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Household responses to malaria and their costs: a study from rural Sri Lanka
TRANSACTIONS
OFTHE
Household
ROYAL
responses
SOCIETY
OFTROPICAL
to malaria
MEDICINE
AND
HYGIENE
127
(1997) 91,127-130
and their costs: a study from rural Sri Lanka
F. Konradsenl. W. van der Hock’. l? H. Amerasinehe2. F. I-‘. Amerasinahe2 and K. T. Fonseka2 of Zoolog;, University of Peradeniya, Sri lInternational Irrigation Management Ins&e, Colombo, Sri Lacka;iDepartment Lanka Abstract A study of the cost of malaria at the household level, community perceptions, preventive measures and illness behaviour linked to the disease was undertaken in 5 villages in the dry zone of Sri Lanka. The surveyed community had a high knowledge of malaria, although side effects of antimalarial drugs were often confused with symptoms of the disease.The community sought prompt diagnosis and treatment at ‘western-type’ facilities, with 84% making use of government facilities as their first choice and 16% preferring private facilities. The preventive measures used were burning coils (54% of families) and special leaves (69% of families), and 93% of the families had their houses sprayed with insecticides. Average direct expenditure on a single malaria episode was USS3, with some families spending more than 10% of the annual household net income per episode. The highest expenditure was on special diets for the sick person, to neutralize the perceived heating effect of the disease and its treatment. Keywords:
malaria, Plasmodiumfalciparum, Plasmodiumvivax, household responses,household expenditure, Sri Lanka
Introduction Planning sustainable malaria control interventions must be based on local analysis of the malaria problem. Such an analysis should not only focus on ecology and epidemiology of the disease but include community knowledge and perception of malaria, coping strategies, treatment seeking behaviour, and the cost of the disease. Few studies have been carried out in Sri Lanka on these aspects of malaria. JAYAWARDENE (1993) described a newly resettled population under the Mahaweli Development Programme which suffered considerable stress due to malaria and led to delays in the development of the agricultural system and homesteads. SILVA (1991) examined, through interviews with practitioners in villages of the Anuradhapura District, the traditional role of ayurveda and indigenous herbal medicine in malaria treatment during the pre- and post-DDT era. The herbal medicines once used for malaria have now almost completely been replaced by ‘western’ antimalarial drugs. However, traditional means of preventing mosquito bites are still maintained, most commonly using smoke derived from herbal ingredients. This study was linked to research activities looking at the relationship between irrigation and health. In continuing discussions with officials from the irrigation and agricultural sector regarding possible environmental management measures for disease vector control, the need to estimate the cost of malaria to rural communities and the impact on agricultural output was stressed. The objective of this study was to describe the community’s perception of malaria, preventive measures used, and treatment seeking behaviour, and to estimate the household costs of malaria. A separate study of one of the survey villages will be undertaken to measure the cost of labour days lost. This would then, together with entomological and epidemiological data, serve as a baseline for interventions that are planned in the area to control malaria. Materials
and Methods
Project area
The study was carried out in 5 villages (Asirigama, Eppawala, Mahameegaswewa, Namalapura, Siyambaladamana) in the Anuradhapura District of Sri Lanka. These villages were originally typical purana (ancient) villages in the dry zone of Sri Lanka. Thepurana concept was still apparent, with each village having its own water reservoir (tank) as the central constituent of the settlement. The tanks, with traditional irrigation systems, supported agricultural production, provided fishing opportunities and acted as a reservoir for the domestic water supply. Other important land uses in the area were chena (slash and burn), forest and homesteads. The population was exclusively Sinhalese, with very close
family ties within each of the villages. The majority of the households were low-income subsistence farmers, with smaller groups seeking work outside the area. The closest health facilities serving the villages were situated at a distance of 7 km (government ayurvedic clinic) and 10 km (government dispensary, private facilities). The nearest hospital was in Kekirawa, 25 km distant. Mobile clinics were run on a regular basis by the Anti-Malaria Campaign, which also undertook house spraying in the area. No health volunteer was active in the study villages. The general pattern of malaria in the dry zone of Sri Lanka is present in the study area, with a sharp increase in the number of malaria cases during the north-eastern monsoon from November to February, and a second but less pronounced peak in the months of June and July (WIJESUNDER~~, 1988). sion periods there is a
In between
the
peak
transmis-
more or less constant low level of transmission. The dry zone of Sri Lanka is an area with unstable malaria and large fluctuations in the number of malaria episodes are experienced from year to year. In 1994 there were 75 500 cases of malaria in the Anuradhapura District, confirmed by blood slides, with an annual parasite index of 104 per 1000 population (ANONYMOUS, 1995). Methods In addition to the entomological, parasitological and epidemiological work taking place in the study area since July 1994, a household questionnaire survey was done in February 1995. The survey was undertaken by a team of 4 social research officers and a supervisor, who were all experienced in conducting interviews for research projects. The questionnaires were in the Sinhala language* and were pre-tested by the same team outside the study area in January 1995. The open and semistructured questions focused on community priorities, knowledge of malaria, preventive measures taken and household income and resources. Detailed information was collected on all malaria episodes that people recalled from the past 3 months, with special attention to treatment seeking behaviour and costs incurred. The survey was done during the peak malaria transmission season, which is also the most important agricultural season, with activities relating to land preparation, broadcasting rice seed in paddies, and the beginning of irrigation. Of the 437 households in the study area, it was considered necessary to take a 50% random sample in order to obtain information on a sufficient number of malaria episodes. The interviewers were instructed to interview the wife of the head of the household or the fe*An English language version is available on request.
