Bipin Adhikari

Background: Community engagement is increasingly recognised as an essential element of health research in underserved settings, yet limited evidence describes how engagement strategies are designed, adapted, and implemented during large-scale intervention trials. This implementation case study describes the development, implementation, and iterative adaptation of a stakeholder and community engagement strategy embedded within a field trial of mass vaccination and drug administration (MVDA) for malaria elimination in Bangladesh. Methods: The cluster-randomised, open-label trial was conducted across 100 villages (~12,000 people) in the Chittagong Hill Tracts, Bangladesh. The paper draws on implementation records, field observations, meeting reports, and structured team reflections generated during programme delivery to describe the engagement process, key adaptations, implementation challenges, and lessons learned. Results: Early stakeholder engagement informed a context-specific engagement strategy that emphasised collaboration with village leaders, culturally tailored communication, responsiveness to community concerns, and integration of basic healthcare support. Throughout implementation, engagement activities were iteratively adapted in response to community feedback, rumours, seasonal livelihood demands, and local cultural and religious beliefs. These iterative approaches were followed by continued engagement across remote and culturally diverse communities, although persistent challenges included geographical isolation, social and political factors, complex trial messaging, competing livelihood priorities, and concerns regarding vaccination, including fears about fertility. Conclusions: Community engagement functioned as an adaptive and responsive process rather than a fixed intervention. These experiences provide transferable lessons for designing stakeholder and community involvement strategies for complex health research conducted in underserved and culturally diverse settings.

Background: Antimicrobial resistance (AMR) is an important health threat in Southeast Asia, where over-the-counter (OTC) antibiotic sales remain widespread. However, the ethical tensions shaping these informal dispensing practices remain underexplored. Methods: Thirty in-depth interviews were conducted among community members, drug dispensers, and healthcare providers in Siem Pang district, northeast Cambodia to explore local perceptions of antibiotic use and the ethical dilemmas surrounding OTC sales. Participants were recruited through purposive and snowball sampling. Coding and thematic analysis were conducted in NVivo 15. Results: Five major themes were identified. Firstly, knowledge and perceptions of antibiotics, their use, and AMR revealed a limited understanding of antibiotic mechanisms and AMR. Secondly, perceived accessibility versus perceived safety of OTC antibiotics as financial and logistical barriers to formal care made informal sources more attractive despite perceived risks. Thirdly, collective versus individual health, whereby treatment decisions prioritize the perceived immediate needs of the individual or household over public health concerns. Fourthly, patient autonomy versus professional responsibility, as an emphasis on autonomy in informal care-seeking was not matched by reliable information or professional responsibility. Finally, justification and personal moral codes, through which informal dispensers framed selling antibiotics as socially responsible or economically necessary. Conclusion: Limited knowledge and financial pressures drive dispensers and consumers to prioritize individual needs over collective risk, sustaining informal OTC antibiotic use. Ethical tensions emerge within systemic constraints, highlighting that interventions must address both economic incentives and knowledge gaps.

Background: Elimination of Plasmodium vivax is challenging due to the dormant liver stages (hypnozoites), which can reactivate weeks or months after the primary infection, causing relapses and ongoing parasite transmission. Despite these challenges, P. vivax clinical case numbers have declined over the past decade in Cambodia. We used parasite genotyping to assess whether declines in reported case numbers were accompanied by changes in parasite diversity and relatedness among symptomatic infections. Methods: Genotyping was conducted on 296 symptomatic P. vivax isolates collected in eastern Cambodia in 2014, 2015, 2019, 2021, 2022, and 2023. A panel of 93 microhaplotype markers (vivaxGEN panel) was genotyped using Illumina. Population genetic measures were applied to determine infection diversity and relatedness (identity-by-descent [IBD]) each year. Results: A total of 289 (20–94 per year) samples were successfully genotyped. The percentage of polyclonal infections was 5% in 2023 compared to 29%–55% in earlier years (P < .05). The cases collected in 2023 also had the highest proportion of infections with IBD >0.95 with 1 or more other infections (81.4% vs 0%–22.3% in 2014–2022). In contrast, cases in 2022 showed higher frequencies of polyclonal infections (55%) and increased population diversity. Conclusions: Our findings illustrate the potential of microhaplotype genotyping to characterize temporal changes in the genetic composition of symptomatic P. vivax infections and to complement conventional epidemiological surveillance.

