Community awareness and health providers' perspectives on zoonotic Plasmodium knowlesi malaria in Thailand: A mixed-methods assessment

Abstract

BACKGROUND: Plasmodium knowlesi poses an emerging challenge for malaria control in Southeast Asia due to its zoonotic nature, diagnostic complexity and lack of species-specific control strategies. These factors complicate both prevention and case management efforts. Understanding both community awareness and healthcare provider perspectives is critical for informing targeted responses. This study aimed to assess awareness of P. knowlesi malaria among at-risk community members in southern Thailand and to explore contextual challenges through qualitative insights from healthcare providers, including provincial officers, district-based malaria control staff, and village health volunteers. METHODS: An explanatory sequential mixed-methods design was employed between April and May 2025. A cross-sectional survey of 300 adults residing in three P. knowlesi-endemic districts was conducted using a structured questionnaire that included eight items assessing overall awareness. Descriptive statistics, violin plots, and multivariable generalized linear modeling were used to identify factors associated with awareness scores. Subsequently, semi-structured interviews were conducted with 28 healthcare providers across various administrative levels. Qualitative data were thematically analyzed. RESULTS: Overall awareness of P. knowlesi malaria was moderate (mean score: 10.7/23; SD ± 2.9; range: 3.0-20.0). Female individuals, living farther from health facilities, receiving malaria-related health education, and having higher attitude scores were significantly associated with increased awareness (p < 0.05). Healthcare providers reported a decline in P. knowlesi incidence, alongside persistent transmission risks in forested areas. Health education efforts were largely reactive, delivered following case detection, but often included information about monkey-to-human transmission. CONCLUSIONS: Awareness of P. knowlesi malaria remains suboptimal among high-risk populations, particularly among men, those who had received limited health education, and individuals with poor attitudes toward malaria. Integrated, proactive, and male-focused health promotion strategies are essential to enhance community knowledge and support disease control efforts.