The studies encouraged in this toolkit are primarily intended to guide action, either

immediately or through information sharing leading to collective regional strategies.

Localized study approaches for example, participatory rural appraisal and BCC design
activities may be so action-focused that they are not commonly identified as research.
Others large population-based surveys, for example require clear presentations to
policy makers as well as regional dissemination using common indicators and definitions.
Study designers should consider action issues before data collection begins.
This toolkit is targeted more to programme managers rather than to researchers. Its
objective is to help managers oversee and manage the surveys component within their
programme strategy, decide the kind of study that would be most useful for them, based
on grant applications to be made or reported, programmatic decisions to be made or
problems to be solved. The toolkit follows a decision-tree format, asking important
questions and recommending study approaches based on answers. It presents
methodological choices and present examples from recent reports.

Decision-tree framework for

selecting study methods for
malaria interventions in mobile
and migrant populations

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 SEA-MAL-278

Decision-tree framework for

selecting study methods for
malaria interventions in mobile
and migrant populations
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Printed in India
 Contributors

Wayne Stinson, Independent Consultant [Author]

Bayo Fatunmbi, WHO ERAR Surveillance, Monitoring and Evaluation

Catherine Smith, University of Queensland

Deyer Gopinath, WHO ERAR Malaria and Border Health

Glaister Leslie, Malaria Consortium

Jaime Calderon, International Organization of Migration,

National Malaria Control Programs in the six Greater Mekong subregion countries

Nigoon Jitthai, USAID Regional Development Mission for Asia, Bangkok

Soy-Ty Kheang, Chief of Party/Regional Director PMI/ USAID Control and Prevention of Malaria (CAP-M)

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations iii
iv Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 Contents

Acronyms....................................................................................................................................... vi

1. Introduction..............................................................................................................................1

1.1 Who are MMPs, and why should we study them?...........................................................1

1.2 What is a study?.............................................................................................................2

1.3 Audience and format of this toolkit.................................................................................3

2. The “Decision-tree” approach to survey management...............................................................4

2.1 Decide on your primary objective....................................................................................4

2.2 Ask if a formal study is the best way to get required information....................................7

2.3 Consider methodological options....................................................................................8

3. Overview of different study methodologies.............................................................................11

3.1 If your objective is to generate quantitative indicators…................................................11

3.2 If your objective is to identify MMP clusters, target those most at risk
and quantify seasonal numbers ....................................................................................12

3.3 If your objective is to improve programme effectiveness...............................................13

3.4 If your objective is to improve continuity.......................................................................15

4. Information to action..............................................................................................................17

5. The decision-tree algorithm.....................................................................................................19

Annexes

1. Systems analyses.....................................................................................................................21

2. Programme effectiveness studies............................................................................................23

3. Population-based surveys........................................................................................................26

4. Migrant mapping and risk analysis..........................................................................................29

Bibliography .................................................................................................................................31

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations v
 Acronyms

BCC Behaviour change communication

ERAR Emergency Response to Artemisinin Resistance
GMS Greater Mekong Subregion
GPS Global Positioning Satellite
IEC Information, education and communication
IRS Indoor Residual Spraying
ITN Insecticide Treated Net
LLIN Long-lasting insecticide treated net
MARC Myanmar Artemisinin Resistance Containment
MMPs Mobile and migrant populations
PMI President’s Malaria Initiative
PSI Population Services International
RBM Roll Back Malaria
SME Surveillance, Monitoring and Evaluation

vi Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 1. Introduction

Malaria is declining almost everywhere in the Greater Mekong Subregion (GMS), and several
countries that suffered from high burdens just a decade ago are now aiming to eliminate
malaria – a major achievement if successful. In fact, elimination would bring major economic
and social benefits to virtually every country in the region, because of reduced health care costs
and increased economic productivity. Malaria weakens workers, makes mothers anemic and
decreases children’s cognitive development. It has been with us for 500 000 years, but diligent
efforts can eliminate it and must be pursued.

Two major challenges confront the region, nevertheless, and have led WHO to declare a
public health emergency. One is that all available medications, both historically and now, have
been weakened and eventually made ineffective by parasite resistance. The only drugs available
now, which are artemisinin-based compounds, are rapidly developing resistance, and can only
be “saved” by eliminating all malaria in areas affected by resistance. More is at stake than the
success or failure of malaria control in the GMS, moreover, because Africa has far more malaria
than the Mekong area; and the enormous gains made in malaria control there since 2005 will
be seriously jeopardized if resistance spreads.

A second major challenge – the subject of this toolkit – is that malaria primarily affects
migrant and mobile populations (MMPs), who are often the most difficult to reach and are
particularly vulnerable because they move in and out of high transmission areas (especially
forests). MMPs are often unpopular or worse, because they are not part of the local community,
may speak a different language, and may even be considered illegal, yet in some cases they
provide the muscle that makes countries grow and prosper. They may even be blamed for
spreading resistant malaria – yet they are actually the first to suffer and the most prominent
victims. MMPs are in fact the most challenging “target” group for both resistance management
and malaria elimination, and ways must be found to better serve their needs.

1.1 Who are MMPs, and why should we study them?

There is general agreement that we do not know what we need to know about migrant and
mobile populations in order to reach them – to ensure that they protect themselves against
infectious diseases, that they obtain prompt and high-quality services when sick, and – very
important for malaria, tuberculosis and other conditions – that they take all necessary steps
to complete treatment and eliminate pathogens that may contribute to drug resistance. As
managers responsible for MMP services, we must obtain funds, procure commodities and train
staff for the populations at greatest risk in our coverage zones, and these include “strangers”
who may be difficult to identify and count.

Who are the MMPs, or – perhaps better stated – who are the MMPs at greatest risk? This
toolkit does not propose a fixed definition of MMPs nor of their subcategories (up to a dozen
definitions have been proposed), but it does encourage anyone conducting MMP studies or
communicating results in regional fora to state clearly what population group has been studied.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 1
 Programmes will define their own study populations based on specific operational concerns;
however, the following types of people are likely to be of special concern:

We need to know where and how many people are at high risk of malaria, not
just now but during the life cycle of current programme plans and grants. We also
need to know more about population movements, living and working conditions,
access to services, and knowledge and behaviour so as to tailor communication to
special populations.

¤¤ Anyone exposed to heightened malaria risk because he or she moves into a high
transmission zone, usually in or near a forest, especially if he or she comes from a low
transmission area; families of such people who may be exposed to malaria after their
return.
¤¤ Anyone in high transmission or artemisinin-resistant areas with restricted access to
preventive or curative services because they are not locally registered, deliberately avoids
official contacts, or speaks a minority language.

More specifically, the following are usually considered MMPs:

¤¤ Seasonal workers who may lack access to established health services because they
originate elsewhere;
¤¤ Miners, tree cutters and others who may avoid government services because their
activities are not officially approved;
¤¤ Members of minority ethnic groups;
¤¤ Soldiers, border police and other security forces who travel through forest areas
(sometimes with their families).

Note that distinctions between internal and external migrants, and between temporary and
longer-term migrants, are primarily important in terms of effect on access to commodities and
services and their comprehension (or incomprehension) of national languages.

1.2 What is a study?

A study, as defined for this toolkit, is an effort to collect new information about MMPs, regardless
of whether results are intended for theoretical application or for immediate problem-solving.
Studies may be sophisticated and robust (easily generalized to other settings) or “simple” and
programmatic, with primary relevance to the local setting. They should be “special,” i.e., not
frequently repeated, but they need not (by this definition) require formal research approval or
even English-language translation. Results may be quantitative (statistical or providing “counts”
of MMPs), or qualitative (descriptive), but they should be “objective,” that is, not influenced by
preconceptions or personal opinions. This is not a universal definition of “study” but rather an
operational one for the purpose of this toolkit. In fact, many of those doing “studies” may consider
them as routine data-based problem-solving, rather than research. (Even routine problem-solving
should be objective and rigorous, however, and should be reported so that others may learn.)

2 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 MMPs are very important participants in many studies which this toolkit will not consider:
programme assessments, operations research, epidemiological analyses, entomological studies,
and therapeutic efficacy studies, for example. Programme managers striving to improve services
should make ample use of these resources, but the toolkit will not consider them as MMP studies
because they focus on programme interventions (where MMPs are objects) rather than on the
MMPs themselves (MMPs as subjects).

1.3 Audience and format of this toolkit

This toolkit is targeted to programme managers rather than to researchers. Its objective is to
help managers oversee and manage the surveys component of the ERAR SME strategy. Ideally
it should help managers decide the kind of study that would be most useful for them, based on
grant applications to be made or reported, and decisions to be made or problems to be solved.
The toolkit will follow a decision-tree format, asking important questions and recommending
study approaches based on answers. It will present methodological choices and present examples
from recent reports. A literature “repository” being developed alongside the toolkit will identify
and provide easy access to many recent studies.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 3
 2. The “Decision-tree” approach to survey management

You are probably considering a study because your team wants to “know more” about MMPs,
or perhaps because an important donor/funder/stakeholder requires quantitative reports. These
are valid reasons, of course, but you may need to be more specific and more certain that a study
(rather than use of existing data) is the best way to get what you need.