Introduction: Understanding community perspectives on malaria treatment and research participation is important for designing ethically appropriate community engagement strategies, strengthening informed consent, and improving the conduct of clinical research while supporting disease control. This study explores treatment-seeking behaviours, perceptions of malaria, and experiences of research participation among community members in the catchment area of a rural research clinic run by the Mahidol-Oxford Tropical Medicine Research Unit (MORU) in Siem Pang district, Cambodia. Methods: This qualitative study was conducted between July and September 2025. We conducted 15 semi-structured interviews and five focus group discussions (FGDs) with 40 purposively selected participants using maximum diversity sampling, including 19 participants previously enrolled in malaria clinical trials and 21 community members familiar with MORU’s research clinic within the Siem Pang Health Centre compound. All interviews and FGDs were conducted in Khmer, the national language of Cambodia. Interviews were audio-recorded, translated into English, transcribed verbatim, and analysed thematically. Transcripts underwent thematic analysis exploring knowledge of malaria, pathways to treatment, perceptions about research staff, and experiences of research participation. Results: Respondents reported heterogeneous understandings of malaria and its transmission, which were reflected in their explanatory models and accounts of treatment-seeking behaviour. We found that treatment choices were influenced by accessibility, cost, and perceived quality. Respondents perceived MORU’s research clinic as a specialized malaria treatment centre. Some described clinical trials as routine treatment services. Respondents reported staff as caring, cautious and thorough in treatment and follow-up. Participants generally described the research activities in the Siem Pang research clinic as trustworthy, effective, and compassionate. Participants reported that research participation provided improved access to care, and close follow-up, and viewed it as contributing to malaria elimination. Participants expressed strong support for the researchers’ continued presence and expansion into broader health research and education. Conclusions: Participants perceived the research unit as providing high-quality clinical care, reflecting their experiences of sustained interactions with the research clinic and its procedures. Participants’ narratives suggested features consistent with therapeutic misconceptions and may have promoted respondents’ liberal trust and participation. Researchers should be aware of the unintended consequences of ethical research practices in remote communities. Acknowledging misplaced trust could enable wider discussion for managing community members’ perceptions of clinical trials.

Antimicrobial resistance (AMR) is one of the defining public health challenges of the 21st century (Aslam et al. 2024). While resistance emerges naturally through evolutionary processes, human beha...

Johnson et al. offer a compelling ethical argument that physicians should prescribe shorter antibiotic courses for common uncomplicated infections, and that the “finish the course” mantra rests on ...

Objectives: Dissemination of study results to research participants is an ethical imperative, yet it is rarely implemented in resource-limited settings partly due to a lack of clear guidance. The purpose of this study was to evaluate and explore dissemination activities that were conducted as part of a multi-site clinical trial of Plasmodium vivax treatment options, informing future dissemination strategies in similar resource-limited settings. Design: Qualitative study using focus group discussions (FGDs) and an inductive–deductive thematic analysis approach. Setting: Clinical trial study site catchment areas in Cambodia, Ethiopia and Pakistan. Participants: Dissemination attendees were invited to participate in FGDs, a subset agreeing and able to participate. There were 25 participants in Cambodia, 34 in Ethiopia and 23 in Pakistan. Results: The dissemination activities were well accepted by participants despite some expectations in receiving individual results rather than only aggregated trial results and suggestions for broader community dissemination. Dissemination participants perceived having learnt from the dissemination, demonstrating their knowledge of the trial and its results and attributing it to the dissemination. Dissemination activities may have failed to correct certain misconceptions, including the blurred distinction between clinical care and trial-related care; however, the dissemination had positive impacts, including making participants feel part of a larger endeavour. Conclusion: Contributing to the limited data on dissemination in resource-limited settings, our findings provide context-informed recommendations that can be applied to similar settings. Our recommendations underscore the importance of tailoring activities according to participant preferences, such as potentially providing individual results and implementing broader community dissemination. Trial registration number: NCT04411836 .

Antimicrobial resistance (AMR) is a major global health threat spanning biomedical, social and ethical domains. Conventional stewardship and regulatory strategies, often vertical and clinically oriented, frequently overlook community realities and the systemic drivers of antimicrobial use. Focusing on low- and middle-income countries (LMICs), this review blends insights from the literature and authors’ experiential knowledge of working on AMR in LMICs and highlights community engagement as an essential yet underexplored component of AMR control. Community engagement encompasses complementary breadth-based approaches (e.g., awareness-raising activities and population-level communication) and depth-based approaches (e.g., community dialogue, coproduction, shared decision-making and accountability), together forming a ‘diagonal approach’ to developing locally relevant and sustainable AMR interventions. This approach integrates population-level communication with context-specific partnerships involving communities and other One Health stakeholders. Drawing on evidence from community engagement, ethics, health systems and One Health, we examine how integrated engagement approaches across various sectors can address the social and structural determinants of antimicrobial use while complementing stewardship efforts and health system strengthening. We argue that embedding meaningful community engagement within AMR policies and interventions can support equitable, context-sensitive and sustainable AMR governance and strengthen the long-term effectiveness of antimicrobial stewardship.