128
F. KONFCADSEN
male head of the household. A house with no responsible adult was revisited up to 3 times within a period of 2 weeks. A respondent was available in 216 of the houses sampled. In the analysis, the arithmetic mean was often influenced by one or 2 extremely high values. In these cases the median and (interquartile) range were used to summarize the data. Results Community knowledge and perception of malaria Respondents were asked to name the 3 biggest problems and the 5 most important diseases in the village. Malaria was ranked as the third most serious community problem, following lack of water for cultivation and poverty. Ninety-five percent of the 2 16 families considered malaria to be their main health problem, followed by diarrhoea and eye diseases. Almost all of the respondents (98%) knew that mosquitoes are involved in the spread of malaria. When asked about the 3 most important signs and symptoms of malaria, most frequently mentioned were shivering (63%), headache (61%)) fever (51%) and body pains (42%). Eighty-nine percent of the respondents were aware of the different types of malaria and mentioned ‘normal malaria’ and ‘brain malaria’, which are the lay names in Sri Lanka for Plasmodi& vivax and l? falciparum malaria. The correct treatment for malaria was indicated bv 98% of the respondents. (Answers were considered correct when chloroquine tablets or chloroquine in combination with primaquine was mentioned.) Sixty percent of the patients complained of side effects of the drugs prescribed, especially fainting (40% of all cases), loss of appetite (29%) and dizziness (22%). However, the majority (8 1%) expressed overall satisfaction with the service and treatment provided by the health facility. Most of those dissatisfied claimed that the drugs were ineffective because they thought that hospitals administered outdated drugs, or blood tests were not carried out properly, or drugs were prescribed without a blood test. A few people interviewed stated that they had had malaria a number of times and that only stronger drugs would now be effective. Table 1. Household expenditure for 178 malaria episodes in five villages in Anuradhapura District, Sri Lanka Expenditure per episode (Sri Lankan rupees)a Transport Blood examination Treatment Meals at health facility Special diet at home Otherb Total
31.8 (O-300) 1.8 (O-95) 19.5 (O-530) 29.6 (o-600) 47.6 (o-350) 18.7 (O-625) 149.0 (o-1092)
=Means (ranges in parentheses); 50 rupees were equal to US01 at the time of the study. bInchiding hiring labour. costs of malaria The median yearly net income of the families was Sri Lankan rupees 12900 (US$ 258), with 19 families reporting no-income at all: The totai direct expenditure on a sinele malaria enisode was annroximatelv US$ 3 (Table lj, with a few families spending more-than 10% of the annual net household income per episode. The use of private facilities meant higher expenditure on treatment compared with the use of government facilities, which provided free treatment. The money spent on special diets for malaria patients was the highest item of expenditure. Food consumed while travelling and waiting at the health facility was mainly tea, soft drinks, biscuits, glucose and oranges. Those interviewed stated Household
ET&..
