General characteristics of participants

The general characteristics of 391 study participants were assessed. The findings revealed that the majority of the participants were female (50.6%) and had completed primary school education (60.1%). More than one-third (44.5%) were household heads. Over half of the participants (51.9%) had migrated to the area over a decade ago, and a significant portion (59.6%) had previously experienced malaria. Most participants were aged 36 years or older (79.3%). Furthermore, nearly 90% were engaged in farming or gardening (92.8%) and the majority were married (90.3%). Most participants lived in households with 1 to 6 family members (89.0%), with an average household size of 4 and the median also being 4 (Table 1).

Knowledge about malaria

Participant’s knowledge regarding malaria was thoroughly evaluated. Nearly all participants (98.5%) identified mosquito bites as the primary cause of malaria. However, misconceptions persisted, with some believing that drinking stagnant water (29.9%) or living in the forest (37.3%) could cause malaria. Furthermore, a significant majority (92.3%) correctly identified the mosquito species responsible for malaria transmission. In term of diagnosis, approximately half of the participants consulted healthcare professionals (46.5%) or underwent blood tests (57.8%) to confirm malaria infection. However, about one-third (38.9%) relied on recognizing symptoms to determine if they had malaria. Most participants correctly identified fever (85.2%), chills and rigor (96.4%), and headache (82.6%) as the main symptoms of malaria. Nearly all participants (98.7%) adhered to prescribed treatment from healthcare providers. While most participants (96.4%) advised using mosquito nets as a preventive measure, a small fraction believed that avoiding drinking water in the forest (4.9%) could prevent malaria. Additionally, the majority (85.9%) suggested using mosquito repellents to prevent mosquito bites. Participants were well aware of the possibility of malaria reinfection (96.2%) even after previously being cured. A significant proportion (41.9%) acknowledged that persistent malaria-like symptoms, even after treatment, might be due to poor treatment adherence (58.1%) or severe infection (46.0%) (Table 2).

Attitudes toward malaria

Table 3 presents the participants’ attitudes toward malaria. Nearly all acknowledged the severity of malaria and agreed that they were susceptible to infection (98.2%). They also agreed that malaria could be fatal (91.6%) and that wealth status was unrelated to the risk of infection (94.9%). Most participants recognized the importance of completing treatment (93.9%) and emphasized the safety of antimalarial drugs (43.5%). More than two-thirds of participants supported preventive measures such as IRS (84.7%), while some (35.8%) were aware that malaria was not confined to specific areas. However, a significant number of participants (46.3%) were uncertain about the potential adverse effects of combining malaria medication with foods such as durian.

Malaria prevention and treatment practices

Table 4 outlines the study participants’ practices regarding malaria prevention and treatment. More than three-quarters of participants (76.0%) had experienced malaria before the study. Among those with a history of malaria, the majority sought treatment at hospitals (72.1%) or malaria clinics (57.6%) and completed their prescribed treatment (99.3%). However, a proportion (17.9%) admitted to stopping their medication once symptoms subsided. Regarding preventive measures, participants mainly used bed nets (94.1%) and mosquito repellents (88.8%). Other strategies, such as burning leaves and wood, to produce smoke to repel mosquitoes (55.2%) or using mosquito coils (18.9%), were also employed. Personal protective measures, such as wearing long sleeves (36.5%) or insecticide-treated clothing (23.5%), were less commonly practiced. Most participants believed that malaria could be eradicated from their villages (76.7%) through collaboration between healthcare workers (80.1%) and community members (87.5%).

Overall knowledge, attitude, and practice levels and associated factors with poor levels

Participants’ KAP regarding malaria prevention and treatment were categorized as “good” or “poor” based on their scores. The results revealed that over half of the participants demonstrated a good level of knowledge (56.5%) and attitudes toward malaria prevention and treatment (54.2%). Additionally, a significant majority of the participants (69.6%) had good preventive and treatment practices (Fig. 2).

Overall malaria knowledge, attitude, and practice levels (n = 391).

