102440 Das et al. Malaria Journal 2013, 12:39 http://www.malariajournal.com/content/12/1/39 RESEARCH Open Access Community perceptions on malaria and care-seeking practices in endemic Indian settings: policy implications for the malaria control programme Ashis Das1*, RK Das Gupta2, Jed Friedman1, Madan M Pradhan3, Charu C Mohapatra3 and Debakanta Sandhibigraha3 Abstract Background: The focus of India’s National Malaria Programme witnessed a paradigm shift recently from health facility to community-based approaches. The current thrust is on diagnosing and treating malaria by community health workers and prevention through free provision of long-lasting insecticidal nets. However, appropriate community awareness and practice are inevitable for the effectiveness of such efforts. In this context, the study assessed community perceptions and practice on malaria and similar febrile illnesses. This evidence base is intended to direct the roll-out of the new strategies and improve community acceptance and utilization of services. Methods: A qualitative study involving 26 focus group discussions and 40 key informant interviews was conducted in two districts of Odisha State in India. The key points of discussion were centred on community perceptions and practice regarding malaria prevention and treatment. Thematic analysis of data was performed. Results: The 272 respondents consisted of 50% females, three-quarter scheduled tribe community and 30% students. A half of them were literates. Malaria was reported to be the most common disease in their settings with multiple modes of transmission by the FGD participants. Adoption of prevention methods was seasonal with perceived mosquito density. The reported use of bed nets was low and the utilization was determined by seasonality, affordability, intoxication and alternate uses of nets. Although respondents were aware of malaria-related symptoms, care-seeking from traditional healers and unqualified providers was prevalent. The respondents expressed lack of trust in the community health workers due to frequent drug stock-outs. The major determinants of health care seeking were socio-cultural beliefs, age, gender, faith in the service provider, proximity, poverty, and perceived effectiveness of available services. Conclusion: Apart from the socio-cultural and behavioural factors, the availability of acceptable care can modulate the community perceptions and practices on malaria management. The current community awareness on symptoms of malaria and prevention is fair, yet the prevention and treatment practices are not optimal. Promoting active community involvement and ownership in malaria control and management through strengthening community based organizations would be relevant. Further, timely availability of drugs and commodities at the community level can improve their confidence in the public health system. Keywords: Malaria, Prevention, Treatment, Sociocultural belief, Community response, India * Correspondence: adas8@worldbank.org 1 The World Bank, Washington, DC, USA Full list of author information is available at the end of the article © 2013 Das et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Das et al. Malaria Journal 2013, 12:39 Page 2 of 12 http://www.malariajournal.com/content/12/1/39 Background and the determinants on community-based approaches Malaria is still a major global public health concern, des- in India. Further, qualitative studies providing deeper pite many countries especially in the endemic Afro- understanding of the pathways of health care seeking on Asian settings, having paid a considerable focus on its malaria are scarce in the country. control [1]. India reports the highest malaria burden in This study aimed at generating evidence on the existing the Southeast Asia region with 61% of the regional mal- community perceptions, practices and their determinants aria cases [2]. In India, the malaria endemic central, east- on malaria control and management to complement the ern and north-eastern regions are characterized by ongoing community-based malaria control programme. substantial indigenous population, difficult terrains, low The study findings will help the programme for evidence- socio-economic development and less developed infra- based policy development and programme management structure [3,4]. for effective malaria control. This qualitative exploration Strengthening the availability of effective and afford- was undertaken in the State of Odisha. In 2010, Odisha able care has been a key strategy of all malaria-endemic contributed the highest number of malaria cases and countries [1]. However, these supply-side strategies were deaths in India [3]. sub-optimally effective, as there was not adequate syn- ergy between the service delivery and the community Methods responses to it [1]. Thus, a concept has emerged as Study setting ‘community-based management of malaria’ with a thrust The study was conducted between November 2009 and of positively shifting the community responses towards January 2010 in the districts of Mayurbhanj and Sun- improvements in healthcare delivery [5]. Yet, as per the dargarh of Odisha State (Figure 1). The NVBDCP existing global evidence, such community approaches selected these malaria-endemic districts to pilot the are ineffective to improve people’s care seeking, if their new programme interventions on community-based perceptions are not formulated and altered positively [6]. management of malaria through the ASHA. The north- Among the known attributes of community perceptions eastern district Mayurbhanj is the largest district (area: and practices on malaria are their sociocultural and be- 10,418 sq