Community perspectives on mass malaria vaccine and drug administration in the Chittagong Hill Tracts, Bangladesh: a qualitative study

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.