bed study table

Privacy Settings

Etsy uses cookies and similar technologies to give you a better experience, enabling things like:

• basic site functions
• ensuring secure, safe transactions
• secure account login
• remembering account, browser, and regional preferences
• remembering privacy and security settings
• analysing site traffic and usage
• personalized search, content, and recommendations
• helping sellers understand their audience
• showing relevant, targeted ads on and off Etsy

Detailed information can be found in Etsy’s Cookies & Similar Technologies Policy and our Privacy Policy .

Required Cookies & Technologies

Some of the technologies we use are necessary for critical functions like security and site integrity, account authentication, security and privacy preferences, internal site usage and maintenance data, and to make the site work correctly for browsing and transactions.

Personalized Advertising

To enable personalized advertising (like interest-based ads), we may share your data with our marketing and advertising partners using cookies and other technologies. Those partners may have their own information they’ve collected about you. Turning off the personalized advertising setting won’t stop you from seeing Etsy ads, but it may make the ads you see less relevant or more repetitive.

Personalized advertising may be considered a “sale” or “sharing” of information under California and other state privacy laws, and you may have a right to opt out. Turning off personalized advertising allows you to exercise your right to opt out. Learn more in our Privacy Policy. , Help Center , and Cookies & Similar Technologies Policy .

Our House Rules

Get to know Etsy's legal terms and policies

• Privacy Policy
• Terms of Use
• Third parties

Sanctions Policy

Etsy provides a direct connection between buyers and sellers around the world. When you use Etsy’s services (we’ll refer to Etsy.com, Pattern by Etsy, our mobile apps, and other services as our “Services”), you are responsible for complying with this policy, regardless of your location.

This policy is a part of our Terms of Use . By using any of our Services, you agree to this policy and our Terms of Use.

As a global company based in the US with operations in other countries, Etsy must comply with economic sanctions and trade restrictions, including, but not limited to, those implemented by the Office of Foreign Assets Control ("OFAC") of the US Department of the Treasury. This means that Etsy or anyone using our Services cannot take part in transactions that involve designated people, places, or items that originate from certain places, as determined by agencies like OFAC, in addition to trade restrictions imposed by related laws and regulations.

This policy applies to anyone that uses our Services, regardless of their location. It is up to you to familiarize yourself with these restrictions.

For example, these restrictions generally prohibit, but are not limited to, transactions involving:

• Certain geographic areas, such as Crimea, Cuba, Iran, North Korea, Syria, Russia, Belarus, and the Donetsk People’s Republic (“DNR”) and Luhansk People’s Republic (“LNR”) regions of Ukraine, or any individual or entity operating or residing in those places;
• Individuals or entities identified on sanctions lists such as OFAC’s Specially Designated Nationals (“SDN”) List or Foreign Sanctions Evaders (“FSE”) List ;
• Nationals of Cuba, regardless of location, unless citizenship or permanent residency outside of Cuba has been established; and
• Items originating from areas including Cuba, North Korea, Iran, or Crimea, with the exception of informational materials such as publications, films, posters, phonograph records, photographs, tapes, compact disks, and certain artworks.
• Any goods, services, or technology from DNR and LNR with the exception of qualifying informational materials, and agricultural commodities such as food for humans, seeds for food crops, or fertilizers.
• The importation into the U.S. of the following products of Russian origin: fish, seafood, non-industrial diamonds, gold, and any other product as may be determined from time to time by the U.S. Secretary of Commerce.
• The exportation from the U.S., or by a U.S. person, of luxury goods, and other items as may be determined by the U.S. Secretary of Commerce, to any person located in Russia or Belarus. A list and description of ‘luxury goods’ can be found in Supplement No. 5 to Part 746 under the Federal Register.
• Items originating outside of the U.S. that are subject to the U.S. Tariff Act or related Acts concerning prohibiting the use of forced labor.

In order to protect our community and marketplace, Etsy takes steps to ensure compliance with sanctions programs. For example, Etsy prohibits members from using their accounts while in certain geographic locations. If we have reason to believe you are operating your account from a sanctioned location, such as any of the places listed above, or are otherwise in violation of any economic sanction or trade restriction, we may suspend or terminate your use of our Services. Members are generally not permitted to list, buy, or sell items that originate from sanctioned areas. This includes items that pre-date sanctions, since we have no way to verify when they were actually removed from the restricted location. Members are also generally not permitted to ship items to or from sanctioned areas. Etsy reserves the right to request that sellers provide additional information, disclose an item's country of origin in a listing, or take other steps to meet compliance obligations. It is important that members provide complete and accurate information regarding the origin of items on the Etsy marketplace to ensure compliance with sanctions programs. We may disable listings or cancel transactions that present a risk of violating this policy.

In addition to complying with OFAC and applicable local laws, Etsy members should be aware that other countries may have their own trade restrictions and that certain items may not be allowed for export or import under international laws. You should consult the laws of any jurisdiction when a transaction involves international parties.

Finally, Etsy members should be aware that third-party payment processors, such as PayPal, may independently monitor transactions for sanctions compliance and may block transactions as part of their own compliance programs. Etsy has no authority or control over the independent decision-making of these providers.

The economic sanctions and trade restrictions that apply to your use of the Services are subject to change, so members should check sanctions resources regularly. For legal advice, please consult a qualified professional.

Resources: US Department of the Treasury ; Bureau of Industry and Security at the US Department of Commerce ; US Department of State ; European Commission

Last updated on May 15, 2024

• Mattress & Sleep
• Kids & Baby Gear
• Beauty & Grooming
• Tech & Electronics

How To Organize Your Bedside Table, According To 7 Sleep Experts

• Share to Facebook
• Share to Twitter
• Share to Linkedin

Getting to sleep—and staying asleep—can be elusive for millions of people. The American Academy of Sleep Medicine and the Journal of Clinical Sleep Medicine recommend getting at least seven hours of sleep each night. However, the National Institutes of Health reports that approximately one-third of Americans get less than that.

We spoke with seven professional sleep coaches who emphasized the importance of organizing your ... [+] bedside table for a good night’s rest.

While a variety of factors contribute to sleep difficulties—both medical and non-medical—one thing we can control is our sleeping environment. Professional sleep coaches often emphasize the importance of setting the stage for a good night’s rest. “When trying to improve sleep, it’s very important to have a clean and clutter-free bedroom,” says sleep coach Cali Bahrenfuss . “Clutter can lead to dust (which is not helpful for the airways or allergies when sleeping) and create stress in the bedroom. A clean and tidy bedroom helps promote a peaceful and relaxing environment.”

One of the major culprits for clutter in our bedrooms? Our bedside table . They become catch-alls for everything from books, lotion, hair ties, stray papers, charging cables and, of course, the major sleep-disturber of them all: our smartphones. According to Bahrenfuss, “A good rule of thumb to go by is this: Pretend you’re traveling and put everything you would bring from your nightstand onto your bed. Those are the items to keep near the nightstand. All the items that you did not put on the bed can either be eliminated completely or put in a more appropriate place.” And, yes, this includes decor items as well.

To help you corral the mess and create a peaceful sleep environment, we spoke to seven sleep coaches about what products they recommend to clients (or use themselves) to organize their nightstands for a good night’s rest.

How To Organize Your Bedside Table

An elegant bedside organizer with plenty of storage compartments, houndsbay admiral dresser valet box.

“I highly recommend having a bedside valet to cut down on clutter and keep things organized. I particularly like this one because it has a charging station attached so you can hide cords. Plus, it has lots of nooks for smaller items like keys, watches, jewelry or a notepad to jot down to-do items for the next day.”

— Christine Stevens , sleep coach

A Soft, Dim Light That Won't Disrupt Melatonin

Casper glow light.

“This minimalistic bedside lamp keeps your nightstand clean and clutter-free. It's portable, so you can carry it around if you need to get up at night. The dim light won’t disrupt melatonin or disturb others, making it ideal for tiptoeing into your baby’s room. You can tap or shake it to turn it on and off. It doesn't use Wi-Fi, but it does connect to your phone via Bluetooth. It's also a great option for travel.”

— Kim Rogers , sleep consultant

A Quality Sleep Mask That's Great At Blocking Out Light

Drowsy silk sleep mask.

“This mask is soft and gentle on the skin, made of silk to prevent creases and damage. It also blocks out light better than any other mask on the market.”

— Brittany Sheehan , sleep coach

A Breathwork Device That Can Helps You Get Back To Sleep

Moonbird breathing & meditation device.

“Lately, I’ve been using a handheld breathwork coach called Moonbird when I wake in the middle of the night. Focusing on my breath often helps me get back to sleep. Studies show that paced breathing can increase heart rate variability and lower heart rate, which can improve sleep quality.”

— Morgan Adams , sleep coach

A Smart Bedside Clock With Several Nifty Features

Loftie smart alarm clock.

“This nifty device has several helpful features, but the most important, in my opinion, is its ability to function as a sound machine with brown noise and provide an easeful way to wake up without needing your phone in the room. Brown noise is less stimulating to the ear, reminiscent of a rushing river, and helps block out external noises that might wake you up at night. The two-step alarm feature mimics the body's natural wake-up process, making it gentler on the body. This means you won't need to keep your phone in the room as an alarm, reducing distractions. Additionally, the Loftie features warm light settings for a nightlight, which help keep cortisol levels in check.”

— Kelly Murray , sleep coach

A Sleek Drawer Organizer To Keep Things Tidy Yet Visible

Walmart.com

The Home Edit Drawer Organizer

“If your nightstand has a drawer or basket, make good use of them by storing most items there, keeping the tabletop as clear as possible. Avoid just transferring clutter from one place to another; use drawer organizers like this one to maintain tidiness even when items aren't visible.”

— Cali Bahrenfuss , sleep coach

An Updated Kindle For Bedtime Reading

Amazon kindle paperwhite.

"My Kindle is a sleep non-negotiable for me!” says Murray. “Ever since Kindle updated their device with a warm-toned light for reading in dark environments, it has made a huge difference in my bedtime routine (yes, adults should have bedtime routines!). I often recommend to my clients, especially those who struggle to quiet their minds at night, to unwind with a book. The Kindle's warm light setting helps to avoid the harsh glare of blue light from screens, creating an environment more conducive to rest and relaxation. Its slim design also means it sits neatly on your bedside table without adding clutter."

A Night Bulb That Emits A Soft Glow To Help You Unwind

Sleepy baby led nursery light.

"There’s a lot of discussion about how blue light from electronics disrupts melatonin. While many are removing cell phones and devices from their bedrooms, light bulbs can still be a concern," explains Rogers. "Most bulbs emit blue light, which disrupts melatonin just like cell phones. This bulb emits a soft amber glow that allows for reading while minimizing melatonin disruption. I even take it with me to hotel rooms for nighttime reading."

A Sleek Charging Station To Keep Your Gadgets Corralled

Best buy essentials 3-in-1 magnetic wireless charger.

"If you have gadgets and gizmos to charge each night, consider combining them into a single charging station for better organization,” explains Bahrenfuss. “It's advisable to charge items away from the bed, ideally on top of a dresser, to discourage excessive phone use in bed and promote a healthier sleep environment by avoiding sleeping next to charging electronic devices."

A Petite Potted Plant That Can Improve Air Quality And Promote Calmness

Snake plant laurentii.

"Adding a small plant to your nightstand can enhance the atmosphere with its pleasing and relaxing presence, while also benefiting air quality. I recommend a miniature snake plant—it's compact enough for a nightstand, improves air quality and requires minimal sunlight and care."

—Maria Lopez, sleep coach and director, Sleep Sense en Espanol

Casper Vs. Nectar: Which Popular Foam Mattress Suits You Better?

The best wayfair outdoor furniture deals to shop this weekend, why trust forbes vetted.

At Forbes Vetted, we’ve researched and written dozens of home decor stories . Author of this piece Esther Carlstone is a regular contributor with over a decade of experience covering lifestyle topics.

This story was overseen by home and kitchen editor Sholeen Damarwala , who has assigned, edited and produced everything from the best washable rugs to how to organize your desk . Carlstone also gathered key insight and guidance from seven sleep experts: Maria Lopez, a sleep coach and director at Sleep Sense en Espanol ; Cali Bahrenfuss, a sleep coach at Delta Sleep Coaching ; Kelli Murray a certified sleep consultant; Christine Stevens , a sleep coach who works with infants and adults; Kim Rogers , a pediatric sleep consultant; Brittany Sheehan , a certified sleep consultant; and Morgan Adams , a double-certified holistic sleep coach.

