What does monkey malaria mean to you? A participatory photovoice study in rural Malaysian Borneo

Zoonotic (monkey) malaria, caused by Plasmodium knowlesi, is an escalating concern in Sabah, Malaysia, where humans, macaques and mosquito vectors share overlapping ecosystems. Conventional research methods often overlook how affected communities perceive and respond to this risk within their cultural and environmental contexts. This study uses photovoice, a participatory visual method to explore the question 'What does monkey malaria mean to you? and to elevate community voices in guiding locally relevant disease prevention strategies.

From January to May 2024, twenty participants aged 18 to 62 from three rural Sabah villages captured photographs over a 20-day period using their smartphones to document their experiences and perceptions on monkey malaria. Follow-up focus group discussions (FGDs) enabled participants to collectively reflect on and interpret their images. Reflexive thematic analysis was applied to the visual and verbal data and findings. Digital tools supported coordination and data management without replacing the participant-researcher engagement.

Five interrelated themes were generated: (1) monkey malaria as an embedded, everyday risk, (2) community resilience manifested through locally derived practices, (3) structural and socio-ecological challenges shaping exposure, (4) the interface of human, wildlife, and environmental health, (5) cultural knowledge and blended practices for coping with malaria risk. Participants articulated how landscape features, economic dependence on forested and plantation areas, and daily routines collectively structure risk, reflecting a dynamic 'landscape of risk'. They also expressed aspirations for collaborative and culturally appropriate strategies.

Using photovoice, participants described how malaria risk is part of their everyday lives, the coping strategies they use and the social and environmental conditions that influence their understanding. By prioritising community voices, the findings show that effective malaria control should go beyond strictly biomedical models to include local priorities, cultural practices and lived experience. Photovoice generated deep insights grounded in the community context and encouraged meaningful participation, providing useful guidance for designing intervention strategies that are culturally appropriate and more sustainable.