Studies are expensive (especially for human resources), take lots of time to complete
and report, and may attract multiple “owners” and agendas.

Since MMP settings change so fast, the situations they were intended to describe
may have moved on before results become available.

Multiple approval requirements, some perhaps not foreseen, may delay

implementation.

2.1 Decide on your primary objective

If you nevertheless need a formal study, start by asking why:
Do you need to report population-based
data to your stakeholder(s)/ donor(s)?

Do you have reliable information on where

MMPs live and work as well as their numbers,
and can you project where they will be several
years from now?
1st:
decide on your
primary objective
Do you know how to make services and pre-
ventive activities more effective for MMPs?

Do you know how to reach MMPs before

they enter high-risk areas and after they
return?

Do you need to report population-based data to the Global Fund or other

donors/funder/stakeholder?
Donors justifiably require quantitative data, and you need them as well to track progress. The
question is whether to develop a big survey for this or to rely on simpler but perhaps less valid

4 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
methods until you know more about MMPs, especially where and how many there are (a survey
based on an unknown or highly transient population may be difficult to interpret).

Surveys typically employ one or more questionnaires addressed to a sample of respondents.

To ensure correct interpretation, planners must design and translate questions with great care,
and data collectors must ask them without attempting to influence responses. They must also
find the right people to interview.

Some indicators relate specifically to MMPs (some even to MMP subcategories), but others
refer to the general population in a specified area. Estimates will not be valid, though, if those
most vulnerable to malaria cannot be reached for an interview, making traditional population-
based surveys inappropriate for highly unstable areas or populations. Techniques exist for
overcoming this problem, notably respondent-driven sampling (RDS, described below), but
estimates derived from RDS cannot be easily merged with those from other sampling frames.

Do you have reliable information on where MMPs live and work and where they
are most vulnerable to malaria? Can you project where they will be during the
lifetime of upcoming grants?
You must have this information (especially estimates of the future) to obtain adequate grants
and to plan services and commodities. However, “guesses” may not be easy to quantify because
MMPs are often “hidden” or so highly transient that numbers are a mere snapshot in time. Some
of the worst malaria outbreaks in recent years have occurred because of unexpected population
movements or because even well-anticipated changes could not be adequately quantified for
grant requests. Moreover, the total number of persons at heightened risk of malaria because
of forest work may be far greater than those present at any specific time, because of seasonal
turnover.

Mobility is not by itself a risk factor for malaria, but the places where mobile populations
go and the conditions they encounter there may be risky, especially if movement has been from
a low malaria transmission area to a high one (or the reverse for sick persons). Forest work
and plantation work during biting times are both high risk. So is sleeping rough in vulnerable
settings. Crossing a small river to another country may significantly reduce access to health
care – or perhaps increase it depending on destination. Living conditions, work environments,
mosquito species and biting behaviour, even the general prevalence of malaria in the region,
will all affect malaria vulnerability.

The types of surveys required for “migrant mapping” and risk analysis are very different
from those needed to produce population-based indicators. Risk analysis, moreover, may require
specialized epidemiological and entomological studies described elsewhere in this toolkit.

Do you know how to make services and preventive activities more effective for
MMPs?
Managers who know risk factors also need to know how to help MMPs to respond, through
both preventive actions and better case management. Do you know how to increase the
likelihood that forest workers will carry and use LLINs, or that persons with fever will respond
quickly and seek appropriate treatment? Do you know what MMPs are doing well now so you

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 5
 can encourage it without unnecessarily introducing unfamiliar concepts? Do MMPs trust the
public health system, or can it be modified so that they do? You may even want to know how
you can make your existing services more attractive to MMPs.

While specific risk factors will take time to change, as described above, there may be much
that can be done to improve services and educate MMP responses; managers need to know
the specific factors that make MMPs vulnerable to malaria.

¤¤ Where do MMPs work, and when (if at all) might they be exposed to infectious biting?
What do they do during evening biting hours, and do they sleep under an insecticide
treated bednet or hammock?
¤¤ What do MMPs know and do to prevent malaria, and where do they go for advice or
drugs when sick?
¤¤ If treatment-seeking behaviour is inappropriate, do managers and staff know why and
what can be done to improve it?
¤¤ Do managers understand underlying health beliefs and family and community interactions
that affect BCC messages and media as well as interpersonal communication?

Studies focused on service improvement may include numbers but are usually best if they
explore situations in depth using focus groups and key informant interviews. Such surveys
generate a wealth of qualitative information about specific MMPs and settings but may be difficult
to generalize to those living differently. Many studies have been done but the programmatic
responses they provide are local and may be difficult to generalize to other settings.

Do you know how to reach MMPs before they enter high-risk areas and after
they return?
MMPs are commonly studied at their destination points rather than at their points of origin, yet
at destinations they are often remote, isolated from services and perhaps “illegal” or otherwise
cut off from authorities. Malaria (and especially artemisinin resistance) is particularly concentrated
along borders, yet the health care context – the “migrant system” (Smith and Whitaker) (see
Figure 1) – often changes dramatically at just the point when it needs to be at its strongest.
Forest-based workers returning to their places of origin, whether internal or across borders, may
carry resistant parasites to home clinics where there is limited malaria expertise.

Analyses that encompass the full range of MMP movements may help to:

¤¤ Reach MMPs before they embark on transit, to advise on malaria risks and possibly to
distribute LLINs
¤¤ Identify potential sources and agents for BCC during transit (buses, taxis)
¤¤ Identify “touch points” in transit, where LLINs might be distributed or emergency care
offered
¤¤ Strengthen services close to MMP destinations
¤¤ Prepare public health services and families at points of origin to receive MMPs and
respond to possible illness.

6 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 Figure 1:

A very important reason for knowing more about personal movements, especially in
artemisinin-resistant areas, is to guide creation of post-treatment surveillance systems for malaria
patients who may move on within the 28-day follow-up period.

2.2 Ask if a formal study is the best way to get required information
It is vitally important to malaria elimination worldwide that we learn more about MMPs in this
region and share that information with others. It is even more important that we strengthen
services; and the time and money that we spend on research may be excessive if it detracts
from services. As a manager, you must set priorities.

One example of existing information is that held by locally based staff who may
know a great deal about MMP movements and risks but have not been encouraged
to communicate it.

Your first option may be to try to use existing information, especially if it has been neglected
in past decision-making:

¤¤ Do lower level staff feel empowered to take action based on local knowledge, and can
ways be found to increase upward communication?
¤¤ Might enhanced internal communication (perhaps stimulated by small grants and
technical support) produce more useful information than a formal study?

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 7
 Who are the primary data users? Is your
audience local, regional or global?

What operational use do you expect to make

of results? Do you just want to know some-
thing, or do you plan to do something?
2nd:
If a formal study
is the best way How quickly do you need results? What
resources do you have available (money,
to get required people, transport)?
information,
then...
Can information be updated or general-
ized using routine data sources?

What study approvals will be required?

¤¤ Would greater national attention to routine surveillance data and HMIS yield significant
information and encourage better reporting?
¤¤ Can cooperative enterprise managers tell you their plans so that you can project labour
flows?
¤¤ Is it even possible that security forces could confidentially alert health authorities to
changes in official and family movements, including periodic cycling between low- and
high-transmission areas?

Some of this – especially the last – may be unlikely but is worth considering before approving
a study. Note also:

¤¤ Studies can be costly and time consuming. Results may be outdated by the time they
become available.
¤¤ Because studies are infrequent and “special,” they may attract multiple owners
(i.e., try to serve too many purposes at once) OR to become so “controlled” as to
become “unnatural.”

At the end of the day, you may well need a formal study, but it is important to know why
and to sort out perhaps conflicting objectives before proceeding to design.

2.3 Consider methodological options

While refined methodological design is best left to research experts, managers should know
the basic choices that have to be made and provide overall guidance. Your objective will be
to get required answers as quickly as possible, at least cost in funds and staff time; whereas a

8 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
researcher’s mandate is to maximize validity and reliability. These interests are both very important
and not inherently incompatible, but compromises may be unavoidable. Broadly speaking, there
are several methodological options:

¤¤ Questionnaire-based surveys
¢¢ based on defined geographic areas (e.g., artemisinin resistance Tier 1)
¢¢ focused on defined population groups (e.g., plantation workers, forest workers)

¤¤ Migrant mapping
¢¢ Comprehensive mapping
¢¢ Employment-based mapping
¢¢ Epidemiological studies
¢¢ Entomological assessment

¤¤ Programme effectiveness studies

¢¢ Ethnographic approaches
¢¢ Participatory rural appraisal, positive deviance models
¢¢ Key informant interviews/focus group discussions
¢¢ Health systems research
¤¤ Analyses of migrant systems

These options are more fully described in Annexes 1–4.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 9
 Note that a major issue in each case is how to get a representative sample of MMPs (especially
in settings where they are “hidden” or transitory).