km) and has the third highest share of popu- havioural factors [6]. There is evidence that the availabil- lation (2,223,456) in the State [9]. It has a 51.9% literacy ity of services alone may not ensure healthy practices, as rate, 57% indigenous tribes, 42% forest cover and 7% they could be influenced by sociocultural barriers and urbanization [9]. The north-western district Sundargarh inappropriate understanding of the disease aetiology [6]. is the second largest district (area: 9,712 sq km) with Community perceptions and attitudes are essential the sixth highest population (1,830,673) in the State. It inputs into healthy behaviours as they influence the has 64.9% literacy rate, 50.2% indigenous tribes, 34% pathways on symptom recognition, perceived disease urbanization and 43% forest cover [10]. Subsistence seriousness, utilization of services, and eventual health farming and manual labour are the major economic ac- outcomes [7]. In the context of a community-based ap- tivities of the inhabitants in these districts. proach, the understanding of community perceptions During 2009, Mayurbhanj and Sundargarh witnessed and practices are crucial for the policy makers to embed 10,798 and 20,796 malaria cases with eight and 12 reported the disease control interventions into the socio-cultural deaths due to malaria respectively. More than 90% were dimensions of the community for effective adoption of falciparum malaria cases in both districts. Among the 30 healthy practices. Odisha districts, Sundargarh ranked seventh and Mayurb- hanj was 15th on the number of reported malaria cases in Rationale 2009 (State Malaria Office, Odisha, pers comm). India has witnessed a slow reduction in disease burden, Each district is further administratively divided into particularly of falciparum malaria, despite considerable ‘blocks’ with an average population of 100,000. Two such investments on malaria control [5]. Recently, its malaria endemic blocks with annual parasite incidence above five programme, embedded under the National Vector Borne (laboratory-confirmed malaria cases per 1,000 population) Disease Control Programme (NVBDCP), has introduced from each district were randomly selected for this study. a shift towards community-level management of malaria. Now, the village-based community health worker, known Study design and sampling as accredited social health activist (ASHA), undertakes This exploratory qualitative study was cross-sectional diagnosis and management of uncomplicated malaria in and employed focus group discussions (FGD) and key high-burden districts [8]. In addition, malaria prevention informant interviews (KII). A total of 26 FGDs and 40 is supported by the introduction of long-lasting insecti- KIIs were conducted in four endemic blocks in two dis- cide-treated nets (LLIN) [8]. However, little is known tricts. The number of interviews was decided on the about the knowledge, attitude and practice on malaria basis of data saturation. There were separate FGD Das et al. Malaria Journal 2013, 12:39 Page 3 of 12 http://www.malariajournal.com/content/12/1/39 Figure 1 Location of study area (Mayurbhanj and Sundargarh districts in Odisha State). Source: www.mapsofindia.org. samples for adult men (Mayurbhanj n=4; Sundargarh prevention and treatment and factors affecting their per- n=5), adult women (Mayurbhanj n=5; Sundargarh n=4) ceptions and practices. The objective of KIIs was to under- and children aged 12 to 15 years (Mayurbhanj n=4; Sun- stand the community’s perceptions and practices from the dargarh n=4), considering the cultural norm and oppor- perspective of the service providers and opinion leaders. tunity for free expression of opinion. The discussions The first author conducted the FGDs and KIIs with the were organized at a common place such as community support of a local anthropologist researcher. The language centres, schools, and community-based organizations of the discussions was the local language Odia. The FGDs (CBO) accessible to all socio-economic groups. The key took about 45 to 75 min and had nine to 12 participants informants were purposively selected according to their each, whereas KIIs ran for 25 to 60 min. The participants roles and responsibility with malaria service delivery and were provided with light refreshments. influence on the community in the study area. The key The FGDs and KIIs were digitally recorded. The informant sample included district malaria officers recordings were transcribed and translated to English by (n=2), staff from non-government organizations (n=3), two independent research assistants. The transcripts block medical officers (n=3), malaria laboratory techni- were later matched and merged to Microsoft Word. The cians (n=3), female health workers (n=4), community electronic multimedia were transcribed within a week of health volunteers or ASHA (n=8), school teachers (n=4), interview and the initial transcripts further guided the traditional healers (n=4), less qualified providers (n=3), researchers to modify the data collection tools. Each and local self-government functionaries (n=6). transcript was coded as per the coding matrix (deductive method) developed during the pretesting of the discus- Data collection and analysis sion guides. These codes along with additional new The interview guides which were pre-tested on its con- codes were organized (inductive method) according to tent and duration guided the discussions. The discus- various themes. The codes and the themes helped in ar- sions revolved around the themes on community ranging the views and opinions in a uniform manner. perceptions, knowledge, practices regarding malaria The transcribed data were