that malaria had a ‘heating’ effect on the body system which could be neutralized by sweet drinks and/or by eating oranges. Oranges are available in many shops but are imported and expensive. Glucose, to help regain energy, was often purchased to help the patient during an attack of malaria. Apart from the direct financial impact, malaria was also seen as a stress factor that exhausted the population and hampered the progress of the villages. This was expressed by some of the respondents as ‘people in our village have been brought down to this level of poverty due to malaria; it drains the energy from people’ and ‘malaria makes you weak for a very long time although the doctor says you are cured’. On average, 7.8 d were lost due to an episode of malaria (median 6. interauartile range l-10). In addition. on average 2.9 ‘d per episode we;e lost by persons ac: companying the malaria patient to the health facility (median 1, interquartile range O-3). In most cases families managed to substitute labour from within the familv. Outside labour was needed in onlv 33 enisodes (i 8.5%). In 12 cases this was paid for in cash and the remaining cases paid in kind, or by exchanging labour between families later. When hired labour was needed, an average of rupees 362 per episode (standard deviation [SD] 189) was paid. Treatment seeking behaviour
Among the 2 16 families included in the study there were 178 self-reported episodes of malaria, occurring in 160 families. Of the 178 cases, 94% had been confirmed by blood slide, with 85 being l? vivax and 83 l? falciparum. The cases were equally distributed between females and males and between children and adults. Home treatment with paracetamol was the first medication taken in 85% of the malaria episodes. This treatment was resorted to on average 1.2 d (SD 0.6) after the onset of symptoms. Only 5 of the households surveyed had stocks of antimalarial tablets in their homes. In all these homes the tablets were those that had been prescribed but not taken during earlier episodes of malaria. All malaria cases had received treatment from ‘westemtype’ facilities (Table 2). In 9% of cases more than one formal treatment facility had been visited. Patients from households with ‘high’ incomes (>rupees 12900 a year) made more use of private facilities than families with low incomes (x2=8.63, fiO.003). Mean expenditure on a malaria episode was higher for the high income group (rupees 152.8 compared with rupees 121.8), although this difference did not reach statistical significance (Mann-Whitney W3.49, P=O.O6). Table 2. Treatment sought for malaria episodes villages in Anuradhapura District, Sri Lanka Malaria Government hospital Mobile clinic Private health facility Other ‘western’ treatment facility Ayurvedic or indigenous treatment Total
in five
episode Time after onset of symptoms (d)a
85 (48%) 53 (30%) 29(16%) 11 (6%) 0 (-) 178(100%)
2.5 (1.2) 2+(1.4) 2-8 (1.5) 2.0 (0.9) a (-) 2-5(1.3)
aMeans (standard deviations in parentheses). Preventive
measures
In 23% of families one or more members used bed nets at a cost of approximately rupees 600-700 per double net. Families with a yearly income of more than the median, rupees 12 900, used significantly more bed nets than the poorer families (&2=4.00, eO.045). Another common preventive measure was burning mosquito coils during the rainy season. An average of 6.3 coils per week, costing rupees 2.50 per coil, were used by 54% of the families. Traditional smokes were used by 69% of the families. Most of the households burned leaves and
HOUSEHOLD
RESPONSES TO MALARIA
seeds of the neem tree (A.aadiruchta in&u) in clay pots during the evening and night to keep mosquitoes away. Another strategy was roasting cashew nut shells in charcoal. As part of the entomological work in the study area, it was noted that only a very few families actively tried to eliminate mosquito breeding sites around their homesteads or elsewhere in the village. Two hundred of the surveyed houses had been visited by the Anti-Malaria Campaign in the previous 6 months, and almost all of the families had their homes sprayed with the insecticide FenitrothionTM. Discussion
Despite the awareness of malaria, with early diagnosis and treatment, and high acceptance of residual spraying, the impact of malaria on this study population was considerable. Knowledge regarding the disease was high, especially compared with other countries (FUNGLADDA, 1991; AWNS et al., 1994). After taking paracetamol at home, people normally sought prompt diagnosis and treatment at a ‘western-type’ health facility, mainly in a government establishment. In this study, Kekirawa Hospital was the most popular facility, probably because this was the only permanent facility where the- patient could get an immediate diagnosis. -Mobile clinics of the Anti-Malaria Camuainn also nrovided immediate blood film examination, -contributing to the very high blood film confirmation rate. This high use of ‘western-type’ facilities for suspected malaria and the awareness of the importance of blood examination has been reported from other rural areas of Sri Lanka (RAMASAMY et al., 1992; ANONYMOUS, 1993). This is in marked contrast to reports from Africa and other Asian countries such as Thailand and Nepal, where self-treatment with antimalarial drugs is common and where shops play an important role in their distribution (RAUYAJIN,
1991; SNOW et al., 1992; FOSTER, 1995). It