Table 5 presents an analysis of the associations between the general characteristics of study participants and their KAP levels regarding malaria prevention and treatment. The findings revealed that gender, marital status, educational attainment, and role in the family did not significantly affect knowledge levels. However, participants aged 36 to 50 years (53.9%), engaged in non-forest-related occupations (57.7%), with fewer than six family members (46.0%), who had recently moved (46.8%), or who had uncertain malaria histories (70.8%) were more likely to exhibit poor knowledge levels compared to other groups. Furthermore, the logistic regression indicated that participants aged 36 to 50 years (aOR: 1.7, 95%CI: 1.0–2.9) and those without a history of malaria (aOR: 2.2, 95%CI: 1.4–3.4) or with uncertain malaria histories (aOR: 4.6, 95%CI: 1.8–11.5) were more likely to have poor malaria knowledge.

Regarding attitude levels, participants with higher education (61.5%), non-forested-related occupations (76.9%), and uncertain malaria histories (70.8%) exhibited poorer attitudes towards malaria prevention and treatment compared to other groups. Participants engaged in non-forest-related occupations (aOR: 4.3, 95%CI: 1.7–11.0) and those with uncertain malaria histories (aOR: 1.1, 95%CI: 1.1–7.1) were more likely to have poor attitudes.

For practice levels, participants aged 36 to 50 years (42.9%), with higher education (41.0%), non-forest-related occupations (42.3%), large families (44.2%), or no history of malaria (51.9%) or undetermined malaria histories (79.2%) exhibited poor practices. Three variables showed higher odds of poor practices: aged 36 to 50 years (aOR: 1.8, 95%CI: 1.0–3.2), large families (aOR; 2.0, 95%CI: 1.0–4.0), or no history of malaria (aOR: 7.1, 95%CI: 4.3–11.7), or uncertain malaria histories (aOR: 24.9, 95%CI: 8.7–71.5) (Table 5).

Community acceptability of Ivermectin MDA and its associated factors

This study assessed the acceptability of ivermectin MDA among study participants. The results showed that the vast majority (96.4%) were willing to participate in ivermectin MDA, while only a small proportion (2.5%) expressed reluctance (Fig. 3). Multivariable logistic regression analyses identified two variables significantly associated with higher acceptability: employment in forest-related occupations (aOR: 4.2, 95% CI: 1.1–16.1), and the belief that malaria could be eliminated from the village (aOR: 9.1, 95% CI: 2.8–29.9) (Table 6).

Reported community acceptability towards Ivermectin mass drug administration (n = 391).

Reasons for non-participation in each round of MDA

In addition to the primary survey, the study team reviewed official MDA attendance records for all 3,137 eligible individuals in the nine study villages. These programmatic data provided insight into the actual coverage achieved during each round of ivermectin MDA. Participation declined across the rounds: 78.6% in round 1, 69.7% in round 2, and 70.8% in round 3. Table 7 summarizes the main reasons for non-participation in each round of MDA. In the first round, more than half (54.3%) of non-participants were absent without providing a specific reason. Absenteeism continued to be a key factor in rounds two and three, with over one-third absent during each round. Reluctance to take ivermectin increased over successive rounds, with 22.3%, 45.1%, and 50.3% of non-participants citing unwillingness. Other reasons included illness, pregnancy, relocation, or mild adverse effects experienced in earlier rounds. Therefore, surveying a subset of participants from the target population may not fully capture the perspectives of the entire population.

After excluding non-participants, over half (59.0%, n = 1,852) of eligible individuals completed all rounds of ivermectin MDA. An additional 15.0% (n = 471) completed two rounds, and 12.0% (n = 375) participated in just one round. In contrast, a small proportion (14.0%, n = 439) missed the entire campaign. Notably, while 5.1% and 8.9% completed the first round but missed the second or third rounds. Interestingly, a few (1.2–4.4%) participated in later rounds despite missing the first round of MDA (Table 8).