subjected to content analysis Das et al. Malaria Journal 2013, 12:39 Page 4 of 12 http://www.malariajournal.com/content/12/1/39 [11]. Qualitative data analysis was performed with NVivo unfiltered water is thought to cause malaria. People who 8 software (QSR International Pty Ltd, Australia). venture into the forest to collect firewood and forest pro- duce are perceived to contract malaria through bathing Ethical considerations and drinking water from forest rivulets. Participants who The community members were informed about the aim of reported mosquitoes to be the cause had differences of this research a week prior to the interviews either by their opinions on how the mosquitoes spread the disease. Many community leader, health volunteer or teacher. The key opined that malaria was transmitted through mosquito informants were contacted individually. Prior to each discus- bites. For some it was through exposure to food and water sion or interview the purpose of the study and intended contaminated with infected mosquito eggs. utilization of the information were explained to the partici- pants. Risks and benefits of the study were explained and When we go to the forest, we have to drink water and written informed consent (thumb imprints for non-literate take bath in the streams and rivulets. Upon our return participants) was obtained. Participation was voluntary and we develop ‘meleria’. [Male FGD participant, participants had the liberty to deny answering any question Mayurbhanj] or withdraw at any point of time. All identities of the partici- Villagers do not cover the food items. When pants were removed during transcription and only opinions mosquitoes and flies sit on it, they contaminate the were presented. The study was conceived, planned and food. If one eats that food, it causes ‘meleria’. [Female implemented in collaboration with the NVBDCP officials of FGD participant, Mayurbhanj] the Department of Health and Family Welfare (DoHFW). Necessary approval was obtained from the DoHFW. As discerned through the KII, health-care providers were aware of community perceptions and attributed the Results misconceptions regarding disease transmission to their Socio-demographic characteristics low level of literacy and superstitions. A few informants The socio-demographic characteristics of the FGD partici- were sceptical of the effectiveness of the current pants are presented in Table 1. A total of 272 respondents behaviour-change campaigns on community behaviour. with an equal gender representation were interviewed. Three-quarters of the sample belonged to the scheduled You see. . .people here are illiterate and superstitious. tribe community and about a half had some years of Their level of awareness is very low. They have their schooling. In terms of occupation, students were the ma- own ideas for the aetiology of every disease, for jority (30%) followed by daily wage labourers (22.4%), instance, they say drinking contaminated water leads farmers (21.3%) and homemakers (18.8%). to malaria. [Medical Officer, Sundargarh] We have been conducting so many awareness sessions Local terminologies and illness perceptions in the community. Despite that we don’t see much Malaria was locally known as ‘meleria’, a term derived improvement. [Malaria laboratory technician, Sundargarh] from the biomedical nomenclature and there was no ver- nacular name. ‘Meleria’ included a cluster of symptoms The FGD participants reported a higher incidence of closely resembling the biomedical presentation of malaria. malaria during the rainy season and the least during the All respondents ranked malaria as the most common dis- dry period. Some could relate rains leading to more ease or health condition in their locality. It was further mosquito breeding sites and hence more malaria. reinforced by the healthcare providers and other key infor- mants. Other perceived common ailments were diarrhoea, In the rainy season we cultivate paddy. Water common cold, skin diseases, typhoid, and tuberculosis. accumulates in the farms and we have plenty of mosquitoes. More mosquitoes mean more ‘meleria’. Nowadays wherever you go, you would see ‘meleria’ [Male FGD participant, Mayurbhanj] patients. Whatever fever a person suffers from, the doctor tells it is ‘meleria’. [Male FGD participant, ‘Meleria’ in the locality was characterized by a combin- Sundargarh] ation of symptoms, closely resembling the clinical pres- Malaria is the common illness in this area [Block entation of malaria. The FGD participants identified medical officer, Mayurbhanj] malaria as a febrile illness associated with severe shiver- ing and headache (Table 3). All participants were able to The participants reported multiple causes of malaria. state the symptoms. The majority perceived feeling cold, As shown in Table 2, although there were diverse shivering, fever, intermittent fever, vomiting, and head- responses, two represented the majority, i.e., dirty (con- ache as malaria symptoms. Vomiting as a symptom taminated) water and mosquitoes. Consuming unboiled or was reported to be more commonly associated with Das et al. Malaria Journal 2013, 12:39 Page 5 of 12 http://www.malariajournal.com/content/12/1/39 Table 1 Socio-demographic characteristics of the focus group discussion participants Variable Mayurbhanj (%) (n=135) Sundargarh (%) (n=137) Total (%) (n=272) Sex Men 70 (51.9) 66 (48.2) 136 (50) Women 65 (48.1) 71 (51.8) 136 (50) Age (years) 12-15 42 (31.1) 41 (29.9) 83 (30.5) 16-30 36 (26.7) 29 (21.2) 65 (23.9) 31-45 41 (30.4) 50 (36.5) 91 (33.5) > 45 16 (11.9) 17 (12.4) 33 (12.1) Community Scheduled caste a 28 (20.7) 19 (13.9) 47 (17.3) Scheduled tribe b 95 (70.4) 108 (78.8) 203 (74.6) Others 12 (08.9) 10 (07.3) 22 (08.1) Education (Years of schooling) Non-literate (0) 48 (35.6) 73 (53.3) 121 (44.5) Primary school (1–5) 59 (43.7) 43 (31.4) 102 (37.5) High school and above (>6) 28 (20.7) 21 (15.3) 49 (18.0) Occupation Farmer 32 (23.7) 26 (19.0) 58 (21.3) Trader 4 (03.0) 5 (03.6) 9 (03.3) Daily-wage labourer 21 (15.6) 40 (29.2) 61 (22.4) Homemaker 28 (20.7) 23 (16.8) 51 (18.8) Student 44 (32.6) 38 (27.7) 82 (30.1) Not working 6 (04.4) 5 (03.6) 11 (04.0) a socio-economically marginalized community, given special focus and privileges by the Government of India. b socio-economically marginalized indigenous tribal population, given special focus and privileges by the Government of India. Table 2 Reported causes of malaria by the focus group discussion participants Perceived causes Perceived transmission mechanism Frequency (# FGDs mentioning out of total 24) N (%) 1. contaminated water A. Drinking 22 (91.7) B. Bathing in forest rivulets 14 (58.3) C. Drinking water from open well without boiling 15 (62.5) 2. Mosquitoes A. Sucking blood 16 (66.7) B. Sitting on food and water 6 (25) C. Laying eggs on food and water 3 (12.5) 3. Environmental and personal sanitation and hygiene Garbage 12 (50) 4. Stale food Eating 11 (45.8) 5. Fatigue Hard physical work and lack of rest 10 (41.7) 6. Housefly Brings germs from garbage to food 9 (37.5) 7. Eating habit Untimely eating 6 (25) 8. Untreated common cold Unexplained 5 (20.8) 9. Change of season Unexplained 4 (16.7) 10. Mother to baby Unexplained 2 (8.3) 11. Blood Transfusion of infected blood 1 (4.2) Das et al. Malaria Journal 2013, 12:39 Page 6 of 12 http://www.malariajournal.com/content/12/1/39 Table 3 Reported symptoms of malaria by the focus group discussion participants Symptom Women (n=8) Men (n=8) Children (n=8) Local terminology (Odia language) Literal English translation Thanda lagiba Feeling cold 8 8 8 Deha thariba Shivering 8 5 4 Banti haba Vomiting 8 2 6 Deha batha Body ache 8 6 1 Munda batha Headache 8 3 4 Jara Fever 6 6 5 Pali jara Intermittent fever 6 5 3 Munda bulei haba Dizziness 2 2 1 Durbala lagiba Weakness 2 2 0 Bhoka na heba Loss of appetite 1 2 1 Patala jhada Diarrhoea 0 0 4 Kasa Cough 0 0 1 Nakaru pani bohiba Running nose 0 1 0 childhood malaria. The female participants reported If we drink boiled water then we will not suffer from more malaria-specific symptoms than the men and the ‘meleria’. [Female school student, Sundargarh] children. Participants were able to differentiate other fevers from malaria by the absence of its periodicity and The communitymembers perceived mosquitoes as shivering. Almost all participants reported the treatment a nuisance. All of them were reported to adopt some by a physician at the primary health centre to be the method of protection from mosquitoes during the rainy more effective than any community-based provider. season when the vector is more prevalent. Among these methods, fumigating the house in the evenings with In ‘meleria,’ when the temperature goes up, the patient dried leaves, husk, straw, or firewood was reported to be shivers, head becomes heavy and aches, whole body the most common way of avoiding mosquitoes. Other aches and vomiting takes place with the loss of reported prevention modalities were application of appetite. The fever comes and goes on alternate days. repellent oils out of neem (Azadirachta indica) and kar- [Female FGD participant, Sundargarh] anja (Pongammia glabra) seeds and burning anti- mosquito coils. Most respondents opined that malaria, if not treated timely will lead to jaundice, typhoid, brain meleria (cere- We burn neem leaves and bark, cow dung cakes, dried bral malaria) and eventually death. The reported time- leaves, grain husk to smoke away mosquitoes when frame for developing these complications varied from six they are too much. [Female FGD participant, to seven days for typhoid, and to 12 to 14 days for jaun- Sundargarh] dice and cerebral malaria. We fumigate the house before we go to bed. Who cares after you are asleep? [Male FGD participant, If a ‘meleria’ patient does not take medicines, the fever Mayurbhanj] climbs up to the head and he behaves like mad. This is brain ‘meleria’, my father has told. [Female school Though most were aware that mosquito nets can pre- student, Mayurbhanj] vent malaria, only a few respondents used them regu- larly. The reported reasons for irregular use were the Reported prevention modalities lack of adequate nets in the household due to unaffor- Malaria prevention methods were reported to revolve dablity, old or torn nets, a feeling of suffocation or heat around maintaining personal and environmental hygiene inside the nets, exhaustion or intoxication at night that and drinking safe water. prevents proper use, and a preference to use nets for something else. FGDs respondents reported about using To prevent ‘meleria’, clothes should be clean, water bed nets for fishing, filtering rice beer, setting traps to should be covered and hands should be clean. [Female catch edible insects, and collecting sal leaves (Shorea ro- FGD participant, Sundargarh] busta) to stitch leaf plates. Das et al. Malaria Journal 2013, 12:39 Page 7 of 12 http://www.malariajournal.com/content/12/1/39 Mosquito nets keep the mosquitoes away when we sleep Immediately they don’t come to me; suppose fever and hence “meleria”. But, one big net (double size) costs comes today then they won’t come today. If it 200 rupees (US$ 4) and we need many nets for a house continues further, they come to me after a couple of as we are too many. From where shall we get this much days. [ASHA, Sundargarh] money? [Male FGD participant, Mayurbhanj] The village-based