• Editorial Standards
• Reprints & Permissions

• Open access
• Published: 26 June 2024

High prevalence and risk of malaria among asymptomatic individuals from villages with high prevalence of artemisinin partial resistance in Kyerwa district of Kagera region, north-western Tanzania

• Salehe S. Mandai 1 ,
• Filbert Francis 2 ,
• Daniel P. Challe 2 ,
• Misago D. Seth 1 ,
• Rashid A. Madebe 1 ,
• Daniel A. Petro 3 ,
• Rule Budodo 1 ,
• Angelina J. Kisambale 1 ,
• Gervas A. Chacha 1 ,
• Ramadhan Moshi 1 ,
• Ruth B. Mbwambo 1 ,
• Dativa Pereus 1 ,
• Catherine Bakari 1 ,
• Sijenunu Aaron 4 ,
• Daniel Mbwambo 4 ,
• Abdallah Lusasi 4 ,
• Stella Kajange 5 ,
• Samuel Lazaro 4 ,
• Ntuli Kapologwe 6 ,
• Celine I. Mandara 1 &
• Deus S. Ishengoma 1 , 7 , 8 , 9  

Malaria Journal volume  23 , Article number:  197 ( 2024 ) Cite this article

167 Accesses

Metrics details

Although Tanzania adopted and has been implementing effective interventions to control and eventually eliminate malaria, the disease is still a leading public health problem, and the country experiences heterogeneous transmission. Recent studies reported the emergence of parasites with artemisinin partial resistance (ART-R) in Kagera region with high prevalence (> 10.0%) in two districts of Karagwe and Kyerwa. This study assessed the prevalence and predictors/risk of malaria infections among asymptomatic individuals living in a hyperendemic area where ART-R has emerged in Kyerwa District of Kagera region, north-western Tanzania.

This was a community-based cross-sectional survey which was conducted in July and August 2023 and involved individuals aged ≥ 6 months from five villages in Kyerwa district. Demographic, anthropometric, clinical, parasitological, type of house inhabited and socio-economic status (SES) data were collected using electronic capture tools run on Open Data Kit (ODK) software. Predictors/risks of malaria infections were determined by univariate and multivariate logistic regression, and the results were presented as crude (cORs) and adjusted odds ratios (aORs), with 95% confidence intervals (CIs).

Overall, 4454 individuals were tested using rapid diagnostic tests (RDTs), and 1979 (44.4%) had positive results. The prevalence of malaria infections ranged from 14.4% to 68.5% and varied significantly among the villages (p < 0.001). The prevalence and odds of infections were significantly higher in males (aOR = 1.28, 95% CI 1.08 –1.51, p = 0.003), school children (aged 5–≤10 years (aOR = 3.88, 95% CI 3.07–4.91, p < 0.001) and 10–≤15 years (aOR = 4.06, 95% CI 3.22–5.13, p < 0.001)) and among individuals who were not using bed nets (aOR = 1.22, 95% CI 1.03–1.46, p = 0.024). The odds of malaria infections were also higher in individuals with lower SES (aOR = 1.42, 95% CI 1.17–1.72, p < 0.001), and living in houses without windows (aOR = 2.08, 95% CI 1.46–2.96, p < 0.001), partially open (aOR = 1.33, 95% CI 1.11–1.58, p = 0.002) or fully open windows (aOR = 1.30, 95%CI 1.05–1.61, p = 0.015).

The five villages had a high prevalence of malaria infections and heterogeneity at micro-geographic levels. Groups with higher odds of malaria infections included school children, males, and individuals with low SES, living in poorly constructed houses or non-bed net users. These are important baseline data from an area with high prevalence of parasites with ART-R and will be useful in planning interventions for these groups, and in future studies to monitor the trends and potential spread of such parasites, and in designing a response to ART-R.

In the past two decades, there have been enhanced malaria control efforts that have resulted in a significant decline in the disease burden globally, but progress has stalled since 2015 [ 1 ]. According to the World Health Organization (WHO), there were an estimated 249 million malaria cases and 608,000 deaths in 2022, with continued limited progress since 2015 [ 2 ]. The WHO African Region (WHO-Afro) had the highest number of malaria cases and deaths, with an estimated 233 million cases (93.6%) and 580,000 deaths (95.4%) in 2022 [ 2 ]. Although the global scale-up of effective malaria interventions has saved millions of lives globally and cut malaria mortality by 36.0% from 2010 to 2020, the resulting optimism leading to hopes and plans to eliminate and ultimately eradicate malaria is facing imminent threats. The biggest contemporary challenges to malaria elimination include insecticide resistance by malaria vectors [ 3 , 4 ], emergence and spread of drug resistance [ 5 , 6 ], the emergence of parasites that cannot be detected by rapid diagnostic tests (RDTs) due to deletions of the histidine-rich protein 2/3 ( hrp2/3 ) gene [ 7 , 8 ] and emergence as well as spread of invasive Anopheles stephensi vectors [ 9 , 10 ]. There are also non-biological threats, such as reduced funding for malaria control, climate change and political will at the global and local/country levels, and these need to be urgently addressed to get progress back on track [ 11 , 12 ].

In Tanzania, over 93.0% of the population is at risk of malaria because they live in areas where transmission occurs [ 13 ]. Due to scaled-up interventions, the country has recently transitioned from very high and stable to areas with varying and/or unstable transmission intensities [ 14 , 15 ]. As in many malaria-endemic countries in the WHO-Afro region, Plasmodium falciparum  is the cause of most of the infections in Tanzania, with other species being Plasmodium ovale spp. and Plasmodium malariae [ 16 , 17 , 18 ]. Although Plasmodium vivax has been reported in a few studies in Tanzania [ 16 , 18 ], its public health significance remains unknown. With the current changes in transmission intensities of P. falciparum , the dynamics and patterns of non-falciparum species will need to be closely monitored to ensure they do not become new threats to malaria elimination especially in WHO-Afro where they are currently less predominant.

To accelerate progress toward its elimination targets by 2030, Tanzania adopted the WHO’s recommendations and has been implementing effective interventions over the past two decades to control and eventually eliminate malaria. The Tanzanian National Malaria Control Programme (NMCP) has endeavoured to ensure high coverage and use of such interventions, focusing on vector control, case management and preventive therapy. Vector control interventions include the use of insecticide-treated nets (ITNs), indoor residual spraying (IRS) and larval source management (LSM). For effective case management, NMCP uses RDTs for parasitological confirmation of malaria parasites and artemisinin-based combination therapy (ACT) to effectively treat patients with confirmed infections. To prevent malaria in pregnancy, NMCP deployed and uses intermittent preventive treatment (IPTp) of malaria during pregnancy with sulfadoxine-pyrimethamine (SP) and strives to increase the proportion of women receiving two or more doses of IPTp-SP to reach the WHO target of 80.0% [ 19 ]. These interventions yielded positive results, with a declining trend of malaria burden which was associated with a decline of prevalence from 18.0% in 2008 to 8.0% in 2022 [ 20 ].

Based on recent reports, malaria remains a major public health problem in Tanzania, and the country still experiences persistent transmission in some regions [ 2 ], but the drivers of these patterns are not clearly known. Malaria transmission in Tanzania has become heterogeneous, with a high burden in the north-western, southern and western regions, while the central corridor, north-eastern and south-western parts of the country have low to very low transmission intensities [ 21 , 22 ]. The recent epidemiological transition and trends of malaria have raised critical questions that need to be addressed to allow the country to progress to its elimination targets by 2030. In addition, Tanzania faces emerging and endemic challenges, such as low coverage of existing interventions, emergence and spread of drug and insecticide resistance and weakness of the public health system [ 23 ]. Most of these challenges are particularly context-specific and require innovative and multifaceted approaches to ensure that high impact is attained and sustained. The interventions should also target and aim to eliminate the remaining pockets in low transmission areas, respond to biological threats, target non-falciparum species, reduce the disease burden in high transmission areas and address populations at higher risk [ 24 ]. Thus, the NMCP needs to strategically and innovatively continue to implement current and new WHO-recommended interventions, including upgrading and making malaria surveillance a core intervention to facilitate ongoing elimination efforts in all areas based on the local burden and level of transmission intensities [ 25 ].

Tanzania faces biological and other threats that may compromise its progress and prospects to eliminate malaria by 2030 [ 26 ]. Of the biological threats, Tanzania has reported a high prevalence of mosquitoes with resistance to multiple insecticides [ 4 , 27 ], and it is at high risk of the invasive An, stephensi vector, which has been reported in Kenya and the Horn of Africa [ 28 ]. In addition, artemisinin partial resistance (ART-R) has been reported in some parts of Kagera region near the border with Rwandan and Uganda, with an average prevalence of Kelch 13 R561H mutation of 7.7% among symptomatic patients and a high prevalence in Karagwe (22.8%) and Kyerwa district (14.4%) [ 29 , 30 ]. These parasites can potentially spread to other regions if not curtailed, suggesting that a rapid response strategy is urgently needed [ 29 ]. Although recent studies have reported a low prevalence of parasites with hrp2/3 gene deletions associated with the failure of HRP2-based RDTs [ 8 ], these threats are still imminent, and the country needs to increase its vigilance through a strong surveillance system. It is also critical to urgently adopt and implement the WHO response strategy for dealing with ART-R [ 31 ] to prevent the spread of resistant parasites from Kagera to other regions.

According to the WHO strategy for responding to ART-R [ 31 ], Tanzania needs to develop and implement a response plan customized to the local context and coordinated with neighbouring countries in the Great Lakes region of Africa (Burundi, Democratic Republic of Congo—DRC, Rwanda and Uganda). Since Kagera is one of the regions with a high burden of malaria [ 32 ], it is also important to deal with other critical issues, including asymptomatic malaria infections. Due to high transmission intensities in Kagera, asymptomatic infections are potentially another threat that may play a critical role in sustaining and perpetuating transmission of the disease in the region. Studies have shown that individuals with parasites but no apparent symptoms, tend to harbour parasites for a long time without seeking medical care and become silent reservoirs, capable of transmitting the infections to others through mosquito bites [ 33 ]. The silent nature of asymptomatic infections which are normally associated with low parasite densities, makes these infections challenging to diagnose and treat promptly, allowing the parasites to persist in the human population [ 34 ]. The continuous circulation of parasites among asymptomatic individuals not only poses a threat to their health by potentially progressing into symptomatic cases but also increases the overall transmission potential [ 35 , 36 ]. These asymptomatic carriers contribute significantly to the persistence of malaria and complicate the efforts to control and eliminate malaria.

In areas like Kagera, where there is a high burden of malaria, emerging reports of ART-R and potentially high prevalence of asymptomatic infections, it is not known yet how resistant parasites will evolve over space and time. Thus, targeting and addressing the high burden of malaria including asymptomatic infections through comprehensive surveillance and intervention strategies are essential in the response to ART-R. This will involve and depend on the ability to detect all malaria infections at health facilities and in the community, and the use of effective interventions to break the cycle of transmission and achieve sustainable malaria control goals [ 37 ]. This study assessed the prevalence and predictors/risk of malaria infections among asymptomatic individuals living in an area with a high prevalence of malaria infections [ 38 ] and a high prevalence of parasites with ART-R in Kyerwa District, north-western Tanzania as recently reported [ 29 ]. The study fills a critical gap by providing data on the magnitude and prevalence of infections in asymptomatic individuals, which serves a potential role in understanding transmission dynamics and risk of infection, including the potential spread of resistant parasites. This study also generated important data that will support the understanding of the burden and risk of asymptomatic malaria infections as well as the epidemiology of parasites with ART-R. The findings will potentially help the government and other stakeholders in planning and implementing strategies for malaria prevention and control as well as responding to the threat of ART-R in Kagera region.

Study design and sites

This was a community-based cross-sectional survey (CSS) that was conducted during the peak of malaria transmission season in July and August 2023. The timing of this CSS was based on experience from previous studies conducted in other parts of Tanzania and elsewhere which showed that the peak of malaria transmission occurs after the rainy season and provides the best estimate of malaria burden in the target area [ 39 , 40 ]. The survey was done as part of the main project on molecular surveillance of malaria in Tanzania (MSMT), which has been running in 13 regions of mainland Tanzania since 2021 [ 8 , 29 , 41 ] and was recently extended to cover all 26 regions in 2023 (Ishengoma D—unpublished data). The study covered five villages (Kitoma, Kitwechenkura, Nyakabwera, Rubuga and Ruko), which are part of the longitudinal component of the MSMT project that was initiated in 2022 to monitor the trends and patterns of malaria in areas with special features such as ART-R and hrp2/3 gene deletions as described elsewhere [ 8 , 29 , 30 ]. The study villages are located in Kyerwa district, which is one of the eight districts of Kagera region (Fig.  1 ). Kyerwa district covers an area of 3,086 km 2 and borders Uganda to the North, Rwanda to the West and Karagwe district to the South. The study villages are located near the Kagera River basin, which forms the boundary between Kyerwa and Rwanda (West) and Uganda (North). According to the 2022 national census, Kyerwa district had a population of 412,910 people, including 211,685 females and 201,225 males, with an average household size of 4.3 and a sex ratio of 95 males per 100 females [ 42 ].

