DESCRIPTION (provided by applicant): Malaria is a leading cause of mortality and morbidity worldwide. Travelers to endemic areas are at risk, and those visiting friends and relatives (VFRs) are known to be less likely to take proper preventive measures and suffer a disproportionate burden of disease. Among U.S. civilians with a reported purpose of travel, 70% of U.S. malaria cases occurred among VFR travelers, with acquisition in Africa being most common. There are limited data published on the knowledge, attitudes and practices of U.S. VFR travelers regarding malaria. There are many known barriers to care: individuals' existing knowledge and understanding of risk, knowledge of preventive strategies, structural barriers (e.g. access to care and medicines), cultural/language barriers, and lack of knowledge and training among healthcare providers. However, other barriers await description and the contribution of each of the known barriers to the failure to prevent malaria has never been evaluated. Further, appropriate interventions have not been systematically designed, tested, and assessed. The objective of this proposal is to identify high-risk populations and their community assets based on geographic mapping, to conduct thorough multidisciplinary assessments of barriers that exist for VFR communities through community outreach and participation, and to design and implement targeted but replicable intervention programs to reduce the risk of malaria acquisition during travel. Using a stepped-wedge cluster randomized trial design for implementation of targeted intervention(s), a consortium of three metropolitan communities (New York City, NY (NYC), Washington D.C. (DC), Minneapolis-St. Paul, MN (MSP)) will measure the relative impact and cost-benefit of each of the interventions. These three metro areas have some of the largest populations of African and Asian populations in the U.S. (NYC ranked #1 for both populations, DC #2 for African & #4 for Asian and MSP #5 for African & #15 for Asian). The end goal is identification of the most successful and cost-beneficial interventions for dissemination. This team brings together physician investigators from Albert Einstein College of Medicine (Bronx, NY), Uniformed Services University of the Health Sciences (Bethesda, MD), and University of Minnesota (Minneapolis, MN) in collaboration with public health professionals from the Departments of Health of Minnesota, New York City, and Maryland. The team has demonstrated expertise in travel & tropical medicine, immigrant health, socio-behavioral health, epidemiology, geographic information systems, health disparities & community outreach, health economics, policy development and implementation, and clinical trials.

PUBLIC HEALTH RELEVANCE: Travelers to malaria endemic areas put themselves at risk, and those who are visiting friends and relatives (VFR's) are known to be be less likely to take proper preventive measures and account for a disproportional burden (70%) of this preventable disease. This proposal seeks to understand barriers to care and implement a package of interventions to reduce malaria cases occurring among U.S. returning travelers.