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Background: Despite achievements in the reduction of malaria globally, imported malaria cases to the United States by returning international travelers continue to increase. Immigrants to the United States from sub-Saharan Africa (SSA) who then travel back to their homelands to visit friends and relatives (VFRs) experience a disproportionate burden of malaria illness. Various studies have explored barriers to malaria prevention among VFRs and non-VFRs–travelers to the same destinations with other purpose for travel–but few employed robust epidemiologic study designs or performed comparative analyses of these two groups. To better quantify the key barriers that VFRs face to implement effective malaria prevention measures, we conducted a comprehensive community-based, cross-sectional, survey to identify differences in malaria prevention knowledge, attitudes, and practices (KAP) among VFRs and others traveling to Africa and describe the differences between VFRs and other types of international travelers. Methods and findings: Three distinct populations of travelers with past or planned travel to malaria-endemic countries of SSA were surveyed: VFRs diagnosed with malaria as reported through a state health department; members of the general VFR population (community); and VFR and non-VFR travelers presenting to a travel health clinic, both before their pretravel consultation and again, after return from travel. A Community Advisory Board of African immigrants and prior qualitative research informed survey development and dissemination. Across the three groups, 489 travelers completed surveys: 351 VFRs and 138 non-VFRs. VFRs who reported taking antimalarials on their last trip rated their concern about malaria higher than those who did not. Having taken five or more trips to SSA was reported more commonly among VFRs diagnosed with malaria than community VFRs (44.0% versus 20.4%; p = 0.008). Among travel health clinic patients surveyed before and after travel, VFR travelers were less successful than non-VFRs in adhering to their planned use of antimalarials (82.2% versus 98.7%; p = 0.001) and employing mosquito bite avoidance techniques (e.g., using bed nets: 56.8% versus 81.8%; p = 0.009). VFRs who visited the travel health clinic were more likely than VFR respondents from the community to report taking an antimalarial (83.0% versus 61.9%; p = 0.009), or to report bite avoidance behaviors (e.g., staying indoors when mosquitoes were out: 80.9% versus 59.5%; p = 0.009). Conclusions: We observed heterogeneity in malaria prevention behaviors among VFRs and between VFR and non-VFR traveler populations. Although VFRs attending the travel health clinic appear to demonstrate better adherence to malaria prevention measures than VFR counterparts surveyed in the community, specialized pretravel care is not sufficient to ensure chemoprophylaxis use and bite avoidance behaviors among VFRs. Even when seeking specialized pretravel care, VFRs experience greater barriers to the use of malaria prevention than non-VFRs. Addressing access to health care and upstream barrier reduction strategies that make intended prevention more achievable, affordable, easier, and resonant among VFRs may improve malaria prevention intervention effectiveness. [ABSTRACT FROM AUTHOR]

Background: Over half of malaria cases reported in the USA occur among people travelling to visit friends and relatives (VFRs), predominantly to West Africa. Few studies have queried VFR travellers directly on barriers to seeking pre-travel care. We aim to describe the knowledge, attitudes and practices of VFRs travelling to malaria-endemic countries from the USA. With these findings, we aim to design interventions to encourage preventive behaviours before and during travel.Methods: Sixteen focus groups were held in two US metropolitan areas with West African immigrant populations: Minneapolis-St. Paul, MN, and New York City, NY. A total of 172 people from 13 African countries participated. Focus group discussions were audio-recorded and transcribed, and modified grounded theory analysis was performed. Participants reviewed themes to verify intent of statements.Results: Participants described the high cost of provider visits and chemoprophylaxis, challenges in advocating for themselves in healthcare settings and concerns about offending or inconveniencing hosts as barriers to malaria prevention. Cultural barriers to accessing pre-travel care included competing priorities when trip planning, such as purchasing gifts for family, travel logistics and safety concerns. When participants sought pre-travel care, most consulted their primary care provider. Participants expressed low confidence in US providers' knowledge and training about malaria and other tropical diseases.Conclusion: Barriers to pre-travel care for VFR travellers are multifaceted and extend beyond their perception of disease risk. Only some barriers previously reported in anecdotal and qualitative literature were supported in our findings. Future interventions should be aimed at barriers identified by individual communities and involve primary and travel specialist healthcare providers. Additional work is needed to address systems-level barriers to accessing care and establishing community-based programs to support West African VFR traveller health. [ABSTRACT FROM AUTHOR]