategies across sub-Saharan Africa. Yet whether CHW programs equitably reach women across socioeconomic and demographic groups remains poorly characterized at the multi-country level. Methods A cross-sectional secondary analysis of Standard DHS-8 data from Ghana (2022), Kenya (2022), Tanzania (2022), and Malawi (2024) was conducted (N = 68,019 women aged 15–49). The primary outcome was self-reported contact with a CHW or fieldworker in the prior 12 months. Survey-weighted logistic regression was performed using Taylor series linearization to account for complex survey design, both individually per country and pooled. The RE-AIM framework guided the evaluation of program reach. Results National CHW coverage varied 7-fold, from 3.1% in Tanzania to 22.8% in Malawi. The most consistent cross-country equity finding was by age: women aged 15–19 had approximately half the adjusted odds of CHW contact compared to women aged 25–29 in every country (pooled aOR = 0.47, 95% CI [0.42, 0.52], p < .001). Pro-poor wealth gradients were significant in Kenya and Malawi, whereas Ghana achieved equitable reach across all wealth quintiles (p = .685). Rural residence was independently associated with higher CHW contact in Kenya (aOR = 1.48) and Malawi (aOR = 1.91). Conclusions Adolescent women aged 15–19 are systematically underserved by CHW programs across sub- Saharan Africa, a finding consistent across four countries with widely different program scales. This adolescent gap is the most consistent equity finding across the dataset, persisting across all four countries regardless of program scale, wealth distribution, or governance structure. Ghana’s Community-based Health Planning and Services (CHPS) program demonstrates that equitable CHW reach across wealth quintiles is achievable at scale. Kenya’s extreme within-county variation indicates that sub-national governance quality is a dominant driver of equity. Targeted strategies, including CHW protocol redesign and school-based outreach, are urgently needed to close the adolescent reach gap.

Extended periods of transit have become a defining feature of migration, driven by restrictive externalization policies globally and under-resourced health and social protection systems in transit countries. Migrants in transit—individuals actively migrating between their place of origin and intended destination—are disproportionately exposed to violence, exploitation, and other adversities that increase their risk for mental health problems. Migrants in transit remain underserved by systems ill-equipped to support mobile populations. To investigate the factors influencing access to mental health and psychosocial support (MHPSS) among migrants in transit, this study used a community-participatory system dynamics approach in Colombia, a key transit country in the Americas. We facilitated 10 group model building workshops in migrant shelters situated along key migration routes to co-develop causal loop and stock-and-flow diagrams illustrating the dynamic processes shaping access to MHPSS. Results revealed three critical delays in the care continuum: barriers to MHPSS awareness, seeking help, and initiating MHPSS. These delays are driven by structural barriers such as legal status, mobility, discrimination, and costs, but may be mitigated through community outreach, leveraging social networks to disseminate information and provide direct support, increasing access to information, providing basic needs and services along migration routes, and improving inter-agency coordination. Findings underscore the urgent need for flexible, low-threshold MHPSS delivery models responsive to migrants’ mobility and realities. This study identifies actionable leverage points for multisectoral policy and program innovation to reduce inequities in access to MHPSS for migrants in transit, a growing but underserved population in Latin America and globally.

"Outreach, Training, and Supportive Supervision: A Package of Strategies That Improves the Quality of Malaria Services and Provides a Model for Monitoring and Evaluating Their Effective Implementation" published on 06 Feb 2024 by The American Society of Tropical Medicine and Hygiene.

