a. Study area
This study was conducted in Champasak Province, one of the five southernmost provinces in Lao PDR, together accounting for 95% of the country’s malaria burden29. As part of a randomized controlled trial, surveys were conducted between December 2017 and November 2018 to assess the effectiveness of active case detection in village-based and forested-based settings30. Across four districts, 56 villages in 14 health center catchment areas (HCCA) were randomized to one of four arms: no intervention, Focal Test-And-Treat (FTAT), an intervention specifically targeting forest-goers, Mass Test-And-Treat (MTAT), where everyone was tested for malaria using rapid diagnostics tests (RDTs) and treated if positive or both interventions. The study area was selected in consultation with the national malaria program based on malaria burden (highest API in 2016). See Fig. 1 for the study timeline and a map of the study area.
The rainy and dry seasons were defined, respectively, as the June to October and November to May periods in consultation with local health ministries and corroborated by actual precipitation data31 (see Supplementary Fig. S4.1).
b. Population Size Estimation
We defined the HRP target population as individuals at increased exposure to malaria vectors due to spending the night outdoors for forest or agriculture activities.
In this paper, we report results from two population size estimation methods: population-based household surveys and capture-recapture. The first approach estimated the population proportion of HRP in the study area from three cross-sectional household surveys conducted at different time points during the year. Each proportion was combined with a census count of the total population in the area to produce three distinct PSEs. The capture-recapture methodology drew on individual information from the household surveys and data collected from an intervention among forest-goers conducted over the course of a year to produce another PSE.
These PSEs are complementary but do not estimate the same quantity. The population-based household surveys estimates are “snapshots” of the population size, corresponding to the time frame when the household surveys were conducted. The capture-recapture estimate represents the total population size of HRPs in the study area over the study period, from December 2017 to November 2018. These four estimates would be equal only if, every month, the same HRP individuals spent at least one night outdoors for forest or agriculture activities. If there is seasonality in forest-going, these PSEs should be different.
c. Data sources
Household census
Over the course of the study, a census of all households and household members in the villages was kept up to date in collaboration with local leaders.
Baseline and endline surveys
For the baseline (December 2017) and endline (November 2018) cross-sectional surveys, simple random sampling was used to select 22 and 35 households respectively in each of the 56 study villages. Following written consent, all residents and visitors present in the household at the time of the visit were invited to participate in the survey. Heads of household were asked to answer questions on behalf of absent household members. Primary caretakers answered any questions pertaining to their children when they could not answer themselves. If no householder was at home at time of visit, the study team tried to revisit three times before randomly selecting a replacement household in the village from the household census. The survey was conducted in Lao language by local members of the ministry of health and the national research institution (Lao Tropical Public Health Institute) after receiving comprehensive training30. The surveys questioned participants on demographics, forest-going behaviors, treatment-seeking attitudes and malaria knowledge.
MTAT survey
Between June 12th and July 23rd 2018, the MTAT intervention was conducted, targeting every household in 28 villages randomly selected from among the 56 villages in the study area. Although questions differed slightly, data collection methods for the survey embedded in this intervention were the same as in the baseline and endline surveys. The study team attempted to visit an absent household three times before marking that household as ‘absent’. The households included in baseline, endline and MTAT were sampled independently from one another30.
FTAT survey
In the FTAT intervention, conducted continuously between March and November 2018, peer navigators (PNs) were employed in intervention HCCAs to conduct test-and-treat activities amongst members of their communities presumed to be “forest-goers” because of their activities in or near the forest. PNs were themselves forest-goers recruited from the local communities via health authorities and trained to conduct continuous surveillance by testing for malaria using Rapid Diagnostic Tests (RDTs)30. PNs were instructed to actively target HRP individuals, and to enroll, once outside the villages, anyone meeting the FTAT HRP eligibility criteria: aged 15 years or older and having spent at least one night outside a formal village in the past 30 days. For 16 HRP individuals interviewed twice in FTAT, we included only data from the first interview.
d. HRP eligibility criteria
Participants in the baseline, endline, and MTAT surveys were classified as members of the HRP target population if they were aged 15 years or older, were usual residents of the household, and met any of the criteria listed in Table 1. These criteria were based on responses to survey questions and varied slightly by survey due to differences in questionnaires. All participants in FTAT were classified as HRP due to the intervention’s eligibility criteria; however, we limited the FTAT sample to individuals who reported residing in the study area (56 villages) to ensure geographic alignment with the other surveys.