is likely that the most important factors encouraging people to seek prompt treatment were their high knowledge, the perceived seriousness of the disease, and the relativelv _ good transport facilities in the area. Despite the high awareness, people often confused side effects of antimalarial drugs with symptoms of the disease. This has also been described from other areas of Sri Lanka. and was found to be a reason for poor patient complii ante ~A~AWARDENE, 1993; PINIKAHANA, 1993). It is notable that not a single case made use of ayurvedic or indigenous physicians, despite the close proximity of 2 functioning ayurvedic hospitals. While ayurvedic treatment is still popular for other conditions, it seems to be a general trend that, for high fever, ‘western-type’ health facilities are used (WOLFFERS, 1989). However, the high expenditure on special food for malaria patients in Sri Lanka reflects the belief that both the disease and the modern antimalarial drugs have a ‘heating’ effect, which should be neutralized by special foods. Household expenditure on special diet for the malaria patient is most often not included in studies on the economic impact of malaria. Mobile clinics were a frequently used alternative to permanent health facilities. These provided blood tests, reduced the cost of transport, and saved time and money that would normally be spent on food while awaiting treatment. A survey approach such as the one used in this study has some methodological difficulties. One of the weaknesses was related to the long recall period. To assess possible recall bias the cases that occurred in the 2 weeks just before the survey were compared with the cases that had occurred more than 2 months earlier. The 2 groups showed no significant difference in the number of days between onset of symptoms, treatment behaviour, and expenditure pattern. Also, obtaining reliable income figures from the households was difficult. Although the interviewers were experienced in calculating income and expenditure figures from rural households with a diverse set of income generating activities,
129
it is still likely that a number of families were reluctant to provide full details of their income. It is possible that a few relatively wealthy families feared that, if they were registered as having a high income, they would lose out on future government food handouts. The ranking of malaria by almost all families as their most important health problem was probably influenced by the fact that the survey was undertaken during the peak malaria transmission period. In addition, as found in other studies (MILLS, 1994), it is difficult to assess the full impact of disease on household income or productive capacity since the economic impact is mediated by the extended family, which may both reduce and disguise the actual impact. Although total direct expenditure on a single malaria episode was less than US$3, it should be realized that malaria is likely to be clustered, as has been found in other studies in Sri Lanka (MENDIS et al.. 1990). and that some families are likely to experience a”large number of malaria episodes in a transmission season which places a substantial burden on the financial resources of the households. In addition, for a farming family, the time of occurrence of the malaria episode is very important. If the disease affects an agriculturally active member of the family for an extended period during the peak cultivation periods of land preparation and harvesting, it can lead to severe hardship. Early diagnosis and treatment are one of the main strategies of control of malaria (WHO, 1993). This study showed that the economic cost can still be considerable, even in a community where people comply with this strategy. Acknowledgements This study was a component of a continuing malaria research project and was supported by the Danish International and the Norwegian Agency Development Agency (DANIDA) for Develooment Co-oueration (NORAD). We thank MS Herath. MS Damavanthi. &lr Tavasena and MS Wanigadewa. Research Officers; who assisted-in carrying out the survey. We are also grateful for the secretarial support provided by Mala Ranawake. References Aikins, M. K., Pickering, H. & Greenwood, B. M. (1994). Attitudes to malaria, traditional practices and bednets (mosquito nets) as vector control measures: a comparative study in five West African countries. Journal of Tropical Medicine and Hygiene, 91, 81-86. Anonvmous (1993). Sri Lanka Nutrition and Health Status of Chz?dren. Battara’mulla, Sri Lanka: Ministry of Policy Planning and Implementation. Anonymous (1995). Anti-Malaria Campaign Annual Report for 1994. Colombo. Sri Lanka: Ministrv of Health Social Services and Highways. Foster, S. (1995). Treatment of malaria outside the formal health services. Journal of Tropical Medicine and Hygiene, 98, 29-34. Fungladda, W. (1991). Health behaviour and illness behaviour of malaria: a review. In: Social and Economic Aspects ofMalar; ia Control, Sornmani, S. & Fungladda, W. (editors). Bangkok, Thailand: Faculty of Tropical Medicine, Mahidol Umversity, pp. 84-99. Jayawardene, R. (1993). Illness perception: social cost and coping-strategies of malaria cases. Social Science and Medicine, 37, 1169-l 176. Mendis. C.. Gamaae-Mendis. A. C.. De Zovsa. A. I? K.. Abhayawardena, T. A., Carter; R., Herath, I’: R: J. & Mendis, K. N. (1990). Characteristics of malaria transmission in Kataragama, Sri Lanka: a focus for immuno-epidemiological studies. American Journal of Tropical Medicine and Hygiene, 42.298308. Mills, A. (1994). The economic consequences of malaria for households: a case-study in Nepal. Health Policy. 29, 209-227. Pinikahana, J. (1993). Illness behavior and preventive behavior of the people and malaria transmission in Sri Lanka. Mosquito-Borne Diseases Bulletin, 10, 12-20. Ramasamy, R., Subanesan, N:, Wljesundere, A., Fernando, N. K. & Ramasamy, M. S. (1992). Observations on malaria patients seeking treatment in hospitals in a rural and urban area of Sri Lanka. Indian Journal of Malariology, 29, 29-34.