Background There are few community-level behaviors change interventions for reducing diabetes and hypertension risk in Africa, despite increasing cases of type 2 diabetes and cardiovascular diseases. Thus, this study was designed to adapt the United States Centers for Disease Control and Prevention’s “Diabetes Prevention Program Power to Prevent” (DPP-P2P) for use in low-income urban communities of Bamako, Mali. Methods Feedback was elicited on an initial French PowerPoint adaptation of the DPP-P2P session guidelines from stakeholders at the ministry of health, organizational partners, and medical care providers. Two community health centers in districts with high levels of diabetes or hypertension were selected to assist in developing the Malian adaptation. Focus groups were conducted with 19 community health workers (CHWs) of these centers. Based on feedback from these discussions, more graphics, demonstrations, and role plays were added to the PowerPoint presentations. The 19 CHWs piloted the proposed 12 sessions with 45 persons with diabetes or at-risk patients over a one-month period. Feedback discussions were conducted after each session, and changes in dietary and exercise habits were assessed pre and post participation in the program. This feedback contributed to finalization of a 14-session sequence. Results The DPP-P2P session guidelines were adapted for use by low-literacy CHWs, converting the written English guidelines into French PowerPoint presentations with extensive use of pictures, role plays and group discussions to introduce diabetes, diet, and exercise concepts appropriately for the Bamako context. CHWs recommendations for a strong family-oriented program led to expanded sessions on eliciting support from all adults in the household. The 45 participants in the pilot adaptation were enthusiastic about the program. At the end of the program, there were significant increases in the frequency of daily exercise, efforts to limit fat intake, and goals for more healthy diets and exercise levels. Conclusion This study documents how an iterative process of developing the DPP-P2P adaptation led to the development of a culturally appropriate set of materials welcomed by participants and having promise for reaching the low-income, low-literacy population with or at risk for diabetes in Bamako, Mali.

Nigeria has the highest malaria burden globally, and anti-malarials have been commonly used to treat malaria without parasitological confirmation. In 2012, Nigeria implemented rapid diagnostic tests (RDTs) to reduce the use of anti-malarials for those without malaria and to increase the use of artemisinin-based combination therapy (ACT) for malaria treatment. This study examined changes in anti-malarial receipt among children aged 6–59 months during a 12-year period of increasing RDT availability. A cross-sectional analysis was conducted using the Nigeria Malaria Indicator Survey (NMIS) data from 2010 (before RDT implementation in 2012), 2015, and 2021. The analysis assessed trends in prevalence of malaria by survey RDT result, and fever and anti-malarial/ACT receipt in the 2 weeks prior to the survey. A multivariable logistic regression was used to account for the complex survey design and to examine factors associated with anti-malarial receipt, stratified by survey RDT result, a proxy for recent/current malaria infection. In a nationally-representative, weighted sample of 22,802 children aged 6–59 months, fever prevalence remained stable over time, while confirmed malaria prevalence decreased from 51.2

BACKGROUND:It has been hypothesized that in high-transmission settings, malaria control in early childhood (<5 years of age) might delay the acquisition of functional immunity and shift child deaths from younger to older ages.METHODS:We used data from a 22-year prospective cohort study in rural southern Tanzania to estimate the association between early-life use of treated nets and survival to adulthood. All the children born between January 1, 1998, and August 30, 2000, in the study area were invited to enroll in a longitudinal study from 1998 through 2003. Adult survival outcomes were verified in 2019 through community outreach and mobile telephones. We used Cox proportional-hazards models to estimate the association between the use of treated nets in early childhood and survival to adulthood, adjusting for potential confounders.RESULTS:A total of 6706 children were enrolled. In 2019, we verified information on the vital status of 5983 participants (89%). According to reports of early-life community outreach visits, approximately one quarter of children never slept under a treated net, one half slept under a treated net some of the time, and the remaining quarter always slept under a treated net. Participants who were reported to have used treated nets at half the early-life visits or more had a hazard ratio for death of 0.57 (95% confidence interval [CI], 0.45 to 0.72) as compared with those who were reported to have used treated nets at less than half the visits. The corresponding hazard ratio between 5 years of age and adulthood was 0.93 (95% CI, 0.58 to 1.49).CONCLUSIONS:In this long-term study of early-life malaria control in a high-transmission setting, the survival benefit from early-life use of treated nets persisted to adulthood. (Funded by the Eckenstein-Geigy Professorship and others.).