Introduction: Malaria remains a major public health burden in Bangladesh, particularly in the Chittagong Hill Tracts (CHT), where indigenous and marginalized populations face persistent transmission risks. The Mass Vaccine and Drug Administration (MVDA) trial is currently being implemented to accelerate malaria elimination. MVDA is socially complex because it involves administering preventive interventions to largely asymptomatic populations in contexts where trust, prior experiences, and sociopolitical factors strongly shape acceptance. Little is known about community perspectives toward such interventions. This study explored local understandings of malaria, health-seeking behaviours, and perceptions of mass vaccine and drug administration in the CHT to inform community engagement and implementation of MVDA. Methods: A qualitative study collected data using focus group discussions (FGDs), in-depth interviews (IDIs), and key informant interviews (KIIs) in Lama and Alikadam sub-districts of Bandarban among community members with no prior exposure to formal research activities. Participants were purposively selected using a maximum variation sampling approach to capture diverse perspectives across socio-demographic and stakeholder groups. Participants included community members, village leaders, traditional healers, local pharmacists, village health workers, religious leaders, and local government representatives. A total of 105 participants from heterogeneous backgrounds participated in this study between September and October 2024. Data were transcribed, translated, and underwent primarily inductive thematic analysis led by a trained qualitative researcher, a Bengali non-native to the study site. Interpretation was conducted reflexively, considering the researcher’s positionality. Results: Malaria was recognized as a recurrent illness, particularly during the rainy season and among traditional farmers. While awareness of malaria symptoms and prevention had increased through non-governmental and government initiatives, health-seeking behaviour remained pluralistic. Communities relied on traditional healers and informal drug sellers before seeking formal care. Village health workers provided malaria diagnosis and treatment but faced challenges of inconsistent services (e.g., irregular supply of health materials). The recent COVID-19 experience seemed to shape vaccine perceptions, with mandates, and adverse event narratives contributing to mistrust. Knowledge of a malaria vaccine was limited, yet participants expressed conditional acceptance, indicating willingness to participate if interventions were perceived as safe, effective, and transparently communicated. MDAs were viewed more positively than mass vaccine administration(s) although adherence, particularly among children and adults was considered a challenge. Trust in institutions and historical political mistrust emerged as key determinants shaping community attitudes toward MVDA. These findings informed the design of community engagement strategies accompanying the MVDA intervention. Conclusions: The success of MVDA depends on achieving high population coverage, which is contingent on trust, legitimacy, and effective community engagement. In socially and politically complex settings such as the CHT, implementation must be grounded in context-specific strategies that are responsive to local social and cultural dynamics and informed by community perspectives.

The Youth Advisory Group on Health and Research Engagement (YAGHRE) has been a collaborative initiative between school students and Mahidol Oxford Tropical Medicine Research Unit (MORU) staff in Siem Pang, Cambodia since 2021. Members provide input on health and research activities conducted by MORU. The main objective of this study was to explore key stakeholders’ perspectives on the YAGHRE. A total of 35 respondents participated in this study, including YAGHRE members (n = 14), teachers (n = 6), healthcare staff (n = 2), school students (n = 6), and family members (n = 7). Data were collected through focus group discussions and individual interviews. Thematic analysis was used to identify cross-cutting patterns in participants’ understandings, experiences, and recommendations related to YAGHRE. YAGHRE members were viewed as a link between MORU and the community for health promotion and engagement with research. Participation in YAGHRE seemed to foster members’ confidence, communication, and digital literacy. Parents and teachers also reported improvements in members’ leadership and youth-led engagement activities. The knowledge and skills acquired were shared with families, peers, and community members, potentially enhancing awareness of health and hygiene. The participatory nature of YAGHRE, where members planned activities with MORU staff seemed to have cultivated a sense of ownership. YAGHRE was perceived as a transformative platform for youth skill-building and health education, strengthening community–research partnerships and local health and research capacity in rural Cambodia. Our engagement model suggests how community-based research and engagement can simultaneously advance scientific goals, build local capacity, and strengthen public trust through participatory approaches.