Table 1: Common study objectives and options for malaria surveys among MMPs:

If your objective is... And you need to... Then consider this... And these issues...

To measure popula- Report to donors Professionally de- • How to include

tion-based indicators signed survey with MMPs in sample
special samples for • How to ensure that
MMPs survey “captures”
Guide local engage- Community-designed MMP needs
ment and commu- questionnaire repre- • How to ensure
nity participation senting all population results are timely
segments • How to ask ques-
tions in MMP
languages
To know where vulner- Plan grant proposals, Migrant mapping; em- • How to identify
able MMPs live and locate facilities, de- ployer/owner surveys MMP clusters
work and how many velop HR plans, order • How to estimate the
are there at different commodities number of MMPs
seasons • How to predict
Target services to Epidemiological stud- rapid changes and
the most vulnerable ies; entomological modify budgets
population groups assessments when needs change
• Are GPS data pos-
sible?
To improve service Develop national Studies of health-seek- • What risk factors
quality and effective- BCC strategies and ing behaviour, based increase malaria
ness (including BCC) messages on a representative vulnerability?
sample • Do LLIN distribution
Strengthen local Participatory rural procedures reach
programmes and appraisal, positive MMPs?
outreach for specific deviance models, • Do BBC approaches
groups process improvement reflect MMP set-
approaches tings? and options?

To strengthen continu- Plan services and Interviews with MMP • Can study design
ity of prevention and BCC at points of key informants regard- include neighbour-
treatment services origin, transit, and ing places of ing cross-border
destination, including origin, transportation districts; also low-
cross-border and routes and methods, transmission points-
interdistrict collabora- and seasonality of-origin?
tion • How can forest-
goers be reached
Same as above but Process improvement before they travel to
for specific popula- models remote areas?
tion groups • Will study results
affect services at
touch-points in low
transmission transit
areas?

10 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 3. Overview of different study methodologies

The rest of this toolkit provides an overview of different study methodologies and how they
can help you achieve your desired objectives. Details of each suggested approach is given in
Annexes 1–4.

3.1 If your objective is to generate quantitative indicators…

Population-based surveys can be very attractive – and are sometimes essential – but they can
also be misleading if based on inappropriate samples or poorly designed questionnaires. They
are usually the only way to measure household-level rates and ratios because they generate
numerators and denominators at the same time, but the families that can be easily reached for
surveys are often not the ones with the weakest access to health care. Some difficulties can
be overcome at the community level and through specialized sampling techniques, but even
specialists may find the challenge difficult if population groups are ill-defined or uncertain.

What information do
What models can you draw from?
surveys produce?
If your ob- Whether focused on There are few examples of population-based
jective is to geographic areas (e.g., quantitative surveys, but most cover geographic
generate quan- MARC Tier 1) or defined areas that include MMPs rather than focusing
titative indica- population groups (e.g., specifically on MMPs; those covering geograph-
tors… plantation employees), sur- ic areas may not reliably represent MMPs:
veys produce quantitative
• Malaria indicator surveys: Recent ex-
indicators, normally stated
amples include the MARC baseline survey
as proportions, e.g., 60%
of children under-five sleep (2011) and the Cambodia Malaria Survey
under LLINs. (2013). Sampling focused specifically on
MMPs is often not possible.
• % of mobile persons
who used an ITN the • Respondent-driven sampling (RDS); with
last time they slept in appropriate techniques, can be used to
transmission areas estimate the number of MMPs of different
categories (http://www.respondentdrivens-
• % of mobile population ampling.org/reports/RDSsummary.html).
with fever in the last 3
months who accessed • Employment-based surveys: Places of em-
parasite-based diagnosis ployment (especially farms and plantations)
may offer easy sampling frames for some
• % with reported fever elements of the MMP population, but only
in the past 2 weeks and those who are officially employed. Those
who had any test for who are most difficult to reach – unregis-
malaria.
tered migrants and individual entrepreneurs
(This is not a complete list). (tree-cutters, miners, etc.) remain unrepre-
sented.
• Community surveys: Community-based
forest-goers are an important component
of the mobile population and can easily be
interviewed within their household of perma-
nent residence.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 11
 3.2 If your objective is to identify MMP clusters, target those most at
risk and quantify seasonal numbers
Any programme that specifically aims to serve MMPs must know where vulnerable people move,
live and work; and they should know roughly how many people are at risk. Since both locations
and numbers are in constant flux, they should have data on seasonal ebbs and flows as well as
predictions that should outlast donor grant cycles. While it may be relatively “easy” to identify
large “authorized” employers and family-owned farms, it may be much harder to map:

¤¤ Short-lived seasonal or opportunistic clusters

¤¤ Informal entrepreneurs
¤¤ Individual forest-goers, some local and some from distant locations or countries
¤¤ Groups that do not want to be known
¤¤ Non-State actors
¤¤ Military
¤¤ Armed groups in rebellion.

Obviously not every person who travels is at risk of malaria, nor is every enterprise employing
MMPs likely to generate malaria. Irrespective of personal behaviour (discussed below), some
environments are inherently risky and others not. Malaria specialists speak of “hot spots”
(locations with much malaria) and “hot pops” (population groups such as MMPs who appear
especially vulnerable). Spots are identified through epidemiological analyses, environmental
and epidemiological studies, and enterprise surveys (discussed here); “pops” can be identified
through behavioural studies (discussed below).

What information do What models can you draw from?

surveys produce?
If your While not all mapping • Comprehensive migrant mapping: Com-
objective is studies do everything, be- prehensive studies attempt to identify every
to identify low is a list of information location. Where MMPs congregate and to
MMP clusters, that they may produce: obtain estimates of MMP numbers. Researchers
target those • GPS-marked locations obtain lists of registered enterprises and ask lo-
most at risk, of MMP settlements cal government authorities about other known
and quantify (“clusters”) as well as locations. They then ask informants to estimate
seasonal temporary areas of population sizes, including family members,
numbers. activity (tree-cutting, although one study from Cambodia com-
stump clearing, infor- mented that farm owners do not keep accurate
mal mining) records. Enterprises which exceed authorized
employment levels, moreover, may significantly
• Estimates of MMP underreport population size. Migrant mapping
numbers, ideally show- provides a snapshot in time and is most useful
ing seasonal ebbs and when linked to routine updates.
flows as well as future
projections

12 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 What information do What models can you draw from?
surveys produce?
• Locations of health • Employer surveys: Mapping need not be
service facilities and comprehensive to be useful, especially in areas
drug-sale outlets, both where most economic activity occurs in large
public and private enterprises. Enterprise owners, while perhaps
initially distrustful, may respond well to ef-
• Roads, river transport
forts to support employee health services and
networks and forest
other collaboration. (Unauthorized enterprises
access points
may be less open, however.) Larger employ-
• Malaria incidence in ers may have good estimates of their labour
different locations force, though perhaps not of family members
or seasonal flows. Additional measures may be
• Locations of forest,
needed to estimate future employment levels.
cleared land, mosquito
breeding areas • Epidemiological analyses: Epidemiological
analyses can highlight areas of high or increas-
• Species and biting
ing malaria transmission and others where
behaviour of malaria
malaria risks are low. Similar but perhaps less
vectors.
reliable information may come from key infor-
mants.
• Ecological studies: Malaria rises, falls (and
may later increase) with development, start-
ing low when forests are left standing, rising
significantly when they are cut, and then falling
(perhaps dramatically) when the land is cleared.
Depending on subsequent development, more
modest increases may follow, especially if mo-
bile workers return and economic activity (e.g.,
rubber tapping) occurs at night. Managers need
ecological information on specific local areas,
but they may not require a special study.
• Entomology studies: See separate discussion
in the entomology chapter of this toolkit.

3.3 If your objective is to improve programme effectiveness...

MMPs are real people, not just numbers, and their personal characteristics and environments
are highly varied. MMPs typically differ from settled populations, moreover, and may speak
unfamiliar languages, requiring information-based efforts to adapt to programmes. Studies
that gather such information often rely heavily on qualitative techniques, probing for unique
factors that are difficult to quantify; however, many gather quantitative data as well (although
sometimes with small samples). Such studies often focus on individual MMP groups, sometimes
those working in a limited range of economic enterprises, to facilitate in-depth analysis of risk
and behaviour factors.

Studies intended to make programmes more effective for MMPs consider community
perceptions, practices and behaviour, and the quality and accessibility of services. Up to
11 subcategories of MMPs have been identified (see Surveillance chapter), with each requiring
a specialized mix of malaria prevention and treatment services. Programme effectiveness studies

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 13
 aim to clarify the optimum mix by refining BCC, community health programmes, and clinic services
and locations; ideally they should lead to improved quality in the private sector as well. Numerous
small information gathering efforts (not necessarily “studies”) may be required because of the
diversity of local conditions and MMP clusters. Most studies attempt to link demand and supply
factors while concentrating data collection on one side or the other.