Table 1
HRP eligibility criteria.
Baseline and Endline criteria
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MTAT criteria
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A - During the past month, stayed overnight away from home AND reason for the absence was working in the rice field, plantation or forest in this province or another province
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D - During the past month, stayed overnight away from home village AND reason for travel was working in a rice field, agricultural or other plantation work, forest foraging, collecting small wood or timber, or logging
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B - Did not sleep in the household the previous night due to working in the rice field, plantation or forest in this province or another province
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E - During the past month, stayed overnight within 10km of home village AND travel destination was forest, forest fringes, rice field, other field or plantation
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C - Spent at least 1 night in the forest, forest fringe, farms, or rice fields in the past month
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F - Spent at least 1 night in the forest in the past month
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e. PSE method 1: population-based household surveys
First, we estimated the population proportion of HRP in the study area, phrp, as the percentage of participants aged 15 years and older in each household survey—baseline, endline and MTAT—that fulfilled the HRP eligibility criteria. Sampling weights and the clustering structure of the respective surveys were specified using the Survey32 R33 package to correctly estimate population proportions and standard errors.
Second, we developed a pooled estimate of the population proportion of individuals aged 15 and older in households in the study area, p15, by combining, in a meta-analysis using inverse variance, the individual estimates from the 3 surveys.
Third, the total household population in the study area, Pop, was obtained by summing the population count listed in the household census across the 56 villages.
Finally, the population-based survey PSE was calculated for each survey as follows:
(1)
The delta method34 was used to calculate 95% confidence intervals for each PSE.
The three PSEs obtained from this method pertain to different time periods starting 1 month prior to the first day of the household survey until the last day of the survey (see Table 2).
Two sensitivity analyses were conducted to strengthen the robustness of our results. First, we considered how the differences among criteria may lead to an underestimate of the PSE for the MTAT survey. Second, we attempted to adjust for potential selection bias because of absent households. See Supplementary Materials 5 for details.
f. PSE method 2: Capture-recapture
Survey participation represented “capture” in the respective survey. To identify participation of the same individual across surveys (i.e., “recapture”), survey records were matched based on age, sex, level of education, first initial and home village. Together, these identifying variables were unique for 99.5% of participants. The matching algorithm allowed plus or minus 2 years for age and 1 level apart for education because rounding age and self-reported education may have introduced errors. See Supplementary Materials 7 for details.
The overlap among the 4 lists of HRP individuals participating in surveys was analyzed using log-linear models35–39 by the Rcapture40 R33 package. The models allowed for temporal dependence due to the potential seasonality of forest-going activities in two ways. First, we estimated a closed population model, where HRP individuals remain in the population all year long but where the probability of being captured differs across surveys because of varying probability of spending a night outside in a given month (Mt models). Second, we estimated an open population model, in which HRP individuals may migrate in and out of the population depending on whether or not they spent a night outside in a given month. Both models were designed to estimate the same PSE: the total number of HRP individuals in the study area any time during the 1-year study period from December 2017 to November 2018. See Supplementary Materials 8 for details.
Two sensitivity analyses estimated a lower bound of the PSE by either relaxing the matching criteria or augmenting the eligibility criteria in FTAT. In a third sensitivity analysis, we leveraged the participation of non-HRP individuals in the three household surveys to assess and correct for potential matching errors in the record linkage algorithm. See Supplementary Materials 6 for details.