F. KONFUDSEN ETAL.
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Rauyajin, 0. (1991). Factors affecting malaria related behavior: a literature review of behavioral theories and relevant research. In: Social and Economic Aspects of Malaria Control, Sornmani, S. & Fungladda, W. (editors). Bangkok, Thai~;-xg~lty ofTropical Medicine, Mahidol University, pp. Silva, K. T. (1991). Ayurveda, malaria and indigenous herbal tradition in Sri Lanka. Social Science and Medicine, 33, 153-160. Snow, R. W., Peshu, N., Forster, D., Mwenesi, H. & Marsh, K. (1992). The role of shops in the treatment and prevention of childhood malaria on the coast of Kenya. Transactions of the
Royal Society of Tropical Medicine and Hygiene, 86, 237-239. WHO (1993). A Global Strategy for Malaria Control. Geneva: World Health Organization. Wijesundera, M. (1988). Malaria outbreaks in new foci in Sri Lanka. Parasitology rOday, 4, 147-150. Wolffers, I. (1989).Traditional practitioners’ behavioral adaptations to changing patients’ demands in Sri Lanka. Social Science and Medicine, 29, 111 l-l 119. Received 26 June 1996; revised 22 October 1996; accepted for publication 22 October 1996
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I
OFTHE
Household
ROYAL
responses
SOCIETY
OFTROPICAL
to malaria
MEDICINE
AND
HYGIENE
127
(1997) 91,127-130
and their costs: a study from rural Sri Lanka
F. Konradsenl. W. van der Hock’. l? H. Amerasinehe2. F. I-‘. Amerasinahe2 and K. T. Fonseka2 of Zoolog;, University of Peradeniya, Sri lInternational Irrigation Management Ins&e, Colombo, Sri Lacka;iDepartment Lanka Abstract A study of the cost of malaria at the household level, community perceptions, preventive measures and illness behaviour linked to the disease was undertaken in 5 villages in the dry zone of Sri Lanka. The surveyed community had a high knowledge of malaria, although side effects of antimalarial drugs were often confused with symptoms of the disease.The community sought prompt diagnosis and treatment at ‘western-type’ facilities, with 84% making use of government facilities as their first choice and 16% preferring private facilities. The preventive measures used were burning coils (54% of families) and special leaves (69% of families), and 93% of the families had their houses sprayed with insecticides. Average direct expenditure on a single malaria episode was USS3, with some families spending more than 10% of the annual household net income per episode. The highest expenditure was on special diets for the sick person, to neutralize the perceived heating effect of the disease and its treatment. Keywords:
malaria, Plasmodiumfalciparum, Plasmodiumvivax, household responses,household expenditure, Sri Lanka
Introduction Planning sustainable malaria control interventions must be based on local analysis of the malaria problem. Such an analysis should not only focus on ecology and epidemiology of the disease but include community knowledge and perception of malaria, coping strategies, treatment seeking behaviour, and the cost of the disease. Few studies have been carried out in Sri Lanka on these aspects of malaria. JAYAWARDENE (1993) described a newly resettled population under the Mahaweli Development Programme which suffered considerable stress due to malaria and led to delays in the development of the agricultural system and homesteads. SILVA (1991) examined, through interviews with practitioners in villages of the Anuradhapura District, the traditional role of ayurveda and indigenous herbal medicine in malaria treatment during the pre- and post-DDT era. The herbal medicines once used for malaria have now almost completely been replaced by ‘western’ antimalarial drugs. However, traditional means of preventing mosquito bites are still maintained, most commonly using smoke derived from herbal ingredients. This study was linked to research activities looking at the relationship between irrigation and health. In continuing discussions with officials from the irrigation and agricultural sector