What information do surveys

What models can you draw from?
produce?
If your Studies primarily focused on Programme-specific information normally
objective is MMPs typically gather informa- comes from routine information systems,
to improve tion on individual (as opposed to including programme assessments and
programme ecological) risk factors, including: supervision visits; but there may be times
effectiveness. when special studies are appropriate.
• Access and health care seek-
ing behaviour • Immersion approaches: Anthropolo-
gists study population groups by living
• Knowledge of malaria, its among them, learning their language,
causes and prevention and actually participating in (not just
enquiring about) their daily lives. Malaria
• Housing conditions
researchers cannot normally afford the
• Exposure to infectious biting time and patience required, so they ask
questions of representative subgroups
• Preventive behaviours, espe- (focus groups) and people who know
cially use of LLINs about them (key informants).

• Language and literacy • Community surveys, participatory ap-

praisals: Community surveys, mentioned
• Access to media including earlier, use questionnaires to request the
BCC messages information (listed in the column on the
left of this table). One such approach,
Once they have identified groups
Participatory Rural Appraisal (PRA), ap-
and gained trust, focus group
plies a basket of tools (e.g., mapping,
discussions and key informant
ranking, seasonal calendars, timelines)
interviews can be used to learn
to engage residents, generally over a
more, often using open-ended
number of days. Another, called Positive
questions to benefit from unan-
Deviance (PD), directly links self-discovery
ticipated information.
with behaviour change. These methods
(An alternative technique – one are not generally called studies but can
not based on formal research – if documented produce much useful
is to simply talk informally with information.
people, either at a clinic or in
• Drug outlet surveys: Surveys of
their temporary settlements.)
locations where anti-malarials may be
Direct assessments of BCC and obtained usually focus on private sellers
services commonly studied: but sometimes include the public sector
as well. This can also entail drug avail-
• BCC: Content, quality, lan- ability, as well as drug quality (including
guage and media presence of substandard and counterfeit
drugs).
• Health workers: Number, skills
and location of those trained
in malaria and referral/treat-
ment

14 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 What information do surveys
What models can you draw from?
produce?
• Private sector: Availability and • Programme assessments: These are
quality of outlets and clinics, not “studies”, as defined here; but some
including diagnostic and treat- combine user perspectives as well as
ment services offered and supply factors. Programme evaluations
drugs sold consider service quality and outreach,
and BCC.
• Public sector: Quality of case
management and prevention • Net preference studies: While quantita-
services, including dependabil- tive studies measure how many MMPs
ity of supply systems use preventive measures, and other stud-
ies (not described here) measure their
Note that the best studies look clinical effectiveness, studies that directly
at supply and demand factors link LLIN supply with demand for and
together, coming up with mea- use of nets can reveal a great deal about
sures and predictors of utilization MMP malaria-related knowledge and
behaviour. These can use key informants
or more community-based studies.

3.4 If your objective is to improve continuity...

Once MMPs approach their “final” destinations, their need for health services may increase – at
just the point where accessibility decreases. Accessibility may decrease because MMPs go to
remote places that local people avoid, or because officials may be indifferent or hostile. The
employers who hire some of them, and the freelance middlemen who buy forest products from
others, may see little to gain in providing health care. While “movement” and “systems” have
been implicit in most migrant studies, few outside the HIV arena have given equal attention to
points of origin, movements and support systems within single countries and on both sides of
international borders (Smith and Whittaker). Studies that give equal attention to both sides of
international borders may be particularly necessary but difficult.

It is recognized that there is a need to reach MMPs and the groups who have contact with
them at their points of origin (and return), as well as in transit if possible; and some innovative
programmes have evolved when this has occurred. The need for continuity will only increase as
programmes enter into elimination phase, and individual cases may need 28-day follow-up to
ensure treatment efficacy. Links are also required with employers, transporters and MMP “touch-
points” (places where MMPs have contact with people and facilities who might help them).

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 15
 What information What models can you draw
do surveys produce? from?
If your Information is needed about MMP Few systems models are available,
objective is origins, destinations and plans although partial approaches are
to improve for return; also about modes of common. MMPs are commonly
continuity. . transport. Information about studied at their destination points
publicly accessible “touch-points” rather than at their places of origin
can be invaluable. (“Touch-points” (perhaps asking about home districts
are locations and facilities that can and movements), yet at destinations
dispense advice and provide services. MMPs are commonly remote, isolated
Examples include retail outlets, from services and sometimes “illegal”
“friendly” border posts, screening or otherwise cut off from authorities.
points, and perhaps local government Interviews at destinations
facilities that might not normally (predeparture) are appropriate and
serve MMPs.) For formally employed useful, but may miss important groups
workers, information on recruitment of “hidden” migrants.
networks and company-provided
transport can be very helpful. Predestination data sources may
produce additional information about
Points of origin for seasonal MMPs how MMPs may be reached before
may serve later as destinations when departure and during transit. Sources
they return; and the capacity of may include employer recruitment
public health facilities for diagnosing offices and transport operators.
and treating any illness they
might carry is critically important. As noted above, capacity
Information is needed about skills, assessments within local public
equipment and drug availability at health facilities on both sides of the
this level. border (origin and destination) are
likely to be useful as well.

16 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 4. Information to action

The studies encouraged in this toolkit are primarily intended to guide action, either immediately or
through information sharing leading to collective regional strategies. Localized study approaches
– for example, participatory rural appraisal and BCC design activities – may be so action-focused
that they are not commonly identified as research. Others – large population-based surveys, for
example – require clear presentations to policy–makers as well as regional dissemination using
common indicators and definitions. Study designers should consider action issues before data
collection begins. Several recommendations might enhance data-based action:

For programme managers:

¤¤ Identify and prioritize study objectives before initiating design; do not turn this decision
over to researchers.
¤¤ Identity and involve intended data users and implementers in design discussions.
¤¤ Encourage simple cross-disciplinary designs, including participatory approaches where
appropriate.
¤¤ Take every reasonable step to encourage prompt approval and implementation of
studies, noting that outdated information will not be useful.
¤¤ Require prompt reporting with recommendations, but do not overinterpret preliminary
results.

For researchers:
¤¤ Understand and respect the programmatic lead, even if ideas differ from yours.
¤¤ Engage national and local staff in all phases. Identify one or more co-investigators from
national programmes.
¤¤ Design cross–disciplinary studies that clarify operational issues, even if they are less
useful for theory; give higher priority to practical issues rather than theory.
¤¤ Define variables respecting regional consensus; explain operational definitions when
interpretations are required.
¤¤ Link “special” data collection with routine information systems so that findings can be
updated and extended to new area.
¤¤ Consider simple implementation “tools” to help programme staff adapt findings to
local circumstances.
¤¤ Analyse and promptly report study results, noting that conference presentations are
insufficient. Results presented at international meetings or in professional journals may
not reach people quickly on the ground. Even low-cost local studies are likely to be of
interest within and across national borders, and should be reported in writing.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 17
 Dissemination of study results (even for “simple” studies) should be done in ways that add
to the growing regional knowledgebase on MMPs, and could be facilitated by WHO. Studies
that define important variables operationally should clearly describe key elements so that
others may compare results. Studies that were mainly intended to solve local problems should
report the way in which information was gathered so that others may adapt them.

18 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 5. The decision-tree algorithm

In developing a decision-tree algorithm, a suggested simplified but essential flow of questions

are suggested below:

1. Do you have essential data that you need to report to your stakeholder(s)/ donor(s)?
a. If yes, consider a survey to better identify migrant locations and numbers (question 2).
b. If population-based data are a high priority, look first for existing data:
i. Community surveys
ii. NGO project reports
c. If data are still needed, consider a population-based survey
i. General population-based survey
ii. Employer-based survey
iii. Community surveys or surveys

2. Do you have reliable information on where MMPs live and work as well as their numbers,
and can you project where they will be several years from now?
a. If yes, consider a qualitative survey (question 3).
b. If not, are you mostly missing recent arrivals and transient populations (requiring only
key informant interviews)?
c. Or do you need a comprehensive study?
i. Migrant mapping
ii. Employer-based survey

3. Do you have the information you need to adapt service delivery and BCC to MMP needs
and preferences?
a. If services are as effective as you think they can be, consider an MMP systems analysis
(question 4).
b. If not, consider a qualitative study among “accessible” MMPs
i. ethnographic study
ii. community survey of malaria-related knowledge and behaviour
iii. Focus group discussions and key informant interviews

4. Do you know how to reach MMPs before they enter high-risk areas and after they return?
a. If yes, work with partners to strengthen continuity of care
b. If not, develop a systems analysis with multiple partners

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 19
20
If population-based data are a high If data are still needed, consider a
priority, look first for existing data: population-based survey
i. Community surveys i. General population-based survey
ii. NGO project reports ii. Employer-based survey
Do you need to report population-based iii. Community surveys or surveys
data to your stakeholder(s)/ donor(s)?

