Navigating Malaria in a Border Zone: A Qualitative Study of Behavioural Determinants, Structural Barriers and Elimination Challenges in Tak Province, Thailand

BACKGROUND: Malaria elimination in the Greater Mekong Subregion (GMS) is still struggling with barriers in border regions, where population mobility, occupational exposure, and health system fragility continue to drive ongoing malaria transmission. Tak Province is a typical example of such challenges along the Thailand-Myanmar border. Qualitative evidence of the lived experience of frontline health actors is crucial for the design of contextually placed elimination strategies. METHODS: This qualitative descriptive study was conducted in Khane Chue Subdistrict, Mae Ramat District, Tak Province, a malaria-endemic area bordering Myanmar. A total of 17 informants participated: 13 village health volunteers, two health workers and two non-governmental organization staffs. Semi-structured instruments were developed to suit each group of participants and used to guide the in-depth interviews. Reflexive thematic analysis was used to analyse data, applying both deductive and inductive coding. RESULTS: Five factors related to malaria prevention behaviours were identified: cross-border mobility and migration; occupational exposure of agricultural and forest workers; a knowledge-behaviour gap related to malaria risk normalization and availability of free treatment; lifestyle routines that coincide with peak vector biting hours; socioeconomic and environmental vulnerability. Five programmatic bottlenecks were also prominent: funding cuts after USAID's exit, human resource shortages and low rates of compensation for community health workers (CHWs), fear-based avoidance of health care services by undocumented migrants, poor uptake of long-lasting insecticidal nets and compounding external shocks such as Myanmar's political instability and COVID-19 pandemic. CONCLUSION: Malaria control in this border area is influenced by the interaction of many behavioural, environmental, and health system determinants on multiple levels. To achieve elimination will need migrant-inclusive health policies, occupation-specific vector control, active surveillance for a prolonged period, cross-border programmatic coordination and stable financing. Findings provide specific recommendations for health planners in similar border contexts in Southeast Asia.