Ever since the 1990s, implementation research in Ghana has guided the development of policies and practices that are essential to establishing community-based primary health care. In response to evidence emerging from this research, the Community-based Health Planning and Services (CHPS) policy was promulgated in 1999 to scale-up results. However, during the first decade of CHPS operation, national monitoring showed that its pace of coverage expansion was unacceptably slow. In 2010, the Ghana Health Service launched a 5-year plausibility trial of CHPS reform for testing ways to accelerate scale-up. This initiative, known as the Ghana Essential Health Intervention Program (GEHIP), included a knowledge management component for establishing congruence of knowledge generation and flow with the operational system that GEHIP evidence was intended to reform. Four Upper East Region districts served as trial areas, while seven districts were comparison areas. Interventions tested means of developing the upward flow of information based on perspectives of district managers, sub-district supervisors and community-level workers. GEHIP also endeavoured to improve procedures for the downward flow and utilization of policy guidelines. Field exchanges were convened for providing national, regional and district leaders with opportunities for participatory learning about GEHIP implementation innovations. This systems approach facilitated the process of augmenting the communication of evidence with practical field experience. Scientific rigor associated with the production of evidence was thereby integrated into management decision-making processes in ways that institutionalized learning at all levels. The GEHIP knowledge management system functioned as a prototype for guiding the planning of a national knowledge management strategy. A follow-up project transferred its mechanisms from the Upper East Regional Health Administration to the Policy Planning Monitoring and Evaluation Division of the Ghana Health Service in Accra.

Background: Three African Health Initiative (AHI) partnership projects in Ethiopia, Ghana, and Mozambique implemented strategies to improve the quality and evaluation of routinely collected data at the primary health care level and stimulate its use in evidence-based decision making. We compare how these programs designed and carried out data for decision-making (DDM) strategies, elaborate on barriers and facilitators to implementation success, and offer recommendations for future DDM programming. Methods: Researchers from each project collaboratively wrote a cross-country protocol based on these objectives. By adapting the Consolidated Framework for Implementation Research (CFIR) through a qualitative theme reduction process, they harmonized lines of inquiry on the design of the respective DDM strategies and the barriers and facilitators of effective implementation. We conducted in-depth interviews and focus group discussions with stakeholders from the primary health care systems in each country, and we carried out multistage, thematic analyses using a deductive lens. Results: Effective implementation of DDM depended on whether implementers felt that DDM was adaptable to context, feasible to trial, and easy to introduce and maintain. The prevailing policy and political environment in the wider health system, learning climate and absorptive capacity for evidence-based change in DDM settings, engagement of external change agents and internal change leaders, and promotion of opportunities and means for team-based reflection and evaluations of what works influenced the success or failure of DDM strategies. Conclusion: Opportunities for team-based capacity building and individual mentorship led to effective DDM programming. External policies and associated incentives bolstered this but occasionally led to unintended consequences. Leadership engagement and availability of resources to act on recommendations; respond to capacity-building needs; and facilitate collaborations between peers, within hierarchies, and across the local health system proved crucial to DDM, as was encouraging adaptation and opportunities for iterative on-the-job learning.

Ghana is positioned to become the first country in sub-Saharan Africa to implement universal health coverage based on nation-wide expansion of geographic access through the Community-based Health Planning and Services initiative. This achievement is the outcome of 3 decades of implementation research that health authorities have used for guiding the development of its primary health care program. This implementation research process has comprised Ghana's official endorsement of the 1978 Alma Ata Declaration, leading to the institutionalization of evidence relevant to the strategic design of primary health care and national health insurance policies and services. Rather than relying solely upon the dissemination of project results, Ghana has embraced a continuous and systemic process of knowledge capture, curation, and utilization of evidence in expanding geographic access by a massive expansion in the number of community health service points that has taken decades. A multisectoral approach has been pursued that has involved the creation of systematic partnerships that included all levels of the political system, local development officials, community groups and social networks, multiple university-based disciplines, external development partners, and donors. However, efforts to achieve high levels of financial access through the roll-out of the National Health Insurance Scheme have proceeded at a less consistent pace and been fraught with many challenges. As a result, financial access has been less comprehensive than geographical access despite sequential reforms having been made to both programs. The legacy of activities and current research on primary health care and national health insurance are reviewed together with unaddressed priorities that merit attention in the future. Factors that have facilitated or impeded progress with research utilization are reviewed and implications for health systems strengthening in Ghana and elsewhere in Africa and globally are discussed.

