Cost, Discrimination Are Common Barriers to Malaria Prophylaxis Among US Travelers to West Africa

Malaria may not be a serious issue in the United States, but efforts to prevent its spread seem to be running into an all too common problem: Money or lack thereof.

That’s among the conclusions of a recent survey of US-based travelers to West Africa published recently in the Journal of Travel Medicine. Figures from the US Centers for Disease Control and Prevention suggest that some 1700 cases of the mosquito-borne virus are reported in the US in any given year; investigators have estimated that roughly half of these cases occur in immigrants from West Africa who return to the region to visit friends and family.

In an effort to “describe the knowledge, attitudes, and practices of American residents traveling to malaria-endemic countries,” investigators from the University of Minnesota, among other agencies and institutions, conducted 16 focus groups in 2016 in 2 American metropolitan areas with high West African immigrant populations—Minneapolis-St. Paul, Minneapolis, and New York, New York—interviewing 172 adults originally from 13 African countries. Participants self-identified as West African and had either traveled to West Africa in the previous 10 years or planned to travel there within 1 year of the study.

Most of the focus group participants reported that their primary source for travel health information was their primary care physician; however, a few participants did use travel medicine clinics, and they reported “mixed experiences”—most notably, providers with limited knowledge of both the areas to which they were traveling and malaria chemoprophylaxis. While most participants agreed that it was “prudent” to visit a health care provider prior to travel, many indicated that they didn't trust the US health care system, either because American physicians lacked knowledge of, or training in, malaria or because of “personal or family experiences of racism or discrimination in health care settings.”

In addition, cost was a significant challenge in accessing malaria chemoprophylaxis and pre-travel medical advice. Even among participants who had health insurance, coverage was often lacking and/or complex. Indeed, “past experiences with large out-of-pocket costs deterred use of these services” for many focus group participants. Among those unable to afford chemoprophylaxis in the US, many skipped it entirely or purchased medication upon arrival at their destination. Still others opted only to treat for malaria if they became ill.

However, in their concluding remarks, the authors noted, “Barriers to pre-travel care…are multifaceted and extend beyond [travelers’] perception of disease risk. Past studies [have]…reported similar barriers of prohibitively high cost for malaria chemoprophylaxis and concerns about inappropriate response if travelers return with malaria or US providers’ lack of malaria management experience. In our study, participants recounted negative experiences with the US health care system that may affect their decisions to seek pre-travel care.”

Investigators added that their focus groups were held in 2016, less than 2 years after the West Africa Ebola outbreak, and that many immigrant populations were impacted by stigma and changes in hospital practices as a result. Somewhat surprisingly, however, they noted that concerns about immigration status, language barriers, or lack of “culturally appropriate” resources were not identified as barriers to using pre-travel services among participants.

To address these and other challenges facing US-based travelers to West Africa, Dr. Walz and her colleagues recommend that providers be educated on both cost-related issues with malaria prophylaxis and the resources available in their local communities to assist those in need. They also advocated for improved communication and collaboration between primary care and travel medicine providers.

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.