Maps showing the 26 regions of Tanzania including Kagera (gold) ( A ), study villages (red) in Kyerwa district in grey ( B ) and the five study villages ( C )

Study population and recruitment of participants

This CSS included individuals aged ≥ 6 months living in the 5 villages that are part of the longitudinal component of the MSMT project and provided consent to participate in the study. The survey aimed and targeted to recruit approximately 30.0% of all individuals from each village who were registered during a census survey that was conducted in February 2023. In this survey, all community members meeting the inclusion criteria were considered to be asymptomatic for malaria because they were not at the health facility located in Kitwechenkura seeking medical care for malaria or any other illnesses. They were all invited to participate in the study, but those who wanted to participate were required to meet the inclusion criteria for the survey, including residence in the study villages, age from 6 months and above, and providing informed consent. Individuals living in other villages or those who declined to give informed consent were excluded from the CSS. The information about the CSS was passed to all household members by a community organizer who broadcasted using a loudspeaker and walked through all parts of the village. Each of the study villages had 3–5 hamlets, and members from 1 to 3 hamlets were invited to meet the study team on specific days during the survey. The study team was stationed at a central location that was set up as a CSS post in each village. Any member who missed out was allowed to visit the survey post on a different day in the same or the next village. Thus, participants were recruited conveniently based on their willingness to take part in the study by visiting the recruitment post and providing consent to take part in the CSS.

Data collection procedures

Household census.

Prior to the CSS, a household census survey was conducted in February 2023 in the study villages. The data collected included demographic, anthropometric, clinical and parasitological data, as shown in Fig.  2 . Initially, basic demographic data were collected during the census survey that covered all households and individuals in each family as previously described [ 43 ]. Researchers/trained assistants visited the household during the census and every member of the community was enumerated and given a unique identification number (ID). Demographic information, education status and occupation of all members of the household were collected, together with information on malaria control including the use of bed nets or other methods to control mosquitoes, such as repellents or burning herbs. Global Positioning System (GPS) coordinates of each house were recorded and observations were made to record information about the type of house, construction materials used, and presence of windows and eaves. Any other physical features of the house and around it which could support the breeding of mosquitoes (such as vegetation cover and the presence of bushes around the house), or access to humans by mosquitoes when feeding was also recorded. Additional information including land use for agriculture and/or keeping livestock, and vegetation cover was collected during the census survey from each household. While at the household, details of ownership and use of bed nets were assessed and verified by recording the number of nets and confirming where nets were hung at night. The nets were physically inspected to determine their intactness or extent of damage which involved reporting numbers and size of holes on the nets using the methods reported earlier [ 44 ]. Ownership of different assets was also recorded for determining the family’s socioeconomic status (SES) as previously reported [ 45 ]. A database of all community members was set up at the National Institute for Medical Research (NIMR) in Dar es Salaam.

Schematic drawing showing the flow of study participants during the cross-sectional community survey [ CSS Cross-sectional survey, DBS dried blood spot on filter paper, HH household, ID Identification numbers, GIS Global positioning system, MSMT  = molecular surveillance of malaria in Tanzania project, RDT rapid diagnostic test and SES socio-economic status

Recruitment and evaluation of participants

During the CSS, each participant was identified using their IDs, which are linked to the main MSMT database containing all community members. After confirming the identity of the prospective participants, they were provided with study identification numbers that were generated specifically for the CSS. Thereafter, participants were interviewed to obtain demographic information on top of those collected during the census, a quality-control step that is built into the CSS to help verify census data. Each study participant was asked to report malaria prevention practices through a series of questions, including ownership and use of bed nets (ITN) the night before the survey. They were also asked to report how frequently other family members used bed nets, their habit of checking and repairing bed nets, and the use of other methods of malaria prevention such as mosquito spray/repellent within their household. Thereafter, they were sent to a designated area for the collection of anthropometric measurements (weight, height and body temperature) and then to the laboratory to test for malaria and collection of blood samples. For the detection of malaria parasites, participants were screened using RDTs, which included Abbott Bioline Malaria Ag Pf/Pan (Abbott Diagnostics Korea Inc., Korea) and Smart Malaria Pf/Pan Ag Rapid Test (Zhejiang Orient Gene Biotech Co. Ltd, China). All recruited participants donated dried blood samples on filter paper (DBS) for laboratory analyses, which will be reported elsewhere. Blood slides for the detection of malaria parasites by microscopy were also collected for reading in the laboratory, but the results are not included in this paper. The final step involved clinical assessment and collection of data on the history of any illness and diagnosis of any presenting illnesses. Additional data including the use of anti-malarials and any other medications which might have been used together with anti-malarials or for the management of other illnesses was collected. Any participant who tested positive by RDT was treated with artemether-lumefantrine (AL) alone and/or other drugs if they had other illnesses with or without malaria (Fig.  2 ).

Malaria control interventions in the study villages

This is the first CSS to be conducted in these villages based on the methods that have been used previously in selected communities of Tanga region since 1992, as described elsewhere [ 46 , 47 ]. Thus, an assessment of malaria control interventions was done to report the use of key interventions recommended by NMCP to account for the impact of the interventions on the burden of malaria in these villages. The five villages are served by the dispensary located in Kitwechenkura village where malaria case management services are provided, based on the national guidelines [ 48 ]. The services include early detection of malaria parasites by RDTs and effective treatment with AL. Pregnant women are tested for malaria at the first antenatal care visit and those with positive RDTs are treated with AL. Information obtained from the district malaria focal person (DMIFP) and through a visit to the dispensary showed that all commodities such as RDTs, anti-malarials and other related medicines were available and stock out of these essential commodities was uncommon. It was also reported that all medical services for malaria are provided free of charge in the public health facilities for under-fives, pregnant women and elderly. Other members of the community have to pay cash or use the community health fund (CHF) for medical care at the public dispensary and other health facilities in case of referral. However, the CHF has been reported to have major limitations to users such as the inability to afford by many people, poor services to subscribers and others which have been described elsewhere [ 49 ]. In the CSS, all participants mainly asymptomatic (and a few symptomatic) were tested with RDTs, and those with positive results were treated with AL for uncomplicated malaria. Participants with malaria and other illnesses and based on clinical indication were treated with AL and other drugs according to the national guidelines [ 50 ]. The services provided during the CSS were free to all participants as compensation and incentive for taking part in the survey.

Through interviews with the DMIFP and during the census survey, information about sources of ITNs and the use of other vector control interventions, such as IRS and LSM, was collected. It was reported that Kyerwa receives bed nets from the NMCP through different campaigns, such as mass distribution, antenatal care (ANC) clinics and school net programmes [ 51 , 52 ], together with private distributors. According to the NMCP reports of 2022, bed-net ownership in Kyerwa was 89.0% and use was > 80.0% (NMCP Unpublished data). During the CSS, the assessment of vector control methods involved asking each participant to report on ownership of bed nets and their use as well as any information about the use of other methods to kill or repel mosquitoes. The study villages and other parts of Kyerwa district and the entire region of Kagera were covered by the IRS programme funded by the US President’s Malaria Initiative (PMI) from 2008 to 2013 [ 53 , 54 ]. The villages were also involved in bio-larviciding operations using bio-larvicides produced in Tanzania between 2016 and 2020, but these activities could not be sustained because of a lack of funding. Additional information about surveys of malaria vectors was explored from the DMIFP and other sources, indicating that the villages took part in entomological surveillance in the past.

Data management and analysis

The data were collected during census and CSS with structured questionnaires created using Open Data Kit (ODK) software, installed and run on tablets. The data were directly transmitted to a central server located at NIMR in Dar es Salaam. The data were downloaded into Excel, cleaned and then transferred to STATA version 13 (STATA Corp Inc., TX, USA) for further cleaning and analysis. Descriptive statistics including frequency, mean, standard deviation (SD) and median (with interquartile (IQR)) were used to summarize data. Chi-square test was used to compare categorical variables while continuous variables were compared using Student’s t-test and Mann–Whitney test. Binary and multivariate logistic regression was used to assess the association between malaria prevalence and different independent variables including demographics and clinical covariates such as sex, age group, use of bed nets, history of fever and fever at presentation (axillary temperature  ≥ 37.5 °C).

Furthermore, the association between the prevalence of malaria with house characteristics such as socio-economic status (SES), family size, type of eaves, type of windows, type of floor and walls, vegetation cover and the presence of bushes around the houses was investigated. The SES for the wealth index was computed using principal component analysis (PCA) as described elsewhere [ 45 ]. In the PCA, the scores from the first component of PCA were extracted and then categorised into three wealth quantiles (low, medium and high). The households falling in the low quantile represented poor households, while those in the high quantile represented households with better SES. Variables that were statistically significant (p-value < 0.25) during univariate logistic regression were retained and included in multivariable logistic regression. During the analysis, two separate models were used: the first model included demographic and clinical variables, while the second model included household and environmental characteristics and cluster standard errors to account for clustering at the village level. Multicollinearity was assessed between pairs of independent variables using variance inflation factor (VIF), and those variables with VIF > 5 were excluded from the multivariate model. A p-value of ≤ 0.05 was considered to be significant.

Baseline characteristics of study participants

A total of 4454 individuals constituting 29.9% (n = 15031) of all community members participated in the CSS from the five villages and most of them were females (59.3%). The median age of participants was 14 years (IQR: 7–36 years), with significant differences in the age of participants among the study villages (p < 0.01). The majority of participants were students/children (49.5%) and 48.8% were peasants or fishermen. Of the adults (aged  ≥ 15 years), 42.8% had completed primary education, while 30.5% did not have formal education. Of all participants (n = 4454), 29.4% (n = 1310) reported a history of fever in the past 48 h before the survey, but only 3.1% (136/4454) had a fever at presentation (with axillary temperature ≥ 37.5 °C) (Table  1 ). The majority of the participants (79.7%) were living in households with ≥ 4 members and low/medium SES (68.0%), and their houses were poorly constructed with open windows and floors made of sand (Table  2 ). A detailed comparison of the sampled participants and the entire population in the five villages is presented in Supplementary Table 2.

Prevalence of malaria

All individuals (n = 4454) were tested with RDTs, and 1979 (44.4%) had positive results. The prevalence of malaria infections in the five villages varied from 14.5% in Nyakabwera to 68.5% in Ruko village and the difference was statistically significant across the villages (p < 0.001). A significantly higher prevalence was detected in males (49.2%) (p < 0.001) in the three villages of Kitoma, Nyakabwera and Rubuga, and among school children in all villages; with the overall prevalence of 61.1% in school children aged 5–≤10 years and 57.4% among those aged 10–≤15 years (Kitoma, Rubuga and Ruko with p < 0.001; Kitwechenkura, p = 0.001 and Nyakabwera, p = 0.037). The lowest prevalence was in adults aged ≥ 15 years (30.4%), and the pattern of age-specific prevalence was similar in all villages (Table  3 ). The majority of study participants with malaria infections were found in Ruko, Kitoma, Rubuga and Kitwechenkura villages as shown in Fig.  3 .

Map of study villages showing the distribution of individuals with malaria parasites detected by rapid diagnostic tests. RDT rapid diagnostic test and RDT results are presented by green dot for negative and red for positive test results.

Bed net use in the study villages

Table 4 shows the use of bed nets the night before the survey and other methods for malaria prevention among study participants. The overall bed net use (in all villages combined) was 63.9%, with significantly higher usage among females (65.6%) compared to males (61.5%) in all villages (combined p < 0.01). Bed net usage was higher in Rubuga (74.9%) and Kitoma (68.0%), while the lowest was reported in Kitwechenkura (51.8%). There was low bed net usage among school children (56.0% and 54.9% in children aged 5–≤10 and 10–≤15 years, respectively) compared to under-fives and adults (≥ 15 years) with usage of ≥ 73.8% (Table  4 ). In all five villages, females, under-fives and adults (≥ 15 years) had higher usage of nets, with three villages of Kitoma, Ruko and Rubuga approaching or exceeding 80.0% (Fig.  4 a, b). Only a small proportion of participants (2.4%) reported the use of other methods to protect themselves against mosquito bites (Table  4 ). Such methods included mosquito repellents (n = 67, 1.5%), mosquito coils (n = 21, 0.5%) and burning insecticides (n = 18, 0.4%).

Bed net usage among individuals of different sex in the five villages of Kyerwa. b Bed net usage among individuals of different age groups in the five villages of Kyerwa

Predictors/Risk factors of malaria infections

After adjusting for demographic characteristics, history of fever, fever at presentation (axillary temperature ≥ 37.5 °C) and bed net use, the results showed that the odds of malaria infections were significantly higher in four villages of Kitoma, Kitwechenkura, Rubuga and Ruko compared to Nyakabwera (p < 0.001) (Table  5 ). Males and individuals who did not use bed nets the night before the survey had higher odds of malaria infections compared to females (p = 0.003), and those who used nets (p = 0.024), respectively. School children and under-fives had significantly higher odds of malaria infections (p < 0.001) than adults (≥ 15 years). The odds of malaria infection were 18 times higher among participants with a history of fever in the past two days before the survey (p < 0.001) and the odds were significantly higher (2.71) in participants with fever at presentation (p < 0.001) (Table  5 ). In the model that involved adjustments for households and environmental-related factors (shown in Table  2 ), individuals from households with four or more members had higher odds of malaria infections (p < 0.001), as did those living in houses with open (p = 0.015) or partially open windows (p = 0.002). Also, participants living in houses with no windows (p < 0.001) and individuals from households with low SES (p < 0.001) had significantly higher odds of malaria infections compared to those living in houses with closed windows or from households with high SES, respectively. Moreover, the presence of long vegetation and bushes around houses was associated with higher odds of malaria infections (Table  6 ).