If not, are you mostly missing May require only key informant inter-
recent arrivals and transient popula- views
Do you have reliable infor-
mation on where MMPs tions?
live and work as well as
their numbers, and can Or do you need a comprehensive
you project where they study?
If yes, you have this information
will be several years from i. Migrant mapping
already, then consider a qualitative
First decide on your now? survey ii. Employer-based survey

primary objective
If population-based data are a high
Do you know how to priority, look first for existing data:
make services and preven-
i. If yes, work with partners to
tive activities more effec-
If services are already as effective as strengthen continuity of care
tive for MMPs?
you think they can be, consider an ii. If not, develop a systems analysis
MMP systems analysis with multiple partners

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
Do you know how to reach MMPs before i. Ethnographic study
they enter high-risk areas and after they If not, consider a qualitative study ii. Community survey of malaria-related
return? among “accessible” MMPs knowledge and behaviour
iii. Focus group discussions and key
informant interviews
 Annex 1
Systems analyses

What they are?

Systems analyses are efforts to “move beyond a focus on mobile populations as a demographic
group towards approaching and responding to mobility as a multifaceted system.” (Smith and
Whittaker). Elements of this system include multiple population groups, official and unofficial
authorities, economic sectors, and network groups (including transportation). HIV programmes
have worked within this broader framework, with significant impact on service outreach and
performance. Similar analyses for malaria are less common; when done, they should include
efforts to describe repeated movements from originating points to destinations, as well as the
interactions MMPs have with touch points between them.

What information should they produce?

Once MMPs approach their “final” destinations, their need for health services may increase – at
just the point where accessibility decreases. Accessibility may decrease because MMPs go to
remote places that local people avoid, or because officials may be indifferent or hostile. The
employers who hire some of them, and the freelance middlemen who buy forest products
from others may see little to gain in providing health care. Use of public health facilities (when
available) may entail long travel and absence from sources of income, making self-treatment
more likely. Services may be better if and when MMPs return to home communities, but most
health systems make no provision for continuity of care, especially across international borders.

What should malaria control programmes know about MMP movements and potential access
to care?

¤¤ Points of origin and transit, including prior periods of short-term residence

¤¤ “Recruitment” method (how information about destinations is obtained and who
provides it)
¤¤ Onward destinations, which may or may not be places of origin
¤¤ Recruitment networks, including employer offices, which facilitate MMP entry into
mobile systems
¤¤ Border crossing points, if any
¤¤ Forest entry points and routes (including roads, rivers and paths)
¤¤ Shops, facilities, people and offices along the way that interact with MMPs and might
provide BCC or referral
¤¤ Modes of transport, including the people who interact with MMPs
¤¤ Quality of health facilities and outlets (public and private) that may serve MMPs at
destination points

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 21
 ¤¤ Referral systems, if any, to maintain contact with recently-treated MMPs once they
move on
¤¤ Malaria preparedness of health facilities at MMP places of return.
While many studies gather some or all of this information, few do so with the aim of strengthening
contacts prior to and after destination points.

What are some recent examples in this Region?

¤¤ MMP survey at destinations: Respondent-driven sampling on the Thailand-Cambodia
border. Can malaria cases be contained in mobile migrant workers? RDS study on
frequency of return: Cambodian and Myanmar mobile workers interviewed in eastern
Thailand about places of origin and frequency of return. Cambodians came from
provinces across that country, whereas those from Myanmar were more concentrated.
Some Cambodians visited their country frequently (up to 72% in the past three months),
and 32% to 68% said they would eventually return; by contrast, most workers from
Myanmar had never returned there, and only 4% had plans to do so.
¤¤ MMP survey upon return: Situational Assessment on the Health of Cambodian Irregular
Migrants Study of Cambodians deported from Thailand: This is a study of Cambodians
recently deported from temporary migration to Thailand or Vietnam, with comparison
groups drawn from the settled population at both border treatment. Most migrants
report harsh treatment in the neighbouring country, partly due to their irregular status.
¤¤ Mapping of migrant system: NGO attempting to strengthen BCC and services for
forest goers analysed transport routes (including rivers), brokers, and “touch points”
where malaria prevention and treatment might be strengthened.

Tools
Advantages and disadvantages
¤¤ Information about MMP contacts before entering high-risk area is very important for
preventive outreach.
¤¤ People who have contact with even “hidden” MMPs may provide referrals and even
treatment, if managers know who they are.
¤¤ Transit routes and modalities, if known, provide excellent opportunities for BCC.
¤¤ Information about public health facilities at places of return may guide quality
improvements.
¤¤ Cross-border studies may facilitate joint cross-border planning and implementation, but
only if financial resources and political approvals are in place.

Recommendations
Use systems model as a tool for encouraging cross-border and multisectoral collaboration, but
do not prioritize a study if there is no ability to act on findings.

22 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 Annex 2
Programme effectiveness studies

What they are?

Programme effectiveness studies look at both user and supply-side factors with an aim to
increase coverage and appropriate use. On the demand side, they are an effort to “know the
people better,” to understand how their living and working conditions, as well as their access
to and use of health care, affects malaria; a common objective, for example, is to improve BCC
and use of LLINs. On the supply side, programme effectiveness studies may involve BCC and
programme assessments as well as studies of private sector outlets. Most studies consider both
demand and supply factors, but concentrate information collection in one or the other. At least
two techniques link information–gathering directly to programme improvement.

What information should they produce?

Programme effectiveness studies typically generate information about community malaria
risks, knowledge about malaria, use of LLINs, what people do when sick, and so forth. In the
case of MMPs, they may capture significant information about housing conditions, population
movements, and access to health facilities. From the supply side, they look at BCC messaging
and media, malaria worker training and placement, and importantly, private drug sellers and
treatment services.

What are some recent examples in this Region?

Studies of this nature are frequent, as they must be because the many MMP groups vary widely.

¤¤ Immersion approaches: Malaria and population dynamics in Cambodia; Ethnographic

investigations in three remote areas (Bourdier): Authors spent approximately 10
days each in Pailin, Samlaut and Trapaeng Prasat (in their words) to “have a deeper
understanding of the social mechanisms underlying the population’s behaviour.” They
looked particularly at “1) migration patterns . . .from original homelands to the new
temporary adopted places; 2) ways of insertion and relations; 3) the place of health
issues in a complex set of perceived risks in day-by-day life; 4) responses and attitudes
towards health problems and visible symptoms: therapeutic associations, access to care
and treatment from self-medication to health services.”
¤¤ Community surveys: Malaria baseline community survey of ethnic minority groups
in five provinces of Lao PDR: Community-based survey in five southern Lao provinces
to support BCC. Researchers interviewed 900 households in 60 villages, asking 72
questions based on four themes. (i) General village information, (ii) knowledge and
understanding of malaria, (iii) prevention of malaria and (iv) health-seeking behaviour.
They also conducted separate focus groups with community leaders, men and women;
and key informant interviews with district health authorities, health workers and health
volunteers.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 23
 ¤¤ Community surveys: An Assessment of the Malaria Knowledge, Treatment-seeking
Behaviours and Preventive Practices among Mobile and Migrant Populations in Western
Cambodia based on a Respondent Driven Sampling Approach: Study used RDS to
identify MMPs in four rural locations and ask about malaria knowledge, prevention
and treatment-seeking behaviour. Most respondents heard or saw health messages on
radio, TV and billboards and through family and friends. Sleeping habits made most
respondents vulnerable to mosquito bites. Despite low health insurance coverage, most
respondents sought treatment for their most recent illness. Study results “provided real
insights into how the programme can be adapted and better targeted to the difficult-
to-reach populations... Improved and targeted prevention and control strategies are
needed for mobile populations (more specifically forest-goers and farm workers), such
as expanding the distribution of long-lasting insecticide treated hammock nets and
repellents...”.
¤¤ Participatory appraisal.
¤¤ Drug outlet surveys: ACTWatch Cambodia Outlet Survey, 2013: Survey of public
facilities and private outlets where anti-malarial drugs could be obtained. Information
concerned current and recent availability of all drugs by type, including artesunate
monotherapy and chloroquine.
¤¤ Programme assessments: Assessing Access to Malaria Prevention and Treatment
Resources among Mobile Workers and Migrants in Tak Province, Thailand: Study in Tak
Province, along Myanmar border. Information obtained from 62 qualitative interviews
(in three languages), including eight focus group discussions, 31 community in-depth
interviews, 11 key informant interviews, and 10 in-depth interviews with health providers.
Seasonal calendars (SC) were developed through focus groups and with migrant workers
from a commercial farm.
¤¤ Net preference studies.

