Beyond coverage: a systematic review and qualitative evidence synthesis of factors influencing community engagement in malaria mass drug administration

Progress toward malaria elimination has slowed, and the asymptomatic parasite reservoir is one important factor that sustains residual transmission. Mass Drug Administration (MDA) is a key strategy to clear this reservoir, but its effectiveness depends on high community participation. Understanding the complex socio-cultural factors that influence participation is critical for programmatic success. This systematic review synthesises qualitative evidence to identify barriers and facilitators to community engagement in malaria MDA. We systematically searched four databases (PubMed, Scopus, Web of Science, and CINAHL) for qualitative or mixed-methods studies from inception to 1 June 2026 exploring community perceptions of malaria MDA. Included studies were appraised using the CASP (Critical Appraisal Skills Programme) Qualitative Checklist, and findings were analysed through thematic synthesis. The search yielded 25 studies for synthesis, drawn primarily from sub-Saharan Africa (n = 14) and the Greater Mekong Sub-Region (n = 10), with one study from South Asia (n = 1). Four themes emerged: perceptual and cognitive factors; individual and household factors; social and community-level dynamics; and health-system and programmatic factors, with the facilitating and impeding form of each factor presented together. Key facilitators included high perceived risk of malaria, strong community leadership, and trust in the health system, which was built through effective engagement, local health workers, and ancillary care. Key barriers included fear of adverse events (side effects) and their economic impact, logistical conflicts with livelihood activities, widespread rumours, and a poor understanding of asymptomatic malaria. Community engagement is a central determinant of MDA success. The decision to participate is a social calculation of perceived risk versus intervention risk, mediated by trust. Malaria elimination programmes must move beyond top-down sensitisation to invest in continuous, responsive engagement, built on partnership with local leaders and a clear demonstration of community benefit. Trial registration : CRD420251182194.