This CSS was conducted as part of a larger project on MSMT that aims to establish the capacity and implement malaria molecular surveillance (MMS) in Tanzania [ 55 ]. The MSMT project has been implemented in 13 regions of Tanzania since 2021, and it has now been extended to cover integrated malaria molecular surveillance (iMMS) in all 26 regions of Mainland Tanzania since January 2023 (Ishengoma et al. Unpublished data). This study generated important baseline data in five villages in an area with a high malaria burden [ 56 ] and a high prevalence of parasites with ART-R in Kagera region, north-western Tanzania [ 29 ]. The study utilized a platform that has been set up by the MSMT project to support studies focused on iMMS in Tanzania. It enrolled asymptomatic individuals from the five villages under the longitudinal surveillance component of MSMT and showed that all villages had a very high prevalence of malaria infections by RDTs (44.4%), with high variability despite their proximity. In these villages, the odds of malaria infections were significantly higher in males, school children, individuals with low SES, and those who were not using bed nets or living in poorly constructed houses. In all villages, the prevalence and odds of malaria infections were heterogeneous at the micro-geographic level but with some evidence of clustering near the lakes, despite the high use of bed nets (over 51.0%), which exceeded 66.0% in three villages. The findings reported here will be critical in future studies to characterize and monitor transmissibility, trends and patterns as well as the spread of parasites with ART-R in Kagera region and other parts of Tanzania. The findings will be particularly useful in the control of asymptomatic cases which are normally not targeted by the current case management interventions.

In this study, the majority of participants were females compared to males, and most of them were farmers or fishermen. In addition, the majority (approximately 70.0%) were either illiterate, did not complete or had primary education, and over 26.0% were schoolchildren. These demographic features present a population of individuals with potentially higher odds of malaria infections due to low SES (shown to be associated with high odds of malaria infections in this study). Preliminary analysis of the census data collected in this community indicates that the majority of the people with low SES had similar features, which included females from households with low SES compared to their male counterparts, reporting low education levels, and being peasants (Challe, unpublished data). Studies conducted elsewhere also reported that women were more likely to take part in research studies due to their role as caregivers and perceived high risk of malaria compared to males [ 57 ]. In previous studies, it was also shown that low SES was an important risk factor for malaria infections [ 45 , 58 , 59 , 60 ], mainly due to the strong association between malaria and poverty [ 61 , 62 ]. Poor people have a higher risk of malaria infections because they cannot afford the cost of malaria prevention and/or treatment and they lack and/or possess a low level of knowledge and skills required to protect themselves against malaria infections [ 63 ].

Although this study targeted asymptomatic individuals from the community, about one-third (29.9%) of the participants reported that they had a fever in the past 48 h, and only 3.1% had a fever at presentation (measured axillary temperature ≥ 37.5 °C). This could be due to overreporting by study participants in anticipation of getting medicines for malaria because all medical services were given for free (C. Mandara, Pers. Commun). In previous studies, it was observed that study participants reported having malaria or any other febrile illnesses because they wanted to obtain better services from the study team and medicines that were given for free. It was also shown that participants reported illness because they would prefer to be given medicines to keep for future use or to share with family members who were not present at the time of the study, or in case they fell sick later. When data analysis was performed to tease out the relationship between reported fever history and the results of RDTs, there was a significant association between a history of fever and malaria infection as reported elsewhere [ 64 , 65 ]. The high association between fever history in this study could also be due to the high prevalence of malaria in the study villages. Thus, fever history was possibly over-reported by participants in anticipation of receiving better services and medicines. Similarly, there was also a strong association between fever at presentation (axillary temperature ≥ 37.5 °C) and malaria infections, which was similar to the findings of other community studies that showed that fever at presentation was a strong predictor of confirmed malaria infections by RDT and/or microscopy [ 66 ].

The overall malaria prevalence in this community was very high (44.4%), with a higher prevalence among males, and in three of the five villages, the prevalence exceeded 61.0%. There was very high heterogeneity across the five villages that are located close to each other, suggesting that there are critical factors associated with the micro-geographic pattern of malaria in this community. In these villages, most of the malaria-infected individuals were clustered around the lakes highlighting the potential role of these water bodies in mosquito breeding and disease transmission. Further studies are warranted to test this observed clustering and understand its causal nature. A recent survey of malaria vectors which was conducted as part of the MSMT has collected a large number of mosquitoes which are being analysed to determine the species composition and their infectiousness (Derua Y, unpublished data). Once these findings are available and when compared to the prevalence of malaria infections reported in this study, it will possibly be clear that most malaria infections in these villages are perpetuated and sustained by the lakes which provide stable breeding sites throughout the year.

The findings of high and variations in the prevalence of malaria infections in asymptomatic individuals in these villages are similar to what was reported elsewhere [ 56 ], where a high level of heterogeneity at microgeographic levels was reported within the wards from 80 councils of Mainland Tanzania [ 67 ]. Although few studies have assessed the prevalence of malaria in asymptomatic individuals of all age groups in Tanzania, the prevalence reported in this study is likely the highest in the country in recent years. Studies conducted in Tanga reported that the prevalence of malaria among under-fives and school children was higher (≥ 68.0%) between 1992 and 1999 but declined to less than 10.0% in 2012 [ 68 ]. Following an increase and a rebound of malaria in Tanga, the prevalence increased, but the highest was 31.4% in 2015 [ 47 ]. In Rufiji, a decline in prevalence was also reported, and the highest was 90.0% in 1985, while the surveys conducted between 2001 and 2006 reported the highest prevalence of 23.0% [ 69 ]. The causes of this high level of prevalence in these villages of Kyerwa district need to be established to guide specific interventions to reduce the burden of malaria, which will potentially reduce the spread of parasites with ART-R currently circulating in this and other areas of Kagera region.

The age-specific prevalence showed a significantly higher prevalence in school children (aged 5–≤15 years) followed by under-fives, while adults (≥ 15 years) had the lowest prevalence (overall and in each of the five villages). A high prevalence of malaria among school children has consistently been reported in studies conducted in Tanga since 2008 [ 47 ] and was attributed to delays in the development of immunity due to declining transmission and reduced exposure to infectious mosquito bites. A similar trend has been reported in other parts of Tanzania, particularly through school surveys. Over the past 10 years, a high prevalence of malaria among school children has been reported, with the prevalence reaching 76.4% in some district councils [ 21 ]. However, a declining trend of malaria in school children has also been observed in school surveys conducted from 2015 to 2021, with an overall decline from 21.7% in 2015 to 11.3% in 2021 (Chacky et al. Pers. Commun.). In this study, the observed high prevalence of malaria among school children, which was ≥ 75.5% in the three villages (Kitoma, Rubuga and Ruko), needs to be monitored to determine the factors associated with this high burden of malaria in this group. Future studies will also need to focus on the potential lack or low impact of different interventions against malaria in this community, specifically those directed at school children.

Three of the five villages had high bed net use (over 66.0%), two villages had low use (less than 60.0%), and one village had very low use of bed nets (51.8%). In all villages, bed net use was higher among females than males and significantly lower in school children (overall and in each of the five villages). High bed net use among females is possibly due to ongoing campaigns to provide free bed nets to pregnant women at ANC visits in Tanzania [ 52 ]. However, low bed net use by school children could account for the high prevalence of malaria in this group, and this is surprising because a school net programme has been running in Tanzania since 2013 [ 70 ]. This campaign aims to control and reduce the burden of malaria in these children. Although previous studies reported an increase in bed net ownership among school children [ 51 , 71 , 72 ], it is possible that ownership could be high, but bed nets are not routinely used. Additional studies are needed to tease out the level of bed net ownership and use in this community and their impacts on the malaria burden since school children who were expected to be protected by nets still had low use and the highest prevalence of malaria.

In all villages, under-fives had significantly higher bed-net use, followed by adults. In three of the five villages, the use of bed nets among under-fives was closer to or exceeded 80%, which is the cut-off recommended by the WHO. However, under-fives had a higher prevalence of malaria in all villages, although it was lower than that observed in school children. It was also shown that a high proportion of adults were using bed nets and, together with high bed net use among under-fives, this could be due to free bed nets given to children and pregnant women attending ANC clinics in Tanzania [ 73 ]. However, the lack of impact of high bed net use in young children in this community needs to be further explored. Previous studies emphasized the importance of behaviour change in assessing malaria prevalence, specifically in relation to bed net coverage, ownership and use, because ownership may not be directly related to the use of nets. In addition, it has been shown that outdoor biting mosquitoes are the main cause of infections even in areas with high coverage and use of nets, especially when humans spend time outdoors during the early hours of the night [ 74 ]. Therefore, it is crucial to investigate the prevalence of outdoor biting mosquitoes and human behaviour that may expose individuals to malaria infection when outdoors or indoors but not when sleeping under bed nets. Besides the influence of outdoor biting behaviour of some vectors on malaria in areas with high bed net usage, recent studies suggest that mosquito behaviour may change in response to bed net use, and factors such as bed net age, the presence of holes, and the effectiveness of insecticides can play crucial roles [ 75 ]. While the initial analysis was not focused on outdoor exposure during early evening hours, the authors acknowledge the need for a more comprehensive exploration of these variables.

The findings of this study showed that the odds of malaria infections were higher in all villages compared to Nyakabwera, among males compared to females and in under-fives and school children compared to adults. It was also shown that individuals who used bed nets had lower odds of malaria infections compared to those who were not using nets, with non-users having higher odds by over 22.0%. Additional risk factors for malaria infections included low SES, living in houses whose floors are made of mud and houses with open windows as well as the presence of tall vegetation and bushes around the house. As shown in previous studies, low SES and poor housing or living conditions are strongly associated with a higher risk of malaria infections [ 45 , 58 , 59 , 60 ]. This suggests that efforts to eliminate malaria need to target groups at high risk and to consider and concurrently implement strategies for poverty reduction.

Although previous studies have shown high heterogeneity in malaria transmission and risk at the macro-geographic level [ 56 , 76 ], there is a paucity of studies on micro-geographic variations in malaria burden and associated risk factors [ 56 ]. This study highlighted some of the factors but more studies are required to further assess the burden of malaria and the risk factors associated with its transmission at different geographic levels. Additional studies will also be required to determine whether such high transmission will support the spread of resistant parasites in this and other areas of the Kagera region and beyond.

This study had some limitations which may be associated with the use of RDTs, with lower sensitivity compared to molecular methods like PCR, especially in detecting low-level parasitaemia. However, it is crucial to recognize the advantages of RDTs since they provide rapid and cost-effective detection of malaria parasites in field settings, rendering them indispensable tools for prompt detection of malaria infections and large-scale surveillance efforts. The use of convenience sampling is another limitation of this study, as it may introduce bias because participants self-selected themselves based on factors such as accessibility or willingness to participate. Participation could have been possibly influenced by the availability of free medications or services, and opportunities to meet project physicians who are not available in the local dispensary. The study population could have potentially been different in case they were randomly selected from the entire population in the community. This approach might have resulted in a non-representative sample that may not accurately reflect the broader population, thereby limiting the generalizability of the findings. However, the results present similar patterns to what have been reported elsewhere in previous studies possibly suggesting that the selection bias was minimal.

This study showed a high prevalence of malaria infections and high heterogeneity at the micro-geographic level in five villages located next to each other. Groups with higher odds of malaria infections included school children, males, individuals with low SES, living in poorly constructed houses, and non-bed net users. These findings provide important baseline data in an area with a high prevalence of parasites with ART-R and will be utilized in future studies to monitor the trends and potential spread of such parasites, and in designing an ART-R response strategy as well as interventions targeting asymptomatic malaria infections.

Availability of data and materials

The data used in this paper are available and can be obtained upon reasonable request from the corresponding author together with institutional approval by NIMR and signing of a data transfer agreement between the donor and recipient.

Abbreviations

Artemisinin-based combination therapy

Antenatal care clinic

Adjusted odds ratio

Confidence interval

Crude odds ratio

Cross-sectional survey

District malaria focal person

Identification numbers

Integrated malaria molecular surveillance

Intermittent preventive treatment in pregnant women

Indoor residual spraying

Insecticide-treated Net

Interquartile range

Larval source management

Malaria molecular surveillance

Medical Research Coordinating Committee

Molecular surveillance of malaria in Tanzania

Rapid diagnostic tests

National Institute for Medical Research

National Malaria Control Programme

Open Data Kit software

President’s Office, Regional Administration and Local Government

Principal component analysis

Socio-economic status

Sulfadoxine-pyrimethamine

World Health Organization

WHO Regional Office for Africa

WHO. World malaria report 2017. Geneva: World Health Organization; 2017.

Google Scholar  

WHO. World malaria report 2023. Geneva: World Health Organization; 2023.

Riveron JM, Tchouakui M, Mugenzi L, Menze BD, Chiang M-C, Wondji CS. Insecticide resistance in malaria vectors: an update at a global scale. In: Manguin S, Dev V (eds); Towards Malaria Elimination—A Leap Forward. IntechOpen. 2018. https://doi.org/10.5772/intechopen.78375.