regarding possible environmental management measures for disease vector control, the need to estimate the cost of malaria to rural communities and the impact on agricultural output was stressed. The objective of this study was to describe the community’s perception of malaria, preventive measures used, and treatment seeking behaviour, and to estimate the household costs of malaria. A separate study of one of the survey villages will be undertaken to measure the cost of labour days lost. This would then, together with entomological and epidemiological data, serve as a baseline for interventions that are planned in the area to control malaria. Materials
and Methods
Project area
The study was carried out in 5 villages (Asirigama, Eppawala, Mahameegaswewa, Namalapura, Siyambaladamana) in the Anuradhapura District of Sri Lanka. These villages were originally typical purana (ancient) villages in the dry zone of Sri Lanka. Thepurana concept was still apparent, with each village having its own water reservoir (tank) as the central constituent of the settlement. The tanks, with traditional irrigation systems, supported agricultural production, provided fishing opportunities and acted as a reservoir for the domestic water supply. Other important land uses in the area were chena (slash and burn), forest and homesteads. The population was exclusively Sinhalese, with very close
family ties within each of the villages. The majority of the households were low-income subsistence farmers, with smaller groups seeking work outside the area. The closest health facilities serving the villages were situated at a distance of 7 km (government ayurvedic clinic) and 10 km (government dispensary, private facilities). The nearest hospital was in Kekirawa, 25 km distant. Mobile clinics were run on a regular basis by the Anti-Malaria Campaign, which also undertook house spraying in the area. No health volunteer was active in the study villages. The general pattern of malaria in the dry zone of Sri Lanka is present in the study area, with a sharp increase in the number of malaria cases during the north-eastern monsoon from November to February, and a second but less pronounced peak in the months of June and July (WIJESUNDER~~, 1988). sion periods there is a
In between
the
peak
transmis-
more or less constant low level of transmission. The dry zone of Sri Lanka is an area with unstable malaria and large fluctuations in the number of malaria episodes are experienced from year to year. In 1994 there were 75 500 cases of malaria in the Anuradhapura District, confirmed by blood slides, with an annual parasite index of 104 per 1000 population (ANONYMOUS, 1995). Methods In addition to the entomological, parasitological and epidemiological work taking place in the study area since July 1994, a household questionnaire survey was done in February 1995. The survey was undertaken by a team of 4 social research officers and a supervisor, who were all experienced in conducting interviews for research projects. The questionnaires were in the Sinhala language* and were pre-tested by the same team outside the study area in January 1995. The open and semistructured questions focused on community priorities, knowledge of malaria, preventive measures taken and household income and resources. Detailed information was collected on all malaria episodes that people recalled from the past 3 months, with special attention to treatment seeking behaviour and costs incurred. The survey was done during the peak malaria transmission season, which is also the most important agricultural season, with activities relating to land preparation, broadcasting rice seed in paddies, and the beginning of irrigation. Of the 437 households in the study area, it was considered necessary to take a 50% random sample in order to obtain information on a sufficient number of malaria episodes. The interviewers were instructed to interview the wife of the head of the household or the fe*An English language version is available on request.
