Barriers to malaria prevention among immigrant travelers in the United States who visit friends and relatives in sub-Saharan Africa: A cross-sectional, multi-setting survey of knowledge, attitudes, and practices

• Published in: PloS one 2020-03, Vol.15 (3), p.e0229565-e0229565
• Main Authors: Volkman, Hannah R, Walz, Emily J, Wanduragala, Danushka, Schiffman, Elizabeth, Frosch, Anne, Alpern, Jonathan D, Walker, Patricia F, Angelo, Kristina M, Coyle, Christina, Mohamud, Mimi A, Mwangi, Esther, Haizel-Cobbina, Joseline, Nchanji, Comfort, Johnson, Rebecca S, Ladze, Baninla, Dunlop, Stephen J, Stauffer, William M
• Format: Article
• Language: English
• Subjects: Adult; Africa South of the Sahara - epidemiology; Ambulatory care facilities; Antimalarials; Antimalarials - therapeutic use; Attitude; Attitudes; Avoidance; Avoidance behavior; Bites (Injuries); Chemoprevention - methods; Chemoprevention - trends; Comparative analysis; Cross-Sectional Studies; Diseases; Emigrants and Immigrants - psychology; Epidemiology; Family; Female; Friends; Health care services accessibility; Health Knowledge, Attitudes, Practice - ethnology; Health surveys; Heterogeneity; Humans; Immigrants; Knowledge; Malaria; Malaria - epidemiology; Malaria - prevention & control; Male; Medical research; Medicine; Medicine and Health Sciences; Middle Aged; Minnesota; Mosquitoes; Noncitizens; Patient satisfaction; People and Places; Polls & surveys; Population Surveillance; Populations; Prevention; Qualitative research; Reduction; Research and Analysis Methods; Setting (Literature); Studies; Sub-Saharan Africa; Surveys; Surveys and Questionnaires; Travel; Travel - statistics & numerical data; Travel medicine; Travel-Related Illness; Travelers; United Kingdom; United States - epidemiology; Vector-borne diseases
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0229565

Despite achievements in the reduction of malaria globally, imported malaria cases to the United States by returning international travelers continue to increase. Immigrants to the United States from sub-Saharan Africa (SSA) who then travel back to their homelands to visit friends and relatives (VFRs) experience a disproportionate burden of malaria illness. Various studies have explored barriers to malaria prevention among VFRs and non-VFRs-travelers to the same destinations with other purpose for travel-but few employed robust epidemiologic study designs or performed comparative analyses of these two groups. To better quantify the key barriers that VFRs face to implement effective malaria prevention measures, we conducted a comprehensive community-based, cross-sectional, survey to identify differences in malaria prevention knowledge, attitudes, and practices (KAP) among VFRs and others traveling to Africa and describe the differences between VFRs and other types of international travelers. Three distinct populations of travelers with past or planned travel to malaria-endemic countries of SSA were surveyed: VFRs diagnosed with malaria as reported through a state health department; members of the general VFR population (community); and VFR and non-VFR travelers presenting to a travel health clinic, both before their pretravel consultation and again, after return from travel. A Community Advisory Board of African immigrants and prior qualitative research informed survey development and dissemination. Across the three groups, 489 travelers completed surveys: 351 VFRs and 138 non-VFRs. VFRs who reported taking antimalarials on their last trip rated their concern about malaria higher than those who did not. Having taken five or more trips to SSA was reported more commonly among VFRs diagnosed with malaria than community VFRs (44.0% versus 20.4%; p = 0.008). Among travel health clinic patients surveyed before and after travel, VFR travelers were less successful than non-VFRs in adhering to their planned use of antimalarials (82.2% versus 98.7%; p = 0.001) and employing mosquito bite avoidance techniques (e.g., using bed nets: 56.8% versus 81.8%; p = 0.009). VFRs who visited the travel health clinic were more likely than VFR respondents from the community to report taking an antimalarial (83.0% versus 61.9%; p = 0.009), or to report bite avoidance behaviors (e.g., staying indoors when mosquitoes were out: 80.9% versus 59.5%; p = 0.009). We observed heterogeneity i