Tungu P, Kabula B, Nkya T, Machafuko P, Sambu E, Batengana B, et al. Trends of insecticide resistance monitoring in mainland Tanzania, 2004–2020. Malar J. 2023;22:100.

Article   CAS   PubMed   PubMed Central   Google Scholar  

White NJ. Antimalarial drug resistance. J Clin Invest. 2004;113:1084–92.

WHO Tackling emerging antimalarial drug resistance in Africa. Geneva; World Health Organization; (2022). https://www.who.int/news/item/18-11-2022-tackling-emerging-antimalarial-drug-resistance-in-africa .

Gamboa D, Ho MF, Bendezu J, Torres K, Chiodini PL, Barnwell JW, et al. A large proportion of P . falciparum isolates in the Amazon region of Peru lack pfhrp2 and pfhrp3: implications for malaria rapid diagnostic tests. PLoS One. 2010;5(1):e8091.

Article   PubMed   PubMed Central   Google Scholar  

Rogier E, Battle N, Bakari C, Seth MD, Nace D, Herman C, et al. Plasmodium falciparum pfhrp2 and pfhrp3 gene deletions among patients enrolled at 100 health facilities throughout Tanzania: February to July 2021. Sci Rep. 2024;14:8158.

Faulde MK, Rueda LM, Khaireh BA. First record of the Asian malaria vector Anopheles stephensi and its possible role in the resurgence of malaria in Djibouti Horn Africa. Acta Trop. 2014;139:39–43.

Article   PubMed   Google Scholar  

Tadesse FG, Ashine T, Teka H, Esayas E, Messenger LA, Chali W, et al. Anopheles stephensi mosquitoes as vectors of Plasmodium vivax and falciparum, horn of Africa, 2019. Emerg Infect Dis J. 2021;27:603–7.

Article   Google Scholar  

WHO Calls for reinvigorated action to fight malaria. Geneva; World Health Organization; (2020). https://www.who.int/news/item/30-11-2020-who-calls-for-reinvigorated-action-to-fight-malaria .

Oladipo HJ, Tajudeen YA, Oladunjoye IO, Yusuff SI, Yusuf RO, Oluwaseyi EM, et al. Increasing challenges of malaria control in sub-Saharan Africa: priorities for public health research and policymakers. Ann Med Surg (Lond). 2022;81: 104366.

PubMed   Google Scholar  

President’s Malaria Initiative Tanzania Malaria Operational Plan FY 2015

Mitchell CL, Ngasala B, Janko MM, Chacky F, Edwards JK, Pence BW, et al. Evaluating malaria prevalence and land cover across varying transmission intensity in Tanzania using a cross-sectional survey of school-aged children. Malar J. 2022;21:80.

Hussein AK, Tarimo D, Reaves EJ, Chacky F, Abade AM, Mwalimu CD, et al. The quality of malaria case management in different transmission settings in Tanzania mainland, 2017–2018. PLoS Glob Public Health. 2023;3: e0002318.

Kim MJ, Jung BK, Chai JY, Eom KS, Yong TS, Min DY, et al. High malaria prevalence among schoolchildren on Kome Island Tanzania. Korean J Parasitol. 2015;53:571–4.

Popkin Hall ZR, Seth MD, Madebe RA, Budodo R, Bakari C, Francis F, et al. Malaria species positivity rates among symptomatic individuals across regions of differing transmission intensities in Mainland Tanzania. MedRxib. 2023. https://doi.org/10.1093/infdis/jiad522 .

Sendor R, Banek K, Kashamuka MM, Mvuama N, Bala JA, Nkalani M, et al. Epidemiology of plasmodium malariae and plasmodium ovale spp in a highly malaria-endemic country: a longitudinal cohort study in Kinshasa Province, Democratic Republic of Congo. Medrxiv. 2023. https://doi.org/10.1101/2023.04.20.23288826 .

Mushi V, Mbotwa CH, Zacharia A, Ambrose T, Moshi FV. Predictors for the uptake of optimal doses of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy in Tanzania: further analysis of the data of the 2015–2016 Tanzania demographic and health survey and malaria indicat. Malar J. 2021;20:75.

Ministry of Health (MoH) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey 2022 Final Report [Internet]. Dodoma, Tanzania, and Rockville, USA. 2022.

Chacky F, Runge M, Rumisha SF, MacHafuko P, Chaki P, Massaga JJ, et al. Nationwide school malaria parasitaemia survey in public primary schools, the United Republic of Tanzania. Malar J. 2018;17:452.

Thawer SG, Golumbeanu M, Lazaro S, Chacky F, Munisi K, Aaron S, et al. Spatio-temporal modelling of routine health facility data for malaria risk micro-stratification in mainland Tanzania. Sci Rep. 2023;13:10600.

Accrombessi M, Issifou S. Malaria control and elimination in sub-Saharan Africa: data from antenatal care centres. Lancet Glob Health. 2019;7:e1595–6.

Baltzell K, Harvard K, Hanley M, Gosling R, Chen I. What is community engagement and how can it drive malaria elimination? case studies and stakeholder interviews. Malar J. 2019;18:245.

WHO. Global technical strategy for malaria 2016–2030. Geneva: World Health Organization; 2015.

WHO. Global technical strategy for malaria 2016–2030. Geneva: World Health Organization; 2021.

Odero JO, Nambunga IH, Masalu JP, Mkandawile G, Bwanary H, Hape EE, et al. Genetic markers associated with the widespread insecticide resistance in malaria vector Anopheles funestus populations across Tanzania. Parasit Vectors. 2024;17:230.

Ochomo EO, Milanoi S. Molecular surveillance leads to the first detection of Anopheles stephensi in Kenya. Research Square. 2023. https://doi.org/10.21203/rs.3.rs-2498485/v2 .

Juliano JJ, Giesbrecht DJ, Simkin A, Fola AA, Lyimo BM, Pereus D, et al. Country wide surveillance reveals prevalent artemisinin partial resistance mutations with evidence for multiple origins and expansion of high level sulfadoxine-pyrimethamine resistance mutations in northwest Tanzania. MedRxiv. 2023. https://doi.org/10.1101/2023.11.07.23298207 .

Ishengoma DS, Mandara CI, Bakari C, Fola AA, Madebe RA, Seth MD, et al. Evidence of artemisinin partial resistance in North-western Tanzania: clinical and drug resistance markers study. MedRxiv. 2024. https://doi.org/10.1101/2024.01.31.24301954 .

WHO. Strategy to respond to antimalarial drug resistance in Africa. Geneva: World Health Organization; 2015.

Joseph JJ, Mkali HR, Reaves EJ, Mwaipape OS, Mohamed A, Lazaro SN, et al. Improvements in malaria surveillance through the electronic Integrated Disease Surveillance and Response (eIDSR) system in mainland Tanzania, 2013–2021. Malar J. 2022;21:321.

Lindblade KA, Steinhardt L, Samuels A, Kachur SP, Slutsker L. The silent threat: asymptomatic parasitemia and malaria transmission. Expert Rev Anti Infect Ther. 2013;11:623–39.

Article   CAS   PubMed   Google Scholar  

Slater HC, Ross A, Felger I, Hofmann NE, Robinson L, Cook J, et al. The temporal dynamics and infectiousness of subpatent Plasmodium falciparum infections in relation to parasite density. Nat Commun. 2019;10:1433.

Chaumeau V, Kajeechiwa L, Fustec B, Landier J, Naw Nyo S, Nay Hsel S, et al. Contribution of asymptomatic Plasmodium infections to the transmission of malaria in Kayin State. Myanmar J Infect Dis. 2019;219:1499–509.

Andolina C, Rek JC, Briggs J, Okoth J, Musiime A, Ramjith J, et al. Sources of persistent malaria transmission in a setting with effective malaria control in eastern Uganda: a longitudinal, observational cohort study. Lancet Infect Dis. 2021;21:1568–78.

Sturrock HJW, Hsiang MS, Cohen JM, Smith DL, Greenhouse B, Bousema T, et al. Targeting asymptomatic malaria infections: active surveillance in control and elimination. PLoS Med. 2013;10: e1001467.

Ministry of Health. National Malaria Strategic Plan 2021–2025 (2020). Dodoma, Tanzania; 2020.

Jones AE, Wort UU, Morse AP, Hastings IM, Gagnon AS. Climate prediction of El Niño malaria epidemics in north-west Tanzania. Malar J. 2007;6:162.

Kaaya RD, Matowo J, Kajeguka D, Tenu F, Shirima B, Mosha F, et al. The impact of submicroscopic parasitemia on malaria rapid diagnosis in Northeastern Tanzania, an area with diverse transmission patterns. Infect Dis Rep. 2022;14:798–809.

Hall ZRP, Seth MD, Madebe RA, Budodo R, Bakari C, Francis F, et al. Malaria species positivity rates among symptomatic individuals across regions of differing transmission intensities in Mainland Tanzania. MedRxiv. 2023. https://doi.org/10.1093/infdis/jiad522 .

The United Republic of Tanzania (URT), Ministry of Finance and Planning, Tanzania National Bureau of Statistics and President’s Office-Finance and Planning, Office of the Chief Government Statistician, Zanzibar. The 2022 Population and Housing Census: Administrative Units Population Distribution Report; Tanzania, December 2022 [Internet]. NBS; 2022.

Kamugisha ML, Mmbando BP, Francis F, Ishengoma DS, Challe DP, Lemnge MM. Establishing and implementing demographic surveillance System as a tool for monitoring health interventions in Korogwe District, northastern Tanzania. Tanzan J Health Res. 2011;13:57–67.

Vanden Eng JL, Mathanga DP, Landman K, Mwandama D, Minta AA, Shah M, et al. Assessing bed net damage: comparisons of three measurement methods for estimating the size, shape, and distribution of holes on bed nets. Malar J. 2017;16:405.

Mmbando BP, Kamugisha ML, Lusingu JP, Francis F, Ishengoma DS, Theander TG, et al. Spatial variation and socio-economic determinants of Plasmodium falciparum infection in northeastern Tanzania. Malar J. 2011;10:145.

Ishengoma DS, Francis F, Mmbando BP, Lusingu JPA, Magistrado P, Alifrangis M, et al. Accuracy of malaria rapid diagnostic tests in community studies and their impact on treatment of malaria in an area with declining malaria burden in north-eastern Tanzania. Malar J. 2011;10:1.

Ishengoma DS, Mmbando BP, Mandara CI, Chiduo MG, Francis F, Timiza W, et al. Trends of Plasmodium falciparum prevalence in two communities of Muheza district North-eastern Tanzania: Correlation between parasite prevalence, malaria interventions and rainfall in the context of re-emergence of malaria after two decades of progressive. Malar J. 2018;17:176.

Ministry of Health. National Guidelines for Malaria Diagnosis, Treatment and Preventive Therapies. Dodoma, Tanzania: National Malaria Control Programme; 2020.

Liheluka EA, Massawe IS, Chiduo MG, Mandara CI, Chacky F, Ndekuka L, et al. Community knowledge, attitude, practices and beliefs associated with persistence of malaria transmission in North-western and Southern regions of Tanzania. Malar J. 2023;22:304.

Ministry of Health, Community Development, Gender, Elderly and Children. Standard Treatment Guidelines and National Essential Medicines List for Tanzania Mainland. 2021.

Yukich J, Stuck L, Scates S, Wisniewski J, Chacky F, Festo C, et al. Sustaining LLIN coverage with continuous distribution: the school net programme in Tanzania. Malar J. 2020;19:158.

Koenker H, Worges M, Yukich J, Gitanya P, Chacky F, Lazaro S, et al. Estimating population ITN access at council level in Tanzania. Malar J. 2023;22:4.

West PA, Protopopoff N, Rowland M, Cumming E, Rand A, Drakeley C, et al. Malaria risk factors in North West Tanzania: the effect of spraying, nets and wealth. PLoS ONE. 2013;8: e65787.

Oxborough RM. Trends in US President’s Malaria Initiative-funded indoor residual spray coverage and insecticide choice in sub-Saharan Africa (2008–2015): urgent need for affordable, long-lasting insecticides. Malar J. 2016;15:146.

Lyimo BM, Popkin-Hall ZR, Giesbrecht DJ, Mandara CI, Madebe RA, Bakari C, et al. Potential opportunities and challenges of deploying next generation sequencing and CRISPR-Cas systems to support diagnostics and surveillance towards malaria control and elimination in Africa. Front Cell Infect Microbiol. 2022;12: 757844.

Thawer SG, Golumbeanu M, Munisi K, Aaron S, Chacky F, Lazaro S, et al. The use of routine health facility data for micro-stratification of malaria risk in mainland Tanzania. Malar J. 2022;21:345.

Okiring J, Epstein A, Namuganga JF, Kamya EV, Nabende I, Nassali M, et al. Gender difference in the incidence of malaria diagnosed at public health facilities in Uganda. Malar J. 2022;21:22.

Degarege A, Fennie K, Degarege D, Chennupati S, Madhivanan P. Improving socioeconomic status may reduce the burden of malaria in sub Saharan Africa: a systematic review and meta-analysis. PLoS ONE. 2019;14:0211205.

