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

## TL;DR

This study explores how well Thai communities and healthcare providers understand zoonotic malaria caused by Plasmodium knowlesi, finding moderate awareness and suggesting targeted education efforts.

## Contribution

This is the first study in Thailand to assess community awareness and healthcare provider perspectives on P. knowlesi malaria using mixed methods.

## Key findings

- Community awareness of P. knowlesi malaria was moderate, with women and those who received health education showing higher scores.
- Healthcare providers reported operational challenges like delayed diagnosis and ineffective control strategies for zoonotic transmission.
- Targeted health education for men and forest-exposed populations is needed to improve disease control.

## Abstract

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.

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.

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.

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.

Zoonotic malaria caused by Plasmodium knowlesi, a parasite naturally carried by monkeys, is an emerging public health concern in Southeast Asia. In Thailand, the number of reported P. knowlesi cases has increased in recent years, particularly in forested areas near the borders with Malaysia and Myanmar. However, little is known about how well at-risk communities understand this disease or how prepared the healthcare system is to respond. This study is the first in Thailand to explore both community awareness and healthcare provider perspectives on P. knowlesi malaria. Using a mixed-methods approach, we surveyed 300 adults living in areas with known P. knowlesi cases and interviewed 28 healthcare workers involved in malaria control. We found that community awareness was moderate, with women and those who had received malaria-related health education showing higher scores. Healthcare providers reported operational challenges, such as delayed diagnosis and limitations of current control strategies that were not designed for zoonotic transmission. Our findings highlight the need for targeted health education, especially for men and forest-exposed populations, and improved strategies to address the unique risks of monkey-to-human malaria transmission. These results can help inform national policies as Thailand moves toward its malaria elimination goals.