traditional healers are not full-time Alcoholism is a major problem in this region, which is professional health-care providers and most of them in- an additional burden on the poverty. Here both men herit the skills from their forefathers. In the locality, and women drink, though men more. They would there were two types of traditional healers: ‘gunia’ (faith borrow to drink than buying a mosquito net. When healer) and ‘baidya’ (herbalist). A ‘gunia’ resorted to sor- they are drunk they forget to hang the net at home, cery and ritual blowing to ward off evil spirits. The ‘bai- even they lie down on the road if they are too much dya’ on the other hand, cured ailments using roots, drunk. [NGO staff, Mayurbhanj] tubers, leaves and their concoctions. Some traditional healers used both principles. Care seeking from these Mosquito nets have been given to them and they are healers is more of a reflection of faith and some even not using it by telling it is too hot inside. Some even rely on them while simultaneously seeking care from catch fish from the canals during the rains. [Female other providers. health worker, Mayurbhanj] First they go to ‘gunia’, perform ‘jhada-phunka’ (ritual If nets are few in a household, there is a preference for blowing) and come to me after five to seven days. [Less the children (at times with their mothers) to sleep under qualified provider, Sundargarh] it. The reported use of bed nets was higher among chil- People consume tablets and visit the ‘gunia’ at the dren and women than men. There was no difference same time; despite knowing that the tablet works. They observed between the participants in both districts. The have a faith that they should be treated by him (faith possessed nets were reported to be either never treated healer) at any cost. [ASHA, Mayurbhanj] with an insecticide or treated at least a year ago. Around half of the participants were sceptical about the efficacy Afterwards, depending upon the progression of disease of nets to prevent malaria as they perceived mosquitoes and perceived severity, care is sought from other health were not the only cause and mosquitoes also bite during care providers or facility, such as the community health the non-sleeping hours. During the summer season, worker, multipurpose village grocery shops stocking anti- reported net use was less as it was hot and humid inside pyretics (paracetamol), analgesics, and anti-malarials the nets. Most of the adult men slept out in the open, (chloroquine); less qualified provider (locally known as where it was difficult to hang the nets. ‘private doctor’), and very rarely the primary health centre. Care seeking for women and elderly, in general, was What kind of protection do these nets give? Even with reported to be delayed. However, immediate care is the nets hung, mosquitoes enter through the holes or sought for infants and children from the public health suck blood from outside. When I wake up in the centres as there is a perceived notion of seriousness of morning I see a lot of mosquitoes in my net with their their situation and inability of the local providers’ meth- bellies full of blood. Despite sleeping under the nets, ods to ensure complete cure. my two children got ‘brain meleria’ six months back. [Male FGD participant, Mayurbhanj] Children are more vulnerable to malaria. We take our children immediately to the health centre when they Reported care seeking for febrile illnesses get fever. ‘Private Doctors’ don’t have good medicines Despite developing fever and malaria-like symptoms, the for the children; we can’t take risk by treating children majority of adult participants reported that care is not at home through them. [Female FGD participant, immediately sought for themselves. Rather they wait for Mayurbhanj] a few days and engage in home remedies like consuming bitter herbal concoctions or a paste made from neem Care seeking from the less qualified providers (LQP) is leaves. If the situation worsens they seek care from the very common considering their geographic vicinity, use local traditional healer. of modern medicine and flexibility in modes of payment. Most LQPs are unqualified (without any education or If we feel feverish, we think it might be weakness due training in medicine or allied health sciences), or less to hard work. We wait and watch for two to three qualified (some education or training in allied health sci- days. [Male FGD participant, Mayurbhanj] ence), but legally are not allowed to practise modern Das et al. Malaria Journal 2013, 12:39 Page 8 of 12 http://www.malariajournal.com/content/12/1/39 medicine. Though the participants expressed their dis- women’s self-help groups have helped to alleviate this bur- satisfaction with the providers’ attitude and cost of care, den, but not reduced the cost of expenditure. their choice of a more convenient alternative was lim- ited. The majority of the participants felt the LQPs are If a card (rapid diagnostic test) test is done, followed overprescribing medicines for their own profit without by three injections of EMAL (arteether) and an considering the villagers’ financial hardship. antibiotic, the cost comes to Rs.350.Only the card and malaria tablets would cost around Rs.150, with the With whatever fever we go to the ‘private doctor’, he antibiotic it will cost a bit more. However, we have to tells it is ‘meleria’ and you have to take high potency inject most patients as they demand it. [Less qualified injections. We don’t know much about the disease, so provider, Sundargarh] we have to obey him. [Male FGD participant, Mayurbhanj] When we realise that one of us needs money for medical purpose, we loan from our group (self-help