Makenga G, Baraka V, Francis F, Minja DTR, Gesase S, Kyaruzi E, et al. Attributable risk factors for asymptomatic malaria and anaemia and their association with cognitive and psychomotor functions in schoolchildren of north-eastern Tanzania. PLoS ONE. 2022;17:0268654.

Mwaiswelo RO, Mmbando BP, Chacky F, Molteni F, Mohamed A, Lazaro S, et al. Malaria infection and anemia status in under-five children from Southern Tanzania where seasonal malaria chemoprevention is being implemented. PLoS ONE. 2021;16:0260785.

Tusting LS, Willey B, Lucas H, Thompson J, Kafy HT, Smith R, et al. Socioeconomic development as an intervention against malaria: a systematic review and meta-analysis. Lancet. 2013;382:963–72.

Tusting LS, Rek J, Arinaitwe E, Staedke SG, Kamya MR, Cano J, et al. Why is malaria associated with poverty? findings from a cohort study in rural Uganda. Infect Dis Poverty. 2016;5:78.

Wafula ST, Habermann T, Franke MA, May J, Puradiredja DI, Lorenz E, et al. What are the pathways between poverty and malaria in sub-Saharan Africa? a systematic review of mediation studies. Infect Dis Poverty. 2023;12:58.

Okiro EA, Snow RW. The relationship between reported fever and Plasmodium falciparum infection in African children. Malar J. 2010;9:99.

Fana SA, Bunza MDA, Anka SA, Imam AU, Nataala SU. Prevalence and risk factors associated with malaria infection among pregnant women in a semi-urban community of north-western Nigeria. Infect Dis Poverty. 2015;4:24.

Mutanda AL, Cheruiyot P, Hodges JS, Ayodo G, Odero W, John CC. Sensitivity of fever for diagnosis of clinical malaria in a Kenyan area of unstable, low malaria transmission. Malar J. 2014;13:163.

Ministry of Health. National Malaria Strategic Plan 2021–2025: Transitioning to Malaria Elimination Phase; 2021.

Ishengoma DS, Mmbando BP, Segeja MD, Alifrangis M, Lemnge MM, Bygbjerg IC. Declining burden of malaria over two decades in a rural community of Muheza district, north-eastern Tanzania. Malar J. 2013;12:338.

Färnert A, Yman V, Vafa Homann M, Wandell G, Mhoja L, Johansson M, et al. Epidemiology of malaria in a village in the Rufiji River Delta, Tanzania: declining transmission over 25 years revealed by different parasitological metrics. Malar J. 2014;13:459.

Lalji S, Ngondi JM, Thawer NG, Tembo A, Mandike R, Mohamed A, et al. School distribution as keep-up strategy to maintain universal coverage of long-lasting insecticidal nets: implementation and results of a program in Southern Tanzania. Global Health Sci Pract. 2016;4:251–63.

Stuck L, Lutambi A, Chacky F, Schaettle P, Kramer K, Mandike R, et al. Can school-based distribution be used to maintain coverage of long-lasting insecticide treated bed nets: evidence from a large scale programme in southern Tanzania? Health Policy Plan. 2017;32:980–9.

Stuck L, Chacky F, Festo C, Lutambi A, Abdul R, Greer G, et al. Evaluation of long-lasting insecticidal net distribution through schools in Southern Tanzania. Health Policy Plan. 2022;37:243–54.

Ngasala B, Mwaiswelo RO, Chacky F, Molteni F, Mohamed A, Lazaro S, et al. Malaria knowledge, attitude, and practice among communities involved in a seasonal malaria chemoprevention study in Nanyumbu and Masasi districts Tanzania. Front Public Health. 2023;11: 976354.

Msellemu D, Namango HI, Mwakalinga VM, Ntamatungiro AJ, Mlacha Y, Mtema ZJ, et al. The epidemiology of residual Plasmodium falciparum malaria transmission and infection burden in an African city with high coverage of multiple vector control measures. Malar J. 2016;15:288.

Govella NJ, Ferguson H. Why use of interventions targeting outdoor biting mosquitoes will be necessary to achieve malaria elimination. Front Physiol. 2012;3:199.

Alegana VA, Suiyanka L, Macharia PM, Ikahu-Muchangi G, Snow RW. Malaria micro-stratification using routine surveillance data in Western Kenya. Malar J. 2021;20:22.

Download references

Acknowledgements

Authors are grateful to the participants for their willingness to participate in the CSS and for providing consent as well as taking part in the study. The contribution of the data collection and laboratory teams is highly appreciated. Authors are also grateful to all members of the CSS team who participated in the data collection and/or laboratory processing of samples; they included Ezekiel Malecela, Oswald Oscar, Ildephonce Mathias, Gerion Gaudin, Kusa Mchaina, Hussein Semboja, Sharifa Hassan, Salome Simba, Hatibu Athumani, Ambele Lyatinga, Honest Munishi, Anael Derrick Kimaro, Ally Idrissa and Amina Ibrahim. Special thanks to the finance, administrative, and logistic support teams at NIMR: Christopher Masaka, Millen Meena, Beatrice Mwampeta, Neema Manumbu, Arison Ekoni, Sadiki Yusuph, John Fundi, Fred Mashanda, Amir Tununu and Andrew Kimboi. Support from the Management of NIMR, NMCP, PO-RALG, and the health authorities in Kagera region and Kyerwa district was critical for the success of this CSS and is therefore appreciated. Authors received and appreciate technical and logistics support from partners at Brown University, the University of North Carolina at Chapel Hill, CDC Foundation and from the Bill and Melinda Gates Foundation team.

This work was supported in full by the Bill & Melinda Gates Foundation [grant number INV. 002202]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission.

Author information

Authors and affiliations.

National Institute for Medical Research, Dar es Salaam, Tanzania

Salehe S. Mandai, Misago D. Seth, Rashid A. Madebe, Rule Budodo, Angelina J. Kisambale, Gervas A. Chacha, Ramadhan Moshi, Ruth B. Mbwambo, Dativa Pereus, Catherine Bakari, Celine I. Mandara & Deus S. Ishengoma

National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania

Filbert Francis & Daniel P. Challe

University of Dar es Salaam, Dar es Salaam, Tanzania

Daniel A. Petro

National Malaria Control Programme, Dodoma, Tanzania

Sijenunu Aaron, Daniel Mbwambo, Abdallah Lusasi & Samuel Lazaro

President’s Office, Regional Administration and Local Government, Dodoma, Tanzania

Stella Kajange

Directorate of Preventive Services, Ministry of Health, Dodoma, Tanzania

Ntuli Kapologwe

Faculty of Pharmaceutical Sciences, Monash University, Melbourne, Australia

Deus S. Ishengoma

Harvard T.H Chan School of Public Health, Harvard University, Boston, MA, USA

Department of Biochemistry, Kampala International University in Tanzania, Dar es Salaam, Tanzania

You can also search for this author in PubMed   Google Scholar

Contributions

DSI conceived of the idea, supervised the implementation of the study and data analysis, and was involved in the interpretation of the results. All authors participated in planning and conducting field data collection under the supervision of DSI, SA, SL, SK and NK. FF, DPC and DAP were involved in data collection, analysis and interpretation of the results. DSI and SSM wrote the manuscript, and all authors contributed to the final version. DSI revised and finalized the manuscript, and all the authors read and approved the manuscript.

Corresponding author

Correspondence to Deus S. Ishengoma .

Ethics declarations

Ethics approval and consent to participate.

This CSS was part of the MSMT project, whose protocol was reviewed and approved by the Medical Research Coordinating Committee (MRCC) of the National Institute for Medical Research (NIMR). Permission to conduct the study was sought from the President’s Office, Regional Administration and Local Government (PO-RALG), regional authorities of Kagera and the District Executive Director of Kyerwa. Leaders of Kitwechenkura ward and the five villages were consulted through meetings that were held at the ward level and agreed for this and other components of the MSMT project to be implemented in their communities. Information about the CSS was given in the community through their village mobilization teams for two consecutive days before the survey. Before taking part in the survey, verbal and written informed consent were sought and obtained from all participants or parents/guardians in case of children.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1., supplementary material 2., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Mandai, S.S., Francis, F., Challe, D.P. et al. High prevalence and risk of malaria among asymptomatic individuals from villages with high prevalence of artemisinin partial resistance in Kyerwa district of Kagera region, north-western Tanzania. Malar J 23 , 197 (2024). https://doi.org/10.1186/s12936-024-05019-5

Download citation

Received : 11 October 2023

Accepted : 16 June 2024

Published : 26 June 2024

DOI : https://doi.org/10.1186/s12936-024-05019-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Asymptomatic infections
• Plasmodium falciparum
• Predictors/risk factors of malaria infections
• Artemisinin partial resistance

Malaria Journal

ISSN: 1475-2875

• Submission enquiries: [email protected]

• Open access
• Published: 27 June 2024

The feasibility and usability of mixed reality teaching in a hospital setting based on self-reported perceptions of medical students

• Michael Johnston 1 ,
• Megan O’Mahony 2 ,
• Niall O’Brien 3 ,
• Murray Connolly 4 ,
• Gabriella Iohom 5 ,
• Mohsin Kamal 1 ,
• Ahmed Shehata 1 &
• George Shorten 5  

BMC Medical Education volume  24 , Article number:  701 ( 2024 ) Cite this article

104 Accesses

Metrics details

Clinical teaching during encounters with real patients lies at the heart of medical education. Mixed reality (MR) using a Microsoft HoloLens 2 (HL2) offers the potential to address several challenges: including enabling remote learning; decreasing infection control risks; facilitating greater access to medical specialties; and enhancing learning by vertical integration of basic principles to clinical application. We aimed to assess the feasibility and usability of MR using the HL2 for teaching in a busy, tertiary referral university hospital.

This prospective observational study examined the use of the HL2 to facilitate a live two-way broadcast of a clinician-patient encounter, to remotely situated third and fourth year medical students. System Usability Scale (SUS) Scores were elicited from participating medical students, clinician, and technician. Feedback was also elicited from participating patients. A modified Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions Questionnaire (mETELM) was completed by medical students and patients.

This was a mixed methods prospective, observational study, undertaken in the Day of Surgery Assessment Unit. Forty-seven medical students participated. The mean SUS score for medical students was 71.4 (SD 15.4), clinician (SUS = 75) and technician (SUS = 70) indicating good usability. The mETELM Questionnaire using a 7-point Likert Scale demonstrated MR was perceived to be more beneficial than a PowerPoint presentation (Median = 7, Range 6–7). Opinion amongst the student cohort was divided as to whether the MR tutorial was as beneficial for learning as a live patient encounter would have been (Median = 5, Range 3–6). Students were positive about the prospect of incorporating of MR in future tutorials (Median = 7, Range 5–7). The patients’ mETELM results indicate the HL2 did not affect communication with the clinician (Median = 7, Range 7–7). The MR tutorial was preferred to a format based on small group teaching at the bedside (Median = 6, Range 4–7).

Conclusions

Our study findings indicate that MR teaching using the HL2 demonstrates good usability characteristics for providing education to medical students at least in a clinical setting and under conditions similar to those of our study. Also, it is feasible to deliver to remotely located students, although certain practical constraints apply including Wi-Fi and audio quality.

Peer Review reports

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” William Osler [ 1 ] . The value placed on medical teaching which directly involves patients is widely recognised by teachers and students. The value is attributed to the role it plays in situating learning in the students’ future workplace and to the opportunity to develop understanding of the relevance of basic science to clinical care (vertical integration) [ 2 ]. However, in many undergraduate medical programmes, the amount of time spent in teaching “at the bedside” has declined [ 2 ]. Reasons include the more rapid turnover of patients in hospital and improved forms of diagnostic tests.

In the light of the Covid 19 pandemic, the infection control risk of bringing students to the bedside has become a significant consideration, alongside the additional strain placed on the precious resource of personal protective equipment. Other considerations include the increasing requirement to provide remote learning and the environmental and wellbeing benefits of reducing the number of journeys medical students are required to undertake to attend clinical teaching. The centralisation of medical services has also led to medical students not having uniform exposure to all specialities. Clinical teaching with real patients in clinical tutorials lies at the heart of health professional education [ 3 ]. It provides students with opportunities to practice their history taking; physical examination; and communication skills [ 4 ]. In the discipline of anaesthesia, clinical judgement during preoperative assessment is critically important to minimise risks of rare events such as anaphylaxis [ 5 ] or difficulty in airway management [ 6 ].

Given the advances in technology-enhanced learning, the opportunity exists to support medical students in accessing and learning from clinical encounters by integrating selected artefacts to build and extend mental models from ‘bench-to-bedside’.

Mixed reality (MR) has been utilised in a diverse range of fields, including healthcare. There is now a body of work specifically looking at the applications of the Microsoft HoloLens 2 (HL2), a head-mounted display, MR Device within healthcare education.