Tools
¤¤ Questionnaires, discussion guides
¤¤ Community calendars and timelines
¤¤ Numerous others depending on context

Advantages and disadvantages

¤¤ Programme effectiveness studies are essential for adapting services and BCC to specific
MMP subcategories.
¤¤ MMP diversity and rapid environmental changes necessitate frequent replication of
simple study models. Larger studies should identify common concerns and develop
simple tools to guide managers in gathering location-specific information.
¤¤ Participatory approaches may link directly to process improvement, but require expert
facilitation.

24 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 ¤¤ Qualitative studies offer insight into the diversity of MMP conditions but are less useful
than quantitative studies in tracking changes over time and for reports to donors.

Recommendations
¤¤ Studies should be small, quick and as participatory as feasible; but should then be
replicated for individual subpopulations.
¤¤ Dissemination should be in the form of information guides and study tools as well as
recommendations for service and BCC improvement.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 25
 Annex 3
Population-based surveys

What they are?

Population-based surveys gather data on household and personal knowledge, beliefs and practices
– in this case regarding malaria prevention and treatment and general health-related behaviour.
They are an effort to quantitatively measure the attributes of a defined population, and as such
they require a statistically robust sample. Robust sampling in turn requires clear identification
of the population of interest – something that is usually difficult for MMPs.

What information should they produce?

Surveys produce quantitative indicators, normally stated as proportions, e.g., 60% of children
under five sleep under LLINs. Examples of indicators under current discussion in GMS include:

¤¤ % of households that own an LLIN

¤¤ % of households that own at least one LLIN for every two persons
¤¤ % of respondents knowing that LLINs can prevent malaria
¤¤ % of households at risk of malaria with at least one long-lasting insecticidal net/
insecticide-treated net and/or sprayed by IRS in the past 12 months
¤¤ % total population sleeping under an ITN/LLIN the previous night
¤¤ % of mobile people who used an ITN the last time they slept in transmission areas
¤¤ % of respondents who could name any ACT
¤¤ % of mobile population with fever in the last 3 months who accessed parasite-based
diagnosis
¤¤ % with reported fever in the past 2 weeks and who had any test for malaria.
(This is not a complete list. Please consult ERAR and Global Fund principal recipients for updated
guidance.)

What are some recent examples in this Region?

¤¤ Myanmar Artemisinin Resistance Containment Project Baseline survey, Final
report: In early 2012, the Department of Medical Research of Lower Myanmar
conducted a baseline survey in Tier 1 and 2 areas for the Myanmar Artemisinin Resistance
Containment (MARC) project, including a household questionnaire among other tools.
As stated in the summary, the purpose “was to assess the overall malaria prevalence in
the containment areas (Tier 1 and Tier 2), to assess and monitor the availability of oral
artemisinin monotherapies . . . and to serve as baseline for the MARC strategic and
Monitoring and Evaluation Framework.” Samples for the household component were
drawn from “a list of all registered and unregistered families in the village obtained

26 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 from local authorities, with additional information provided by village based volunteers
wherever possible.”
¤¤ Respondent-driven sampling on the Thailand-Cambodia border II. Knowledge,
perception, practice and treatment-seeking behaviour of migrants in malaria
endemic zones: RDS was used to select 1719 respondents representing two
subcategories of MMPs (Cambodian and Myanmar) in Thai areas bordering Cambodia.
The authors summarize the methodology as follows: “Health care workers and survey
staff from each study area were trained in RDS methodology. The teams then chose six
initial participants, or ‘seeds’ in the target community at each study site. These seeds
received three uniquely numbered and identifiable coupons to recruit other participants
in the community. Those participants, once interviewed, received 2–3 coupons to recruit
additional participants, and the survey continued in this way until the required sample
size was reached. The social network size was defined as all migrants living in the same
community that the participant knew by first name or vice versa, and with whom they
had met in the previous month.” Respondents were questioned about migration histories
and malaria knowledge and practices.
¤¤ Malaria community survey of ethnic minority groups in five provinces of Lao
PDR: Researchers interviewed 900 households in 60 villages, asking 72 questions based
on four themes. (i) General village information, (ii) knowledge and understanding of
malaria, (iii) prevention of malaria, and (iv) health-seeking behaviour. They also conducted
separate focus groups with community leaders, men and women; and key informant
interviews with district health authorities, health workers and health volunteers.

Tools
¤¤ RBM Malaria Monitoring and Evaluation Reference Group (MERG): Household survey
indicators for malaria control
¤¤ PMI Malaria BCC Indicator Reference Guide
¤¤ Closed and open-ended questionnaires
¤¤ Respondent Driven Sampling Analysis Tool v. 5.6.0 (RDSAT)

Advantages and disadvantages

¤¤ Quantitative indicators essential for measuring change and comparing regions. Major
donors require them as a condition for grants.
¤¤ On the other hand, standard sampling frames and procedures only work for stable
populations and may not produce valid or reliable estimates for MMPs.
¤¤ Cross-sectional and longitudinal comparisons, moreover, may be less useful for MMPs
than for other groups because contexts are highly variable and change rapidly.
¤¤ “Creative” sampling procedures (RDS, employment-based samples) are recommended
for MMP surveys, but RDS in particular requires expert guidance and cannot cover a
large area.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 27
 ¤¤ Community surveys extremely valuable for local data but rarely suffice for donor
reporting.

Recommendations
¤¤ Give highest priority to satisfying donor requirements, but start by seeing if available
data sources satisfy immediate needs.
¤¤ If survey is required, use creative sampling approaches (e.g. RDS) to represent all
population groups.
¤¤ Consider community surveys but primarily for local measurements.

28 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 Annex 4
Migrant mapping and risk analysis

What is it?
Migrant mapping is an effort to determine where migrants live and work, including efforts to
quantify their numbers. “Migrant” is variably defined to include both temporary and “permanent”
residents; it may or may not include seasonal workers, but ideally should include every visitor,
short or long term, who may need malaria prevention and treatment services. A first stage is
normally to identify MMP “clusters”: farms and plantations, mines, areas of forest clearance, new
settlements, military encampments and so forth. A second step is to estimate population sizes.

Not every mobile subgroup is of significant risk of malaria, hence the need for risk analyses
based on epidemiology, entomology and livelihood assessment.

Mapping should ideally include GPS coordinates to show roads, clinics and other points of access.

What information should it produce?

Whether comprehensive (covering everyone) or employer-based (more limited), migrant mapping
identifies locations where MMPs live and work (“clusters”) and attempts to estimate their
numbers. It also shows the location of roads, health facilities, and other resources, ideally on
detailed maps. Results augment those available from typical household registration and census
counts to show the total number of people needing malaria services and where they live and
work. If reflective of planned developments and hiring, they will also indicate where movements
or settlements might occur during the full duration of a planning or donor funding cycle.

What are the methodological options?

¤¤ Full mapping exercise: identification and mapping of MMP clusters; estimation of
population sizes and seasonality; mapping of roads, clinics and other infrastructure
¤¤ Employer survey: Mapping focused on identifiable employers and estimated labour force
¤¤ Epidemiological analyses: Identification of hot spots and “hot pops”
¤¤ Entomological assessments: (See toolkit chapter on entomology)

What are some recent examples in this Region?

¤¤ Full mapping exercise: Malaria on the Move. Mapping of Population Migration and
Malaria in the South-Eastern Region of Myanmar (IOM). In 2011–2012, the International
Organization for Migration (IOM) undertook a comprehensive MMP mapping exercise
in eastern Myanmar, aiming to locate migrant pockets; estimate the size of MMPs and
their demographic composition; assess migration patterns; and identify factors related
to malaria risk and vulnerability. The primary focus was on locating settlements, a
stepwise process starting with local officials. A total of 3805 clusters were found in 21

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 29
 townships, of which 59% were temporary; of 1.12 million residents in the area, 13%
were MMPs. Authors recommended that future studies should: define MMPs in the
context of malaria; map the entire migration processes from departure, transit, arrival
and return as well as associated risks of malaria; assess work environments rather than
occupations to determine malaria risk/vulnerability; and integrate qualitative methods.
Information should be obtained from the MMPs themselves, moreover, rather than
through “expert opinions.”
¤¤ Employer survey: National Mapping Survey of Plantations and Private Companies
in Cambodia (PSI): Researchers obtained lists of land concessions from the Ministry
of Agriculture, Forestry and Fisheries and identified other enterprises using snowball
techniques. In addition to mapping, the study attempted to determine the peak number
of workers by season/month, as well as the availability and accessibility of health
services. Authors noted, however, that “the lack of worker lists on many sites and the
ebb and flow of workers on a daily basis, means that these data should be interpreted
as indicative and not absolute. What is clear is that the number of workers employed
at any one time fluctuates dramatically and while some enterprises have extremely
well-organized systems for recording the number of permanent and seasonal workers
on site, others appear to have much weaker systems to track this data.”
¤¤ Epidemiological analysis: Malaria Burden and Artemisinin Resistance in the Mobile
and Migrant Population on the Thai–Myanmar Border: Epidemiological analysis of 12
years of Shoklo Clinic medical records. Data covered Myanmar migrants and refugees
on both sides of the Thai-Myanmar border.