Achieving universal health care coverage requires the adoption of primary health care policies and delivery strategies that are evidence based. Although this has been confronted by manifold challenges, particularly in the health systems of sub-Saharan Africa, there are promising approaches for accomplishing this objective. Salient among these is embedding implementation research (i.e., the study of methods to promote the systematic uptake of evidence-based interventions (EBIs) into routine practice) into policy making and implementation processes. Since 2007, the African Health Initiative of the Doris Duke Charitable Foundation supported partnerships that strengthened primary health systems and policy implementation in 7 countries in sub-Saharan Africa using the embedded implementation research as a core strategy. This programmatic review and analysis aims to identify the core features and processes that characterized how the partnerships operationalized the embedded implementation research approach and understand the factors that helped and constrained partnerships' effective use of this approach. For this, we drew upon findings from a desk review that consisted of 30 examples of embedded implementation research conducted by 3 African Health Initiative partnerships between 2016 and 2021 in Ethiopia, Ghana, and Mozambique. In addition, we conducted and analyzed 13 in-depth interviews with embedded implementation research stakeholders of the 3 projects. Core features and processes of embedded implementation research were: (1) the leadership role of policy decision makers and implementation leaders; (2) positioning research with program implementation at multiple levels of health systems; (3) multidisciplinary and multisectoral partnerships; (4) focus on research capacity building; and (5) real-time feedback loops and knowledge translation. Factors influencing the effectiveness of the embedded implementation research experiences involved: (1) the implementation climate and leadership; (2) opportunities and capacities to circulate and absorb new information; and (3) stakeholders' baseline knowledge and embedded scientists' identification within their organizations.

Background. Global gains toward malaria elimination have been heterogeneous and have recently stalled. Interventions targeting afebrile malaria infections may be needed to address residual transmission. We studied the efficacy of repeated rounds of community-based mass testing and treatment (MTaT) on malaria infection prevalence in western Kenya. Methods. Twenty clusters were randomly assigned to 3 rounds of MTaT per year for 2 years or control (standard of care for testing and treatment at public health facilities along with government-sponsored mass long-lasting insecticidal net [LLIN] distributions). During rounds, community health volunteers visited all households in intervention clusters and tested all consenting individuals with a rapid diagnostic test. Those positive were treated with dihydroartemisinin-piperaquine. Cross-sectional community infection prevalence surveys were performed in both study arms at baseline and each year after 3 rounds of MTaT. The primary outcome was the effect size of MTaT on parasite prevalence by microscopy between arms by year, adjusted for age, reported LLIN use, enhanced vegetative index, and socioeconomic status. Results. Demographic and behavioral characteristics, including LLIN usage, were similar between arms at each survey. MTaT coverage across the 3 annual rounds ranged between 75.0% and 77.5% in year 1, and between 81.9% and 94.3% in year 2. The adjusted effect size of MTaT on the prevalence of parasitemia between arms was 0.93 (95% confidence interval [CI], .79-1.08) and 0.92 (95% CI, .76-1.10) after year 1 and year 2, respectively. Conclusions. MTaT performed 3 times per year over 2 years did not reduce malaria parasite prevalence in this high-transmission area.

Most countries have implemented restrictions on mobility to prevent the spread of Coronavirus disease-19 (COVID-19), entailing considerable societal costs but, at least initially, based on limited evidence of effectiveness. We asked whether mobility restrictions were associated with changes in the occurrence of COVID-19 in 34 OECD countries plus Singapore and Taiwan. Our data sources were the Google Global Mobility Data Source, which reports different types of mobility, and COVID-19 cases retrieved from the dataset curated by Our World in Data. Beginning at each country’s 100th case, and incorporating a 14-day lag to account for the delay between exposure and illness, we examined the association between changes in mobility (with January 3 to February 6, 2020 as baseline) and the ratio of the number of newly confirmed cases on a given day to the total number of cases over the past 14 days from the index day (the potentially infective ‘pool’ in that population), per million population, using LOESS regression and logit regression. In two-thirds of examined countries, reductions of up to 40% in commuting mobility (to workplaces, transit stations, retailers, and recreation) were associated with decreased cases, especially early in the pandemic. Once both mobility and incidence had been brought down, further restrictions provided little additional benefit. These findings point to the importance of acting early and decisively in a pandemic.