The HL2 has been used intraoperatively to displaying complex holographic three-dimensional models based on patients’ pre-operative Computerised Tomography scans and aid surgical navigation [ 7 ]. A study by Bala et al. demonstrated the ability to use the HL2 to deliver a remote access MR ward round, in a real clinical setting and that this was found to be educationally effective and feasible [ 8 ]. Mill et al. also demonstrated live streaming of ward rounds using the HL2 and found the patient and student experience to be good but highlighted issues such as background noise, steep learning curves and Wi-Fi connectivity as barriers to delivery [ 9 ]. Wolf et al. utilised the HL2 to teach medical students the highly technical skill of extracorporeal membrane oxygenation cannulation; the MR group performed significantly fewer errors when compared with the conventional teaching group [ 10 ].

MR refers to a rendered experience blending the physical and digital world. The term mixed reality was first coined in a 1994 paper and defined as merging of real and virtual worlds somewhere along the virtuality continuum which connects completely real environments to completely virtual ones’ [ 11 ] . The blending of real and digital worlds allows users to interact and manipulate with real and virtual elements concurrently.

MR offers a potential solution to a number of challenges in medical education including providing students with meaningful access to patients, across different clinical specialties; infection control issues; and the provision of remote learning. Furthermore, it may serve as an effective means of supporting students in applying previously learned principles to the care of a specific patient who is present.

MR allows for the inclusion of digital artefacts into a real environment. This may offer potential to improve student learning by displaying three dimensional models; overlaying digital artefacts over live patients; utilising gestures and interactive features to highlight information to the learner. Combining audio-visual information may also reduce the cognitive load burden increasing learning efficacy [ 12 ].

Importantly, a MR supported clinical encounter may be used to enable students to associate their learning of basic scientific principles (for instance in anatomy or physiology) to relevant clinical applications; this could provide a valuable addition to teaching approaches integrating basic science knowledge and understanding with specific clinical challenges [ 13 , 14 ].

The HL2 allows a live clinical encounter can be streamed to remote users. The HL2 is head-mounted device with a built-in camera which shows exactly what the tutor can see but with the addition of mixed reality allowing digital artefacts to be placed into the real environment. This stream of audio-visual data from the HL2 can be streamed to students situated remotely either on a single or to multiple devices. Bidirectional sound allows for the students, clinician, and patient to communicate in a manner similar to conventional bedside teaching. There is no upper limit on the number of students who could join the scenario remotely, unlike with conventional bedside teaching where only small groups are realistic. MR teaching may also uniform access and exposure to all specialities for medical students.

Given the inevitable challenges of introducing a new technology into the already complex healthcare environment we set out to examine the usability and feasibility of using the HL2 for teaching medical students. We examined this question using a prospective, observational, mixed methods study design. The tutorials were designed around clinical encounters with real patients during their perioperative pathway, and within a busy tertiary referral hospital.

Methodology

The study was approved by the Clinical Research Ethics Committee of the Cork Teaching Hospitals. All patient and student participants provided written informed consent prior to participating in the study. All participants were aged over 18 years and deemed to have capacity to consent prior to enrolment in the study.

Student participants

This study examined the use of the HL2 to facilitate a live two-way broadcast of a clinician patient encounter, utilising MR features of the HL2 device, which was streamed to Fourth Year Direct Entry and Third Year Graduate Entry University College Cork medical students. Medical students were invited to participate in the study which took place during their one-week placement in anaesthesia and intensive care medicine. Those invited to participate constituted a convenience sample as they were members of eight student groups (group size 3–10 students) scheduled to undertake this attachment from January 13th to March 31st 2023. The study took place in Cork University Hospital, a busy tertiary referral teaching hospital. All patients who participated were located on the Day of Surgery Assessment (DOSA) Unit having had their day case surgery completed. Background data was collected on medical students including age and previous degree level qualifications.

Technical set-up

The tutorials took place on a once weekly basis from January to March 2023 ( n  = 8). All tutorials were delivered by a clinician investigator (MJ) and all sessions were facilitated by another investigator (NB). NB had significant prior experience with MR including specific experience with the HL2 Device.

NB facilitated the audio and visual connection between the clinical encounter and the tutorial room. MJ underwent informal training of how to use the Microsoft HoloLens 2 which took approximately 8 h to gain a working knowledge and an appreciation of the hand gestures required for smooth operation (comprising 4 h Microsoft remote assistance).

MJ wore the HL2 as a head mounted device and was face to face with the patient. The software package Microsoft Remote Assist alongside Microsoft Teams was used to enable a live two-way broadcast to the remote environment where the medical students were situated. The Cork University Hospital institutional Wi-Fi was used to transmit the broadcast. This provided a secure encrypted password protected network.

Medical students were situated remotely in a tutorial room with the facilitator NB they were able to communicate directly with the clinician via a microphone and audio was provided via an external speaker. The clinician was able to communicate with the students via an external microphone on the HL2 Device and audio was provided by Headphones attached to HL2. The students were unable to communicate directly with the patient, but the clinician could act as a conduit for any questions (see Fig.  1 ).

Physical set up of MR tutorial. Technician located with medical students in tutorial room. Clinician wearing HL2 with patient in Day of Surgery Admission Unit (DOSA)

Hardware requirements were as follows:

• Microsoft HoloLens 2

Saramonic External Microphone (HoloLens 2)

Apple 3.5mm Headphones (HoloLens 2)

BeoPlay A1 Portable Bluetooth Speaker (Tutorial Room)

Rode Compact Directional Microphone (Tutorial Room)

Laptop capable of running Microsoft Teams

Tutorial structure

At completion of their one-week anaesthesia and intensive care module the medical students attended for a mandatory three-hour tutorial comprising three sections; clinical case presentation; airway assessment; and 20 multiple choice questions on anaesthesia. Following the tutorial, the students had a 20-min break and then the students who had chosen to participate underwent the MR clinical airway tutorial. All MR tutorials were delivered by the same clinician (MJ) and the same technical facilitator (NB).

The MR tutorial involved performing a basic airway assessment of a real patient and during this process the clinician was able to populate the shared view with artefacts to illustrate key teaching points such as the Mallampati score and mandibular protrusion test (see Fig.  2 ). A picture of a patient with several features of a difficult airway was then displayed and the students were asked to highlight concerning features. The second section of the tutorial focussed on clinical anatomy, a three-dimensional rendering of the upper airway was displayed, which could be rotated; zoomed in to; and highlighted using hand gestures within the HoloLens software. Collectively the students were asked to label the anatomical features and MJ further questioned the students on the clinical relevance of the anatomy.

Artefact demonstrating Mallampati score alongside patient

The following purchases were required to facilitate the tutorials. Microsoft HoloLens 2 device (€3500), Saramonic external microphone for HoloLens 2 (€88), headphones for HoloLens 2 (€10), portable BeoPlay speaker for tutorial room (€250), Rode microphone for tutorial room (€57), annual licence cost for HoloLens (€275) n  = 2. In addition, NB provided his personal laptop, HDMI cable, and the tutorial room was equipped with a 36-inch, high-definition monitor to mirror the laptop screen onto.

The System Usability Scale (SUS) was employed to assess the usability of the MR environment for teaching. SUS were completed by all 3 of the relevant parties: medical students, teaching clinician, and technician. SUS forms were completed immediately after the tutorial.

A modified Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions Questionnaire (mETELM) was completed by the medical students and patients, which used a 7-point Likert scale. The questionnaire included questions on previous experience with mixed or virtual reality; feasibility data relating to visual clarity and three-way audio broadcast; and data about how the MR tutorial compared with both a conventional PowerPoint presentation and in-person bedside teaching. There was also an area for free text feedback.

Although learning efficacy attributable to the HL2 use was not formally or comprehensively assessed, we examined academic performance (based on the end of year Objective Structured Clinical Examinations results in the airway examination station) for students who attended the MR tutorial compared with those who just underwent the conventional teaching.

This was a mixed methods prospective observational study, which took place in a busy tertiary referral hospital in the Day of Surgery Assessment Unit involving real patients on their perioperative journey.

Eight clinical tutorials involving 8 separate patients took place between 13/1/23 and 31/3/23. Of a total of 53 medical students who were eligible to participate in this study (as scheduled to attend MR tutorial) 47 elected to participate having provided written informed consent. The 47 medical students comprised of 21 males and 26 females. The participants comprised 18 graduate entry third medical students (mean age = 28.5 years, SD = 3.78) and 29 Direct entry fourth year medical students (mean age = 22.3 years, SD = 0.97).

All 47 medical students fully completed the SUS and the mETELM Questionnaire. The Clinician and technician also completed the SUS.

Of the 8 patients who participated (having provided written informed consent), 7 completed the mETELM questionnaire. 1 patient did not complete the mETELM due to feeling nauseous.

Overall, a mean score of 71.4 (SD = 15.4) on the SUS was elicited from the 47 participating medical students (See Fig.  3 ). A SUS score of 68 is considered to demonstrate satisfactory usability, with a score of 68- 80.3 considered good usability and > 80.3 considered excellent usability [ 15 ]. Therefore, we can state that, in the context of our study, the medical students found the HL2 to have good usability characteristics.

SUS Score- Medical Students

The clinician/teacher (MJ) and education technician (NB) also completed the SUS (score = 75 and 70 respectively). The clinician/teacher and technician were generally positive about use of the device. The clinician teacher found the HL2 to be comfortable to wear, to provide an unrestricted field of view and have good battery life. However, he found that the process of opening up the three-dimensional airway model to be time consuming, as it involved opening Microsoft edge web browser and then opening and expanding the model, (taking approximately 30 s).

Student and patient mETELM questionnaires

The students mETELM Questionnaire responses are displayed in Fig.  4 . There was limited previous experience with MR, but significant experience with gaming consoles and computers. Audio and video quality was felt to be clear. The MR tutorial was felt to be universally more beneficial than a PowerPoint presentation and replicate a live patient encounter. The results were borderline for if the MR tutorial was as beneficial as a live patient encounter. MR seemed to support learning, and there was a positive response to further MR teaching being incorporated into future tutorials. It was felt that the tutorial did not require inappropriately high technical skills, and that MR was not a distraction from the content of the tutorial.

Students mETELM Questionnaire responses. Median and Interquartile Range displayed

The patients mETELM Questionnaire responses (see Fig.  5 ) suggest the HL2 did not affect communication with the doctor but did form a distraction to some patients. The HL2 did not make patients feel uncomfortable and they felt safe during the sessions. Interestingly, patients collectively expressed a preference for the MR supported tutorial format over small or large student group tutorials at their bedside; most patients described the MR enabled tutorials as an enjoyable experience and indicated that they would favour participating in similar tutorials again.

Patient mETELM Questionnaire responses. Median and interquartile range displayed feasibility

Overall, we found that it was feasible to deliver teaching using the HL2 in a live clinical environment, but we encountered certain significant barriers. The institutional Wi-Fi was generally acceptable for providing adequate quality audio and visual streams, but on occasion connectivity dropped and was not resumed until the laptop and HL2 had both been restarted. Our occasional attempts to record a session would significantly reduce the quality of the connection, forcing us to restart both the HL2 and laptop. Despite this we always managed to run the MR tutorials but sometimes there would be delays of up to 15 min whilst we established a good quality connection. After 2 tutorials we improved the student’s ability to communicate with the clinician with the addition of an external microphone in the tutorial room.

Prior to delivery of the teaching the clinician had to learn how to use the HL2 device, a process which took around 8 h. The technician was already familiar with the HL2 and Microsoft Teams and Remote Assist. There were significant costs in terms of hardware, software, and licensing to run MR tutorials with the HL2.

Additional findings

Representative quotes from students’ free text are on mETELM questionnaire are detailed below in Table  1 .

The medical students completed an end of year OSCE on airway examination. The OSCE was 50% related to what we taught in the HL2 tutorial and 50% related to other aspects of airway management. The interval between the HL2 tutorial and the OSCE varied significantly between students from 6 weeks to 4 months. The airway OSCE was scored out of 50. The scores for students who completed the HL2 tutorial ( n  = 47) and those who had conventional teaching only ( n  = 139) were similar (HL2 teaching- mean 45.1, SD 4.9, versus conventional teaching- mean 44.1, SD 7.0). The unpaired student t-test two tailed value was 0.58. No difference in learning efficacy was found between the HL2 group and those who underwent conventional teaching.

The most important finding of this study is that the HL2 demonstrates good usability characteristics for providing clinical education to medical students in a real clinical setting. Within the infrastructure of a busy teaching hospital and using institutional Wi-Fi, it is feasible to deliver bedside clinical teaching to a group of remotely located medical students. We propose that MR-enhanced teaching may allow for educational institutions to provide consistent and uniform access to clinical teaching.

We also found that students expressed great openness to and enthusiasm for this way of learning, both in their Questionnaire responses and at semi structured interview. This provides encouragement for future use of MR devices within the clinical space.

Our findings are broadly consistent with others which have demonstrated that that the teaching of medical students within a variety of clinical environments using MR showed good usability and feasibility characteristics and are generally acceptable to patients, students, and teachers [ 8 , 9 , 16 , 17 , 18 ]. Mill et al. highlighted some issues similar to those we experienced regarding Wi-Fi connectivity, and background noise disrupting sessions [ 9 ]. Our study results are also consistent with those of Levy et al. in that some patients preferred and felt more comfortable having a single clinician wearing a HL2 compared with having a group of healthcare professionals at the bedside [ 19 ].