Tools
¤¤ See attached data collection form
¤¤ Handheld geographic positioning system (GPS)
¤¤ Census data

Advantages and disadvantages

Migrant mapping exercises are difficult but invaluable. They are difficult because many of
the MMP “clusters” most vulnerable to malaria are also those least likely to be recognized by
government authorities because they are isolated, “unofficial,” or perhaps too transitory to
register. As noted in the PSI Cambodia study quoted above, many enterprises rely on transient
labour, or are too small to warrant official attention. For some purposes, predictions of future
population movements may be more useful than retrospective analyses, especially in areas
prone to rapid change.

Recommendations
Better information on the location and movements of MMPs is essential for planning, proposing
and reporting; hence, some effort at identifying settlements and estimating populations must
be part of every operational plan. Since change is rapid, simple and easily replicated, techniques
are preferable to big studies.

30 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 Bibliography

Studies of MMP mobility and malaria risk factors

1. ACTWatch. “ACTWatch Study Reference Document, Cambodia Outlet Survey, 2013”
2. Allen, Denise Roth and Eugenie Poirot. Assessing Access to Malaria Prevention and Treatment
Resources among Mobile Workers and Migrants in Tak Province, Thailand. Centers for Disease Control
and Prevention, Atlanta. 2012
3. Bourdier, Frédéric, Chea Bunnary and Taing Sok Penh. Institut de recherche pour le developpement,
“Malaria and population dynamics in Cambodia Ethnographic investigations in three remote areas
(Pailin, Samlaut andTrapaeng Prasat), 2010
4. Carrara VI, KM Lwin, Phyo AP, Ashley E, and Wiladphaingern J.” Malaria Burden and Artemisinin
Resistance in the Mobile and Migrant Population on the Thai–Myanmar Border, 1999–2011: An
Observational Study.” PLoS Med 10(3): e1001398. doi:10.1371/journal.pmed.1001398. 2013.
5. Indochina Research (Laos). Malaria baseline community survey of ethnic minority groups in five
provinces of Lao PDR. Undated meeting presentation
6. International Organization for Migration. “Situational Assessment on the Health of Cambodian
Irregular Migrants,” 2011
7. Jitthai, Nigoon. MIGRATION AND MALARIA: Knowledge, Beliefs, and Practices among Migrants in
Border Provinces of Thailand. International Organization for Migration, 2012
8. Jitthai, Nigoon. Malaria on the Move. Mapping of Population Migration and Malaria in the South-
Eastern Region of Myanmar. International Organization for Migration, 2012
9. Khamsiriwatchara, Amnat, Piyaporn Wangroongsarb, Julie Thwing, et al.: “Respondent-driven sampling
on the Thailand-Cambodia border. I. Can malaria cases be contained in mobile migrant workers?”
Malaria Journal 2011 10:120
10. Kingdom of Cambodia. “Cambodia Malaria Survey, 2010”
11. Kingdom of Cambodia. “Cambodia Malaria Survey 2013: Survey Protocol”
12. Kingdom of Cambodia. Ministry of Planning. Migration in Cambodia: Report of the Cambodian Rural
Urban Migration Project (CRUMP). August 2012.
13. Kingdom of Cambodia. “Workshop on Research Relating to Mobile Migrant Populations and Access
to Diagnosis and Treatment: Summary Report. 2012
14. Leslie, Glaister and Muhammad Shafique. “Positive deviance: an innovative approach to
15. improve malaria outcomes in Myanmar; Preliminary Evaluation Results.” Malaria Consortium 2014
16. Li, Nana, Daniel M. Parker, Zhaoqinq Yang, et al.”Risk factors associated with slide positivity among
febrile patients in a conflict zone of north-eastern Myanmar along the China-Myanmar border.”
Malaria Journal 2013 12:361
17. Ly, Po, et al. “An Assessment of the Malaria Knowledge, Treatment-seeking Behaviours and Preventive
Practices among Mobile & Migrant Populations in Western Cambodia based on a Respondent Driven
Sampling Approach.”

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 31
 18. Malaria Consortium. “Report of the Greater Mekong Sub-Region Malaria Operational Research
Symposium,” 2010
19. Malaria Consortium. An Innovative Approach to improve malaria outcomes among mobile and
migrant workers in Cambodia: The Positive Deviance Process. 2011
20. Moore, Sarah J, Xia Min, Nigel Hill, Caroline Jones, Zhang Zaixing and Mary M Cameron, “Border
malaria in China: knowledge and use of personal protection by minority populations and implications
for malaria control: a questionnaire-based survey.” BMC Public Health 2008, 8:344 doi:10.1186/1471-
2458-8-344
21. Myanmar Artemisinin Resistance Containment Project Baseline survey, Final report
22. Ngoun, Chea, Julie Thwing, Colleen McGinn, Top Samphor Narann, Seshu Babu Vinjamuri, Najib
Habibullah, Po Ly. “An exploratory study on the mobility and work patterns of internal migrants in
Western Cambodia based on a respondent-driven sampling approach.”
23. Pindolia et al: “The demographics of human and malaria movement and migration patterns in East
Africa.” Malaria Journal 2013 12:397.
24. PSI. National Mapping Survey of Plantations and Private Companies in Cambodia. 2013
25. Smith, Catherine and Maxine Whittaker. “Beyond mobile populations: a critical review of the literature
on malaria and population mobility and suggestions for future directions,” 2014
26. Sudathip, Prayuth. “Final Report of Research on Migrants classification and their treatment seeking
behaviours in artemisinin resistant areas in Thailand, 2013
27. Tipmontree, Rungrawee, Wijitr Fungladda, Jaranit Kaewkungwal, MA Sandra B Tempongko and Frank-
Peter Schelp. “Migrants and malaria risk factors: a study of the Thai-Myanmar border”. Southeast
Asian Journal of Tropical Medicine and Public Health. Vol 40 No. 6. 2009
28. Vryheid, Robert. Phuket Migrant Workers Malaria Rapid Qualitative Appraisal Report for Phuket
Elimination Project in Phuket, Thailand. 2011.
29. Wai et al.: Spatial distribution, work patterns, and perception towards malaria interventions among
temporary mobile/migrant workers in artemisinin resistance containment zone. BMC Public Health
2014 14:463.
30. Wangroongsarb, Piyaporn, Wichai Satimai, Annat Khamsiriwatchara, et al. “Respondent-driven
sampling on the Thailand-Cambodia border. II. Knowledge, perception, practice and treatment-seeking
behaviour of migrants in malaria endemic zones.” Malaria Journal 2011 10:117.
31. Wangroongsarb, Piyaporn, Prayuth Sudathip and Wichai Satimai. “Characteristics and malaria
prevalence of migrant populations in malaria-endemic areas along the Thai-Cambodian border.”
Southeast Asian Journal of Tropical Medicine and Public Health, Vol. 43:2, 2012
32. Xu, Jian-Wei, Qi-Shang Xu, Hui Liu, and Yi-Rou Zeng. “Malaria treatment-seeking behaviour and related
factors of Wa ethnic minority in Myanmar: a cross-sectional study.” Malaria Journal 2012 11:417.

Indicator frameworks
1. MEASURE Evaluation. Household survey indicators for malaria control, 2013
2. President’s Malaria Initiative. “Malaria BCC Indicators Reference Guide,” 2014
3. UNOPS. Monitoring and Evaluation Plan for the Regional Artemisinin Initiative (RAI). 2014

32 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
4. World Health Organization, et. al. “Bi-Regional Malaria Indicator Framework: Monitoring and
Evaluation of Malaria Control and Elimination in the Greater Mekong Subregion,” January 2011