Background: There is continuing uncertainty about the effectiveness of testing, tracing, isolation, and quarantine (TTIQ) policies during the pandemic. Methods: We developed proxy indicators of the implementation of TTIQ policies at subnational and national (Republic of Korea), and international level (111 countries) from the beginning of 2020 to September 2021. These were: proportion of quarantined population (“Q-proportion”) among newly diagnosed COVID-19 cases/week, ratio of quarantined people to cases, and ratio of negative tests to new cases, with higher values suggesting more complete TTIQ. We used linear regression to analyze the association between TTIQ indicators and 1-week lagged cases and cumulative deaths, separating periods before and after vaccines becoming available. Findings: We found consistently inverse associations between TTIQ indicators and COVID-19 outcomes, with gradual attenuation as vaccination coverage rose. Q-proportion overall (β= -0·091;p -value < 0·001) and log-transformed quarantined population per case (β ranges from -0·626;p < 0.001 to -0·288;p = 0·023) in each of 9 provinces were negatively associated with log-transformed 1-week lagged incidence in Korea overall. The strength of association decreased with greater vaccination coverage. The ratio of negative test results/new case was also inversely associated with incidence (β= -1·19;p -value < 0·001) in Korea. Globally, increasing negative test ratio was significantly associated with lower cumulative cases and deaths per capita, more so earlier in the pandemic. Jurisdictions with lower vaccination coverage showed the strongest association. Interpretation: A real-world evaluation demonstrates an association between performance of testing, contact tracing, isolation, and quarantine and better disease outcomes. Funding Information: Ministry of Foreign Affairs, Republic of Korea. Declaration of Interests: None to declare.

Implementation research often fails to have its intended impact on what programs actually do. Embedding research within target organizational systems represents an effective response to this problem. However, contradictions associated with the approach often prevent its application. We present case studies of the application of embedded implementation research in Bangladesh, Ghana, and Tanzania where initiatives to strengthen community-based health systems were conducted using the embedded science model. In 2 of the cases, implementation research standards that are typically embraced without question were abandoned to ensure pursuit of embedded science. In the third example, statistical rigor was sustained, but this feature of the design was inconsistent with embedded science. In general, rigorous statistical designs employ units of observation that are inconsistent with organizational units that managers can control. Structural contradictions impede host institution ownership of research processes and utilization of results. Moreover, principles of scientific protocol leadership are inconsistent with managerial leadership. These and other embedded implementation science attributes are reviewed together with contradictions that challenged their pursuit in each case. Based on strategies that were effectively applied to offsetting challenges, a process of merging research with management is proposed that is derived from computer science. Known as "agile science," this paradigm combines scientific rigor with management decision making. This agile embedded research approach is designed to sustain scientific rigor while optimizing the integration of learning into managerial decision making.

Ensuring access to vaccines against COVID-19 for refugee and displaced populations and addressing health inequities are vital for an effective pandemic response.