The LQPs almost uniformly narrated the treatment group) at nominal interest with flexible repayment for fever and malaria-like illness with an anti-malarial period. Like this we have supported many of us. injection (arteether), an antibiotic, paracetamol, iron [Female FGD participant, Mayurbhanj] and multivitamin syrups. There is a perceived advan- tage of injections in the community as they think On the other hand, LQPs have certain natural advan- more pain during the treatment will give them a more tages because of their geographical proximity and flexi- effective cure. Also, the community perceives that the bility in modes of payment, which can be paid in kind or injection directly delivers the medicine in their blood in instalments. Visiting a far-off government health stream, so it will give them quick relief and they will centre can be time consuming, expensive and inconveni- be able to resume their work early. On the other hand, ent if regular transport facilities are not available. In the oral formulations would reach the blood through contrast, LQPs would visit the household on receiving a the stomach and some have prior experience of side phone call. There are community health workers in the effects like dizziness, vomiting, or tinnitus with tablets. villages or in the neighbourhoods providing care free of That is why, in certain cases, the patients demand cost, but they hardly get recognized as they do not use injections. RDT or ‘inject’ medicines. Villagers believe that the more they have to undergo By realizing our financial condition, he (LQP) receives pain during treatment, the more effective it is. Though the payment when we can afford. This payment takes the tablets are cheaper; still the people are prepared to place within two to three days when he visits us for the pay more for the injections. [Less qualified provider, injection. At times he allows us a month or two. We Mayurbhanj] arrange money by borrowing from the neighbours or the moneylender at 5% interest rate. Some mortgage or With one injection it needs a day to recover as it goes sell their goats, bullocks and even land. [Male FGD directly to my blood, but consuming tablets will take participant, Sundargarh] at least two to three days. How my family will eat if I don’t go to work for those days? We don’t want to get Here more people get treated in credit and repay the into more trouble (drug side effects) by consuming amount within two to three months. [Less qualified tablets. [Male FGD participant, Sundargarh] provider, Mayurbhanj] The treatment for an episode of fever in this fashion You see. . .the ASHA in the village does not have card costs around INR 300 to 700 (US$ 7–15), and in case of test (RDT) and injections. How can we expect quick complicated malaria it can reach up to INR 2,000 to 3,000 cure if you don’t have these? [Male FGD participant, (US$ 45–65). This level of health-care expenditure can se- Mayurbhanj] verely burden an average rural family with one breadwin- ner engaged in subsistence farming or wage labour. The The choice of providers is driven by faith and conveni- peak malaria transmission season (June to September) ence (proximity, flexible payment modes, and perceived coincides with the “lean” period when income is at a sea- quick relief ). Although most villages have a community sonal low. At times households have to borrow from a health worker, the community does not have faith in moneylender with high interest rates or sell scarce assets them. The CHW does not have community’s acceptance such as land, jewellery, or livestock to arrange for the for treatment of fever and malaria-like illnesses as there treatment. The growing presence of microfinance–related, are frequent drug stock-outs. Das et al. Malaria Journal 2013, 12:39 Page 9 of 12 http://www.malariajournal.com/content/12/1/39 Whenever we go to them (CHW), they would tell that Prevention modalities medicines are not there, so we do not go to them The use of prevention methods was determined by four nowadays. [Male FGD participant, Sundargarh] factors; (1) perception of causes and disease transmis- sion; (2) mosquito nuisance; (3) affordability and (4) cli- mate. The reported practices on maintaining personal Discussion and environmental hygiene for malaria prevention were Despite increasing investments in malaria control, access consistent with the local perception of causes and dis- to prompt and effective treatment has remained a major ease transmission. Examples from the African settings challenge in most endemic settings [12]. The inability to also demonstrate incorrect perceptions of disease trans- consider local contexts, perceptions and cultural dynam- mission leading to inappropriate preventive behaviours ics while designing policies for malaria control can lead without any change in malaria incidence [6,18]. to suboptimal community acceptance. Mosquitoes were perceived more as a nuisance than a vector that spreads malaria. Thus, the adoption of pre- Local illness concepts vention methods was confined only to seasons with This study found that the community had adopted the high vector densities as evidenced from endemic set- biomedical-equivalent term of malaria, known as ‘meleria’ tings in Africa [22-26]. Almost all participants reported to describe a broad range of illnesses. Studies from Tanzania adopting some method of driving the mosquitoes away and The Philippines also showed a similar phenomenon during the rainy season, when their population substan- where local nomenclatures have evolved from the biomed- tially increases. Fumigation of the house by burning dry ical term [13,14]. This phenomenon may be due to their leaves and