Strategies for mobile populations

1. Benach Joan, Charles Muntaner, Carlos Delclos, Maria Mene´ndez, and Charlene Ronquillo. “Migration
and Low-Skilled Workers in Destination Countries.” PLoS Med 8(6): e1001043.doi:10.1371/journal.
pmed.1001043. 2011
2. Chantavanich, S., C. Middleton and M. Ito (eds.). On the Move: Critical Migration Themes in ASEAN.
Bangkok, International Organization for Migration and Chulalongkorn University–Asian Research
Center for Migration, 2013. Editors Supang Chantavanic
3. Davies, Anita, Rosilyne M Borland, Carolyn Blake, and Haley E. West. “The Dynamics of Health and
Return Migration. PLoS Med 8(6): e1001046. doi:10.1371/journal.pmed.1001046. 2011.
4. Edwards, Hannah Margaret, et. al.” Novel cross-border approaches to optimise identification
of asymptomatic and artemisinin-resistant Plasmodium infection in mobile populations crossing
Cambodian borders”
5. Gushulak, Brian D. and Douglas W MacPherson. “Health Aspects of the Pre-Departure Phase of
Migration.” PLoS Med 8(5): e1001035. doi:10.1371/journal.pmed.1001035. 2011.
6. Hall, Andy. Myanmar and Migrant Workers: Briefing and Recommendations. Mahidol Migration
Center, Institute for Population and Social Research. Mahidol University, April 2012
7. Informal Consultation on Improving Access to Malaria Control Services for Migrant/Mobile Populations
In the Context of the Emergency Response to Artemisinin Resistance In the GMS, Yangon Myanmar.
April 2014
8. International Organization for Migration. Guidelines on the prevention and control of malaria for
migrants in Myanmar. 2012
9. Lynch, Caroline and Cally Roper. “The Transit Phase of Migration: Circulation of Malaria and Its
Multidrug-Resistant Forms in Africa.” PLoS Med 8(5): e1001040. doi:10.1371/journal.pmed.1001040.
2011.
10. Malaria Consortium. “Workshop to Consolidate Lessons Learned on BCC and Mobile/Migrant
Populations in the Strategy to Contain Artemisinin Resistant Malaria,” 2011
11. The malERA Consultative Group on Monitoring, Evaluation, and Surveillance. “A Research Agenda
for Malaria Eradication: Monitoring, Evaluation, and Surveillance.” PLoS Medical 8(1), 2011
12. Technical Consultation on Improving Access to Malaria Control Services for Migrant/Mobile Populations
in the context of the Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion,
May 22-23, 2014, Hanoi Vietnam
13. Vietnam. Ministry of Planning and Investment General Statistics Office. Vietnam Population and
Housing Census 2009 Migration and Urbanization in Vietnam: Patterns, Trends and Differentials.
14. Zimmerman, Cathy, Ligia Kiss, and Mazeda. Hossain. “Migration and Health: A Framework for 21st
Century Policy-Making.” PLoS Med 8(5): e1001034. doi:10.1371/journal.pmed.1001034. 2011.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 33
 Other studies and analyses
1. Cambodia. Ministry of Planning. Migration in Cambodia: Report of the Cambodian Rural Urban
Migration Project (CRUMP). August 2012.
2. Hickey, Jason, et al. “Pandemic preparedness: perceptions of vulnerable migrants in Thailand
3. towards WHO-recommended non-pharmaceutical interventions: a cross-sectional study,” BMC Public
Health 2014, 14:665 doi:10.1186/1471-2458-14-665
4. International Organization for Migration. Country Mission in Thailand and Asian Research Center
for Migration. Assessing potential changes in the migration patterns of Myanmar migrants and their
impacts on Thailand, Chulalongkorn University2013
5. Liu, Yaobao, Michelle S. Hsiang, Weiming Wang, et al. “Malaria in overseas labourers returning to
China: an analysis of imported malaria in Jiangsu Province, 2001–2011.” Malaria Journal 2014 13:29.
6. Nithipanich, Juthamas. Beliefs and Rituals of “Khwan” in Tai Khoen Community in Khengthun, Shan
State, Republic of the Union of Burma. Mekong Institute, Research Working Paper Series 2012
7. Pindolia, Deepa K. Andres J. Garcia, Zhuojie Huang, et al. “Quantifying cross-border movements and
migrations for guiding the strategic planning of malaria control and elimination.” Malaria Journal
2014 13:169.
8. Steel, Zachary, Belinda J. Liddell, Catherine R. Bateman-Steel, and Anthony B. Zwi. “Global Protection
and the Health Impact of Migration Interception.” PLoS Med 8(6): e1001038. oi:10.1371/journal.
pmed.1001038. 2011
9. Tse, Julia, “Mapping Local Effects of Globalization in China: 21st-Century Migration Flows from
Southeast Asia to Yunnan Province,” Proceedings of the National Conference On Undergraduate
Research (NCUR) 2013 University of Wisconsin La Crosse, WI April 11 – 13, 2013
10. Yang, Bo, Hua Guo, Yi Yang et al. “Modeling and mining spatiotemporal patterns of infection risk
from heterogeneous data for active surveillance planning.” 2014.
11. Yin J-h, M-n Yang, S-s Zhou, Y. Wang, J. Feng. “Changing Malaria Transmission and Implications in
China towards National Malaria Elimination Programme between 2010 and 2012.” PLoS ONE 8(9):
e74228. doi:10.1371/journal.pone.0074228. 2013.

Other documents not considered MMP study reports

1. Back Pack Health Worker Team, Provision of Primary Healthcare among the Internally
2. Displaced Persons and Vulnerable Populations of Burma
3. Benach Joan, Charles Muntaner, Carlos Delclos, Maria Mene´ndez, and Charlene Ronquillo. “Migration
and Low-Skilled Workers in Destination Countries.” PLoS Med 8(6): e1001043.doi:10.1371/journal.
pmed.1001043. 2011
4. Aung Min and Kudo, K. “New Government’s Initiatives for Industrial Development in Myanmar” In
Economic Reforms in Myanmar: Pathways and Prospects, edited by Hank Lim and Yasuhiro Yamada,
BRC Research Report No. 10, Bangkok Research Center, IDE-JETRO, Bangkok, Thailand. 2012
5. Behaviour Change Communications Review and Strategy Development: Workshop for Malaria Global
Fund-Single Stream Funding Partners, March 2012
6. Brown, Tyler, Linda Smith, Eh Kalu Shwe Oo, et al. “Molecular surveillance for drug-resistant
Plasmodium falciparum in clinical and subclinical populations from three border regions of Burma/

34 Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations
 Myanmar: cross-sectional data and a systematic review of resistance studies”. Malaria Journal 2012
11:333.
7. Canavati, Sara, Chea Nguon, Philippe Guyant, Arantxa Roca-Feltrer and Shunmay Yeung. Strategy
to address migrant and mobile populations for malaria elimination in Cambodia. Malaria Consortium,
2013
8. Chantavanich, S., C. Middleton and M. Ito (eds.). On the Move: Critical Migration Themes in ASEAN.
Bangkok, International Organization for Migration and Chulalongkorn University–Asian Research
Center for Migration, 2013. Editors Supang Chantavanic
9. Cox, Jonathan and Steven Mellor. “Malaria surveillance strengthening in Myanmar: Implementation
plan,” Malaria Consortium 2014
10. Lowe, David and Caroline Francis. Protecting People on the Move: Applying Lessons Learned in Asia
to improve HIV/AIDS interventions for mobile people. Family Health International, 2006
11. Maltoni, Bruno. Migration in Cambodia: Internal vs. External Flows, 8th ARPMN Conference on
“Migration, Development and Poverty Reduction”, in Fuzhou (China), 25-29 May 2007
12. Roll Back Malaria Partnership, “Malaria-Endemic Countries Unite to Extend Malaria Control to Hard-
To-Reach Migrant and Mobile Communities,” Undated press release.
13. Roll Back Malaria, “Multisectoral Action to Defeat Malaria,” 2013
14. Steel, Zachary, Belinda J. Liddell, Catherine R. Bateman-Steel, and Anthony B. Zwi. “Global Protection
and the Health Impact of Migration Interception.” PLoS Med 8(6): e1001038. oi:10.1371/journal.
pmed.1001038. 2011
15. Technical Consultation on Improving Access to Malaria Control Services for Migrant/Mobile Populations
in the context of the Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion,
May 22-23, 2014, Hanoi Vietnam
16. University Research Corporation, “Malaria Control in Cambodia: Building a Community-based
response,” August 2010.
17. “Workshop for Harmonization of Cross-Border IEC/Behaviour Change Communication Strategies in
Thailand,” Nonthaburi, June 2012
18. World Health Organization, “A situational analysis of malaria and migration in the Greater Mekong
Subregion in the context of Artemisinin Resistance” DRAFT
19. Zimmerman, Cathy, Ligia Kiss, and Mazeda. Hossain. “Migration and Health: A Framework for 21st
Century Policy-Making.” PLoS Med 8(5): e1001034. doi:10.1371/journal.pmed.1001034. 2011.

Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations 35
The studies encouraged in this toolkit are primarily intended to guide action, either
immediately or through information sharing leading to collective regional strategies.
Localized study approaches for example, participatory rural appraisal and BCC design
activities may be so action-focused that they are not commonly identified as research.
Others large population-based surveys, for example require clear presentations to
policy makers as well as regional dissemination using common indicators and definitions.
Study designers should consider action issues before data collection begins.
This toolkit is targeted more to programme managers rather than to researchers. Its
objective is to help managers oversee and manage the surveys component within their
programme strategy, decide the kind of study that would be most useful for them, based
on grant applications to be made or reported, programmatic decisions to be made or
problems to be solved. The toolkit follows a decision-tree format, asking important
questions and recommending study approaches based on answers. It presents
methodological choices and present examples from recent reports.

Decision-tree framework for

selecting study methods for
malaria interventions in mobile
and migrant populations

World Health House

Indraprastha Estate,
Mahatma Gandhi Marg,
New Delhi-110002, India
www.searo.who.int SEA-MAL-278