Background Studies evaluating mass drug administration (MDA) in malarious areas have shown reductions in malaria immediately following the intervention. However, these eGects vary by endemicity and are not sustained. Since the 2013 version of this Cochrane Review on this topic, additional studies have been published. Objectives Primary objectives To assess the sustained eGect of MDA with antimalarial drugs on: - the reduction in malaria transmission in moderate- to high-transmission settings; - the interruption of transmission in very low- to low-transmission settings. Secondary objective To summarize the risk of drug-associated adverse eGects following MDA. Search methods We searched several trial registries, citation databases, conference proceedings, and reference lists for relevant articles up to 11 February 2021. We also communicated with researchers to identify additional published and unpublished studies. Selection criteria Randomized controlled trials (RCTs) and non-randomized studies comparing MDA to no MDA with balanced co-interventions across study arms and at least two geographically distinct sites per study arm. Data collection and analysis Two review authors independently assessed trials for eligibility and extracted data. We calculated relative risk (RR) and rate ratios with corresponding 95% confidence intervals (CIs) to compare prevalence and incidence, respectively, in MDA compared to no-MDA groups. We stratified analyses by malaria transmission and by malaria species. For cluster-randomized controlled trials (cRCTs), we adjusted standard errors using the intracluster correlation coeGicient. We assessed the certainty of the evidence using the GRADE approach. For non-randomized controlled before-and-aLer (CBA) studies, we summarized the data using diGerence-in-diGerences (DiD) analyses. Main results Thirteen studies met our criteria for inclusion. Ten were cRCTs andthree were CBAs. Cluster-randomized controlled trials Moderate- to high-endemicity areas (prevalence >= 10%) We included data from two studies conducted in The Gambia and Zambia. At one to three months aLer MDA, the Plasmodium falciparum (hereaLer, P falciparum) parasitaemia prevalence estimates may be higher compared to control but the CIs included no eGect (RR 1.76, 95% CI 0.58 to 5.36; Zambia study; low-certainty evidence); parasitaemia incidence was probably lower (RR 0.61, 95% CI 0.40 to 0.92; The Gambia study; moderate-certainty evidence); and confirmed malaria illness incidence may be substantially lower, but the CIs included no eGect (rate ratio 0.41, 95% CI 0.04 to 4.42; Zambia study; low-certainty evidence). At four to six months aLer MDA, MDA showed little or no eGect on P falciparum parasitaemia prevalence (RR 1.18, 95% CI 0.89 to 1.56; The Gambia study; moderate-certainty evidence) and, no persisting eGect was demonstrated with parasitaemia incidence (rate ratio 0.91, 95% CI 0.55 to 1.50; The Gambia study). Very low- to low-endemicity areas (prevalence < 10%) Seven studies from Cambodia, Laos, Myanmar (two studies), Vietnam, Zambia, and Zanzibar evaluated the eGects of multiple rounds of MDA on P falciparum. Immediately following MDA (less than one month aLer MDA), parasitaemia prevalence was reduced (RR 0.12, 95% CI 0.03 to 0.52; one study; low-certainty evidence). At one to three months aLer MDA, there was a reduction in both parasitaemia incidence (rate ratio 0.37, 95% CI 0.21 to 0.55; 1 study; moderate-certainty evidence) and prevalence (RR 0.25, 95% CI 0.15 to 0.41; 7 studies; lowcertainty evidence). For confirmed malaria incidence, absolute rates were low, and it is uncertain whether MDA had an eGect on this outcome (rate ratio 0.58, 95% CI 0.12 to 2.73; 2 studies; very low-certainty evidence). For P falciparum prevalence, the relative diGerences declined over time, from RR 0.63 (95% CI 0.36 to 1.12; 4 studies) at four to six months aLer MDA, to RR 0.86 (95% CI 0.55 to 1.36; 5 studies) at 7 to 12 months aLer MDA. Longer-term prevalence estimates showed overall low absolute risks, and relative eGect estimates of the eGect of MDA on prevalence varied from RR 0.82 (95% CI 0.20 to 3.34) at 13 to 18 months aLer MDA, to RR 1.25 (95% CI 0.25 to 6.31) at 31 to 36 months aLer MDA in one study. Five studies from Cambodia, Laos, Myanmar (2 studies), and Vietnam evaluated the eGect of MDA on Plasmodium vivax (hereaLer, P vivax). One month following MDA, P vivax prevalence was lower (RR 0.18, 95% CI 0.08 to 0.40; 1 study; low-certainty evidence). At one to three months aLer MDA, there was a reduction in P vivax prevalence (RR 0.15, 95% CI 0.10 to 0.24; 5 studies; low-certainty evidence). The immediate reduction on P vivax prevalence was not sustained over time, from RR 0.78 (95% CI 0.63 to 0.95; 4 studies) at four to six months aLer MDA, to RR 1.12 (95% CI 0.94 to 1.32; 5 studies) at 7 to 12 months aLer MDA. One of the studies in Myanmar provided estimates of longer-term eGects, where overall absolute risks were low, ranging from RR 0.81 (95% CI 0.44 to 1.48) at 13 to 18 months aLer MDA, to RR 1.20 (95% CI 0.44 to 3.29) at 31 to 36 months aLer MDA. Non-randomized studies Three CBA studies were conducted in moderate- to high-transmission areas in Burkina Faso, Kenya, and Nigeria. There was a reduction in P falciparum parasitaemia prevalence in MDA groups compared to control groups during MDA (DiD range: -15.8 to -61.4 percentage points), but the eGect varied at one to three months aLer MDA (DiD range: 14.9 to -41.1 percentage points). Authors' conclusions In moderate- to high-transmission settings, no studies reported important eGects on P falciparum parasitaemia prevalence within six months aLer MDA. In very low- to low-transmission settings, parasitaemia prevalence and incidence were reduced initially for up to three months for both P falciparum and P vivax; longer-term data did not demonstrate an eGect aLer four months, but absolute risks in both intervention and control groups were low. No studies provided evidence of interruption of malaria transmission.

A recent commentary published in this journal correctly notes the important challenges that must be addressed to mitigate the effects of the COVID-19 pandemic in Africa. While we agree with the basic assumptions and arguments of their essay, we argue that common social institutional norms in most rural settings could be marshalled for organizing preventive measures.