A review article by McBain et al. examined the effect of using virtual, augmented and mixed reality to teach clinical anatomy to medical students using three dimensional digital models and our study showed globally similar positive findings with regards to usability and feasibility [ 20 ]. Other investigators have also noted (in the context of a clinical teaching during a pandemic) that the HL2 can facilitate ongoing delivery of clinical teaching with a lesser need for personal protective equipment use and increased safety for all [ 21 ].

Our study was relatively novel as it was implemented within a busy clinical environment with real patients on their perioperative pathway. The usability data we collected employed two different tools (SUS and mETELM) and rendered similarly positive results. We interpret that similarity as supporting the validity of our findings. Our usability dataset was elicited from the different perspectives of medical students, a clinician, patients, and a technician. (Only one patient did not complete the mETELM Questionnaire).

The ETELM instruments were designed originally by Cook et al. [ 22 ] using a combined inductive/ deductive approach and comprehensive literature review to ensure that relevant domains were captured (based on frameworks widely applied to mainstream education) and inclusion of specific items of relevance to health professionals’ education. The designers specify that the ETELM instrument is intended to be adapted to “context and situation-specific needs” [ 22 ]. We did not conduct within-study assessments of face, content, or test–retest validity of the mETELM. The risk that the information elicited using this instrument is invalid may be offset by the selection of an instrument specifically designed both for educational technology and for health professional learners.

All MR teaching was delivered by a single clinician which ensured uniformity of teaching style and approach. Three-way communication between patient, clinician and medical students allowed for communication in a similar style to in person bedside teaching. A different patient participated in each clinical tutorial leading to a diverse range of clinical findings and discussion points.

Utilising the HL2 technology to provide both a clinical tutorial involving a real patient and then progressing onto three-dimensional anatomy teaching demonstrated the capabilities of the device, utilising the basic audio-visual streaming features, with adjacent MR artefacts.

This was a relatively small study with a limited number ( n  = 47) of medical students participating. The study only focused on a single highly specific clinical domain. The study took place in one location (DOSA) in one hospital; therefore, our findings cannot necessarily be extrapolated to other hospital environments. Because the patients who participated were all elective patients on a day case surgical pathway, our findings cannot necessarily be extrapolated to patients of different backgrounds or differing degrees of acuity. We did not assess the feasibility of streaming the sessions to multiple personal devices.

Use of MR clinical teaching via a device like the HL2 is feasible and has positive usability characteristics. The feedback reported in this study indicates that MR offers potential for technology enhanced learning and specifically to improve vertical integration within an undergraduate medical curriculum.

There are many potential future applications of MR technology within the healthcare setting. These may include bedside teaching in more diverse environments, sharing three dimensional models during surgery, anatomy teaching including specific applications within regional anaesthesia.

One possibility to scale a MR enabled learning resource would be a library of MR teaching sessions which students would be able to access at their own discretion to allow for uniform access to clinical teaching and a potentially unlimited number of students to participate. This set up would be enhanced further by collecting engagement data from students and embedding pop quizzes into the tutorials. Allowing students to use their own devices to join sessions clearly offers practicality benefits to the students and environmental benefits but raises questions regarding data protection and maintaining confidentiality.

Although we do not provide here enough information to provide a needs analysis for scaling up or transferring the type of mixed reality teaching described to other institutions, our results indicate that faculty training, suitably chosen hardware and software, secure and reliable Wi-Fi will be pre-requisites.

The HL2 has a training curve associated with basic competence and an interesting area of research would be to ascertain how long it would take a group of clinicians to become competent to deliver a clinical tutorial using the device. With a larger group of trained clinicians, a more diverse range of subjects could be delivered using MR.

Our results point to the likelihood of employing MR to apply basic science principles to clinical practice (including diagnosis and management decisions). It will be important to examine whether this potential can be realised without distracting or overwhelming the learner. Further work on this question is warranted.

The most important finding of this study is that MR supported teaching using the HL2 demonstrates good usability characteristics for providing clinical education to medical students at least in a clinical setting and under circumstances similar to those we describe here. Within the infrastructure of a busy teaching hospital and using institutional Wi-Fi it is feasible to deliver teaching related to clinical encounters to remotely located medical students, although certain practical constraints apply including the quality of Wi-Fi and audio connections.

Availability of data and materials

Any data used by the authors can be made available if requested. Please contact corresponding author Michael Johnston if required.

Abbreviations

• Mixed reality

modified Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions Questionnaire

System Usability Scale

Day of Surgery Assessment Unit

University College Cork

Stone MJ. The wisdom of sir William Osler. Am J Cardiol. 1995;75(4):269–76. https://doi.org/10.1016/0002-9149(95)80034-p .

Article   Google Scholar  

Peters M, Ten Cate O. Bedside teaching in medical education: a literature review. Perspect Med Educ. 2014;3(2):76–88. https://doi.org/10.1007/s40037-013-0083-y .

Burgess A, van Diggele C, Roberts C, Mellis C. Key tips for teaching in the clinical setting. BMC Med Educ. 2020;20(Suppl 2):463. https://doi.org/10.1186/s12909-020-02283-2 .

Hafler JP, Ownby AR, Thompson BM, Fasser CE, Grigsby K, Haidet P, et al. Decoding the learning environment of medical education: a hidden curriculum perspective for faculty development. Acad Med. 2011;86(4):440–4. Available from: https://journals.lww.com/academicmedicine/fulltext/2011/04000/Decoding_the_Learning_Environment_of_Medical.12.aspx . Cited 2023 May 31

Anaphylaxis during Anesthesia in Norway A 6-Year Single-center Follow-up Study Torkel Harboe. Anesthesiology. 2005;102:897–903.

Shorten GD, Alfille PH, Gliklich RE. Airway obstruction following application of cricoid pressure. J Clin Anesth. 1991;3(5):403–5. https://doi.org/10.1016/0952-8180(91)90185-p .

Wang L, Zhao Z, Wang G, Zhou J, Zhu H, Guo H, et al. Application of a three-dimensional visualization model in intraoperative guidance of percutaneous nephrolithotomy. Int J Urol. 2022;29(8):838–44. https://doi.org/10.1111/iju.14907 .

Bala L, Kinross J, Martin G, Koizia LJ, Kooner AS, Shimshon GJ, et al. A remote access mixed reality teaching ward round. Clin Teach. 2021;18(4):386–90. https://doi.org/10.1111/tct.13338 .

Mill T, Parikh S, Allen A, Dart G, Lee D, Richardson C, et al. Live streaming ward rounds using wearable technology to teach medical students: a pilot study. BMJ Simul Technol Enhanc Learn. 2021;7(6):494–500. https://doi.org/10.1136/bmjstel-2021-000864 .

Wolf J, Wolfer V, Halbe M, Maisano F, Lohmeyer Q, Meboldt M. Comparing the effectiveness of Augmented reality-based and conventional instructions during single ECMO cannulation training. Int J Comput Assist Radiol Surg. 2021;16(7):1171–80. https://doi.org/10.1007/s11548-021-02408-y .

Milgram P, Kishino F. A taxonomy of Mixed Reality visual displays. IEICE Trans Inf Syst. 1994;E77-D(12):1321–9. Available from: https://search.ieice.org/bin/summary.php?id=e77-d_12_1321 . Cited 2023 May 31

Rudolph M. Cognitive theory of multimedia learning. Ufsc.br. Available from: https://moodle.ufsc.br/pluginfile.php/3883644/mod_resource/content/1/Rudolph%202017%20Cognitive%20Theory%20of%20Multimedia%20Learning.pdf . Cited 2023 May 31

Wijnen-Meijer M, van den Broek S, Koens F, Ten Cate O. Vertical integration in medical education: the broader perspective. BMC Med Educ. 2020;20(1):509. https://doi.org/10.1186/s12909-020-02433-6 . Cited 2023 May 31.

Brauer DG, Ferguson KJ. The integrated curriculum in medical education: AMEE Guide No. 96. Med Teach. 2015;37(4):312–22. https://doi.org/10.3109/0142159X.2014.970998 .

Will T. Measuring and interpreting System Usability Scale (SUS). UIUX Trend. 2017. Available from: https://uiuxtrend.com/measuring-system-usability-scale-sus/ . Cited 2023 May 31

Sivananthan A, Gueroult A, Zijlstra G, Martin G, Baheerathan A, Pratt P, et al. Using mixed reality headsets to deliver remote bedside teaching during the COVID-19 pandemic: Feasibility trial of HoloLens 2. JMIR Form Res. 2022;6(5):e35674. Available from: https://formative.jmir.org/2022/5/e35674 . Cited 2023 May 31

Rafi D, Stackhouse AA, Walls R, Dani M, Cowell A, Hughes E, et al. A new reality: Bedside geriatric teaching in an age of remote learning. Future Healthc J. 2021;8 (3):e714–6. Available from: https://www.rcpjournals.org/content/futurehosp/8/3/e714 . Cited 2023 May 31

Minty I, Lawson J, Guha P, Luo X, Malik R, Cerneviciute R, et al. The use of mixed reality technology for the objective assessment of clinical skills: a validation study. BMC Med Educ. 2022;22(1):639. https://doi.org/10.1186/s12909-022-03701-3 .

Levy JB, Kong E, Johnson N, Khetarpal A, Tomlinson J, Martin GF, et al. The mixed reality medical ward round with the MS HoloLens 2: Innovation in reducing COVID-19 transmission and PPE usage. Future Healthc J. 2021;8(1):e127–30. Available from: https://www.rcpjournals.org/content/futurehosp/8/1/e127 . Cited 2023 May 31

McBain KA, Habib R, Laggis G, Quaiattini A, M Ventura N, Noel GPJC. Scoping review: The use of augmented reality in clinical anatomical education and its assessment tools. Anat Sci Educ. 2022;15(4):765–96. Available from: https://doi.org/10.1002/ase.2155 .

Martin G, Koizia L, Kooner A, Cafferkey J, Ross C, Purkayastha S, et al. Use of the HoloLens2 mixed reality headset for protecting health care workers during the COVID-19 pandemic: Prospective, observational evaluation. J Med Internet Res. 2020;22(8):e21486. Available from: https://www.jmir.org/2020/8/e21486/ . Cited 2023 May 31

Cook DA, Ellaway RH. Evaluating technology-enhanced learning: A comprehensive framework. Med Teach. 2015;37(10):961–70. Available from: https://pubmed.ncbi.nlm.nih.gov/25782599/ . Cited 2024 Jan 16

Download references

Acknowledgements

Not applicable.

This study was supported by UCC Dept of Anaesthesia.

Author information

Authors and affiliations.

Peripheral Nerve Block Fellow, Cork University Hospital, Cork, Ireland

Michael Johnston, Mohsin Kamal & Ahmed Shehata

Medical Student, University College Cork, Cork, Ireland

Megan O’Mahony

Department of Anaesthesia, University College Cork, Cork, Ireland

Niall O’Brien

Coombe Women’s and Infants University Hospital, Dublin, Ireland

Murray Connolly

Anaesthesiologist Cork University Hospital, University College Cork, Cork, Ireland

Gabriella Iohom & George Shorten

You can also search for this author in PubMed   Google Scholar

Contributions

All authors contributed in a meaningful way to generating the manuscript. MJ was lead author, led the organisation, planning and data collection, and led all MR tutorials. NB acted as a facilitator for all sessions and contributed significantly to the technical set up and planning of the study. GS had the overview of the whole project and how it fits into previous work, GS also contributed significantly to the manuscript. MM conducted the semi structured interviews and contributed to the manuscript. MC provided guidance based on his experience of using HL2. GI, AS and MK contributed to facilitating the tutorials.

Corresponding author

Correspondence to Michael Johnston .

Ethics declarations

Ethics approval and consent to participate.

The study was approved by the Clinical Research Ethics Committee of the Cork Teaching Hospitals and the guidance and regulations offered by the Clinical Research Ethics Committee of the Cork Teaching Hospitals and Helsinki declaration were followed. All patient and student participants provided written informed consent prior to inclusion in the study. All participants were aged over 18 years and deemed to have capacity to consent prior to enrolment in the study.

Consent for publication

All patient and student participants provided written informed consent prior to inclusion in the study. It was explicitly stated that the aim of the study was to publish the results in a medical journal but there would be no identifiable patient or student data. With relation to the image in Fig.  2 written informed consent was obtained from the participant for the publication of the information/images in an open access publication.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Johnston, M., O’Mahony, M., O’Brien, N. et al. The feasibility and usability of mixed reality teaching in a hospital setting based on self-reported perceptions of medical students. BMC Med Educ 24 , 701 (2024). https://doi.org/10.1186/s12909-024-05591-z

Download citation

Received : 18 July 2023

Accepted : 22 May 2024

Published : 27 June 2024

DOI : https://doi.org/10.1186/s12909-024-05591-z

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Augmented reality
• Feasibility
• Undergraduate
• Medical students
• Technology enhanced learning

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
• General enquiries: [email protected]