wood in the evenings was the most prevalent frequent exposure to the disease in the family and neigh- prevention method. The protection offered by this kind bourhood leading to regular interactions with the service of fumigation will be the least when most malaria- providers. Further, awareness generation activities conducted spreading mosquitoes (even though less in number) in the community by the DoHFW and NGOs could be bite late in the night. This specific behaviour fails to a contributor in this regard. The community’s ranking recognize that malaria vectors can effectively transmit of malaria as the most common disease was in tandem the disease even at low densities. with the actual prevalence of disease and service provi- Affordability was a determinant of mosquito-net owner- ders’ opinions. ship, though the net was perceived to be an effective tool Malaria was perceived primarily to be a water-borne for protection from mosquito bites. Large family size and disease with faeco-oral mode of transmission. Though sleeping patterns would require a rural household to pur- the community recognized the role of mosquitoes in chase multiple nets, which is beyond the financial capacity causing malaria, the perceived mechanism of disease of many households. Considering the impoverished and transmission was often incorrect. Many stated multiple vulnerable status of tribal communities, there is a clear non-biomedical causes of disease transmission as ground for the state to provide them with either free or reported from other endemic settings in Africa and subsidized mosquito nets. Examples from Africa demon- Southeast Asia [15-21]. It is worth noting that lack of strate improved health-seeking behaviour and health sta- proper understanding of the causal link between the dis- tus after mass distribution of bed nets to vulnerable ease and vector leads to inadequate use of preventive populations [27-30] and this constraint is expected to be methods. This was evident in this study as the partici- somewhat alleviated under the new NVBDCP strategy pants reported the use of inappropriate personal and en- that will distribute two LLINs free of cost to every house- vironmental hygiene measures to prevent malaria. hold [8]. Though community knowledge of the causes of mal- However, providing bed nets alone may not be suffi- aria was not fully accurate, the symptoms enumerated cient given the sociocultural perceptions and behavioural were very similar to the clinical presentations. Respon- patterns of the community. The use of bed nets was ra- dents could clearly differentiate fever due to malaria ther limited for malaria control as mosquito bites were from other fevers and were aware of the complications not perceived to be the only cause of malaria. The alter- of malaria if not treated on time. This could be due to native uses of bed nets were reported in this study; due the community members’ personal experiences of illness to the intricacies of cultural and livelihood compulsions. and the health awareness messages through community This is also reported by studies from Solomon Islands level health service providers. Women were found to be and Kenya [22,31]. Learning lessons from earlier more aware of the symptoms than men, which could be experiences, sustained behaviour-change communication explained by their role as the primary caregiver at home (BCC) activities may be undertaken post-distribution to and close link with the female community health volun- ensure the nets are being used appropriately. Inconsist- teers (ASHA). ent use of nets during the hot and humid nights due to Das et al. Malaria Journal 2013, 12:39 Page 10 of 12 http://www.malariajournal.com/content/12/1/39 Figure 2 Reported common pathways and duration to care seeking for febrile illness. Notes: Number of days denotes duration of care seeking from the day of onset of symptoms; straight and curved arrows denote adult and child care seeking respectively; dotted arrows show obsolete pathways of care seeking after negative experiences with community health worker. physical discomfort has been reported from Africa and a matter of concern for an area with high incidence of Asia [32-34]. Provision of bed nets with larger mesh size, falciparum malaria. In a matter of few hours, falciparum which allow ventilation during summer nights, may be a malaria can progress towards severe and fatal complica- potential solution to this problem prevalent in tropical tions [41]. At the village level, though the CHWs have and sub-tropical climates. There is an evidence of young been trained to dispense anti-malarials, there are fre- children and mothers receiving priority use of bed nets quent drug stock-outs due to inherent problems in as in other Afro-Asian settings [35,36], consistent with supply-chain management. If a few febrile patients re- the public health messaging. turn empty handed from the CHW, it leads to negative publicity and others start to look for alternative service Care seeking for febrile illnesses providers. Lack of faith in the CHW due to unavailability Care seeking for fever was found to be a complex inter- of drugs has been observed by earlier studies conducted action between sociocultural belief, risk perception, eco- in similar settings [21,42]. nomic and livelihood factors. The pathways of care This study showed that cost of care for malaria in seeking for adult members consisted of multiple modal- rural areas can be substantial. The households have to ities as found in other endemic settings [37-39]. For most spend a quarter of their monthly income for a single epi- adults (Figure 2), it started typically with home remedies, sode of uncomplicated malaria. Though participants followed by faith healing, community health worker or cited cost as a deterrent for acquiring nets, in fact they LQP, and only continued up to the primary health centre spend two to three times the price of a single net to treat when complete cure was not yet achieved. The preference one episode of malaria. This could be due to the desper- of home and traditional remedies could be explained by ation to treat malaria as early as possible so that liveli- its low cost and easy availability as well as the commu- hoods can be restored. Perceived ineffectiveness of nets nity’s faith on traditional methods of healing. in preventing malaria may also be a deterrent to net pur- Care from modern health care practitioners was only chase and usage. On the other hand, higher prices sought when it could not be managed by the local provi- charged to poor households by the LQPs through over- ders. However, the primary health centre was the first point prescription could add to the financial burden of the of contact for sick infants and young children as the phys- household. This calls for alternative strategies for LQPs ician of the health centre was thought to possess the most including the possible mainstreaming of LQPs into mal- necessary skills. Like most traditional societies, faith healers aria control after adequate capacity development, as sug- remained the first point of contact outside the household gested by examples from Kenya and Nigeria [43,44]. and public health system [15,40]. The public health system Qualitative studies have their limitations in being less can leverage this community role of traditional healers to generalizable to larger contexts. Though limited in geo- galvanize appropriate community behaviour. Possibly they graphic and cultural scope, most of the findings in this can be included in the malaria control programme either study are similar to many endemic settings locally and as counsellors who direct patients to appropriate treatment globally. Adequate care has been undertaken to ensure providers or as drug distributors. representativeness of the study setting by including par- There were reported delays of more than 48 hours in ticipants from a wide sociocultural, demographic and care seeking for most uncomplicated episodes, which is economic spectrum. Opinions from the perspectives of Das et al. Malaria Journal 2013, 12:39 Page 11 of 12 http://www.malariajournal.com/content/12/1/39 the service providers and community opinion leaders Authors’ contributions were collected and triangulated with that of the commu- AD, JF, RD, MP, CM, and DS designed the study; AD, CM, DS collected and analysed the data. All authors read and approved the final draft. nity members. Acknowledgements This study was conducted under the guidance of the Malaria Impact Policy implications Evaluation Programme at the World Bank with funding from Spanish Impact Local community beliefs about disease transmission, avail- Evaluation Fund (SIEF) and Department of International Development (DFID). The funding sources had no role in the design, data collection, analysis, ability and perceived quality of services are directly linked interpretation, writing the manuscript or decision to publish the manuscript. with health-seeking behaviour. For instance, provision of We would like to thank the community and the respondents for providing free bed nets might not induce adequate utilization if the their valuable time and information. We are grateful to the National Vector Borne Disease Control Programme and Department of Health and Family majority of the population believes malaria is transmitted Welfare for the outstanding support they provided. We express our gratitude by contaminated water. Despite large investments in health to the anonymous reviewers for their valuable comments on the manuscript. infrastructure and human resources, if the programme We thank Bianca Brijnath for critically reviewing the manuscript and Satya Narayan Mohanty for his support to design the map of the study area. does not take these beliefs into account during its planning Sincere thanks to Mary Margaret Kindo, Nirod Bhuyan, Dinabandhu Swain, and implementation, the change in health-seeking behav- Surendra Badi, Sibabrata Das, and Debananda Mohanta for facilitating the iour might not be adequate. India has reached a crucial study. We also thank GNV Ramana, Ramesh Govindaraj, Sridhar Srikantiah, and Allan Schapira for their continuous guidance and support during this juncture with revised strategies such as ACT and LLIN in study. The views expressed in this paper are those of the authors and do not its fight against malaria. In the context of introduction of necessarily represent the views of the authors’ organizations. more effective and expensive methods (eg, ACT and Author details LLIN), it becomes imperative to ensure adequate and ef- 1 The World Bank, Washington, DC, USA. 2National Vector Borne Disease fective utilization. Evidence has shown that communities Control Programme, Ministry of Health and Family Welfare, Government of adopt practices if they have ownership of the intervention India, New Delhi, India. 3Department of Health and Family Welfare, Government of Odisha, Bhubaneswar, India. rather than imposing a ‘top-down’ approach [45-47]. The village health and sanitation committees (VHSC) under Received: 14 September 2012 Accepted: 17 January 2013 the framework of National Rural Health Mission and self- Published: 29 January 2013 help groups in India are such forums for community par- References ticipation in community health interventions. Adequate 1. 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