128
F. KONFCADSEN
male head of the household. A house with no responsible adult was revisited up to 3 times within a period of 2 weeks. A respondent was available in 216 of the houses sampled. In the analysis, the arithmetic mean was often influenced by one or 2 extremely high values. In these cases the median and (interquartile) range were used to summarize the data. Results Community knowledge and perception of malaria Respondents were asked to name the 3 biggest problems and the 5 most important diseases in the village. Malaria was ranked as the third most serious community problem, following lack of water for cultivation and poverty. Ninety-five percent of the 2 16 families considered malaria to be their main health problem, followed by diarrhoea and eye diseases. Almost all of the respondents (98%) knew that mosquitoes are involved in the spread of malaria. When asked about the 3 most important signs and symptoms of malaria, most frequently mentioned were shivering (63%), headache (61%)) fever (51%) and body pains (42%). Eighty-nine percent of the respondents were aware of the different types of malaria and mentioned ‘normal malaria’ and ‘brain malaria’, which are the lay names in Sri Lanka for Plasmodi& vivax and l? falciparum malaria. The correct treatment for malaria was indicated bv 98% of the respondents. (Answers were considered correct when chloroquine tablets or chloroquine in combination with primaquine was mentioned.) Sixty percent of the patients complained of side effects of the drugs prescribed, especially fainting (40% of all cases), loss of appetite (29%) and dizziness (22%). However, the majority (8 1%) expressed overall satisfaction with the service and treatment provided by the health facility. Most of those dissatisfied claimed that the drugs were ineffective because they thought that hospitals administered outdated drugs, or blood tests were not carried out properly, or drugs were prescribed without a blood test. A few people interviewed stated that they had had malaria a number of times and that only stronger drugs would now be effective. Table 1. Household expenditure for 178 malaria episodes in five villages in Anuradhapura District, Sri Lanka Expenditure per episode (Sri Lankan rupees)a Transport Blood examination Treatment Meals at health facility Special diet at home Otherb Total
31.8 (O-300) 1.8 (O-95) 19.5 (O-530) 29.6 (o-600) 47.6 (o-350) 18.7 (O-625) 149.0 (o-1092)
=Means (ranges in parentheses); 50 rupees were equal to US01 at the time of the study. bInchiding hiring labour. costs of malaria The median yearly net income of the families was Sri Lankan rupees 12900 (US$ 258), with 19 families reporting no-income at all: The totai direct expenditure on a sinele malaria enisode was annroximatelv US$ 3 (Table lj, with a few families spending more-than 10% of the annual net household income per episode. The use of private facilities meant higher expenditure on treatment compared with the use of government facilities, which provided free treatment. The money spent on special diets for malaria patients was the highest item of expenditure. Food consumed while travelling and waiting at the health facility was mainly tea, soft drinks, biscuits, glucose and oranges. Those interviewed stated Household
ET&..
that malaria had a ‘heating’ effect on the body system which could be neutralized by sweet drinks and/or by eating oranges. Oranges are available in many shops but are imported and expensive. Glucose, to help regain energy, was often purchased to help the patient during an attack of malaria. Apart from the direct financial impact, malaria was also seen as a stress factor that exhausted the population and hampered the progress of the villages. This was expressed by some of the respondents as ‘people in our village have been brought down to this level of poverty due to malaria; it drains the energy from people’ and ‘malaria makes you weak for a very long time although the doctor says you are cured’. On average, 7.8 d were lost due to an episode of malaria (median 6. interauartile range l-10). In addition. on average 2.9 ‘d per episode we;e lost by persons ac: companying the malaria patient to the health facility (median 1, interquartile range O-3). In most cases families managed to substitute labour from within the familv. Outside labour was needed in onlv 33 enisodes (i 8.5%). In 12 cases this was paid for in cash and the remaining cases paid in kind, or by exchanging labour between families later. When hired labour was needed, an average of rupees 362 per episode (standard deviation [SD] 189) was paid. Treatment seeking behaviour
Among the 2 16 families included in the study there were 178 self-reported episodes of malaria, occurring in 160 families. Of the 178 cases, 94% had been confirmed by blood slide, with 85 being l? vivax and 83 l? falciparum. The cases were equally distributed between females and males and between children and adults. Home treatment with paracetamol was the first medication taken in 85% of the malaria episodes. This treatment was resorted to on average 1.2 d (SD 0.6) after the onset of symptoms. Only 5 of the households surveyed had stocks of antimalarial tablets in their homes. In all these homes the tablets were those that had been prescribed but not taken during earlier episodes of malaria. All malaria cases had received treatment from ‘westemtype’ facilities (Table 2). In 9% of cases more than one formal treatment facility had been visited. Patients from households with ‘high’ incomes (>rupees 12900 a year) made more use of private facilities than families with low incomes (x2=8.63, fiO.003). Mean expenditure on a malaria episode was higher for the high income group (rupees 152.8 compared with rupees 121.8), although this difference did not reach statistical significance (Mann-Whitney W3.49, P=O.O6). Table 2. Treatment sought for malaria episodes villages in Anuradhapura District, Sri Lanka Malaria Government hospital Mobile clinic Private health facility Other ‘western’ treatment facility Ayurvedic or indigenous treatment Total
in five
episode Time after onset of symptoms (d)a
85 (48%) 53 (30%) 29(16%) 11 (6%) 0 (-) 178(100%)
2.5 (1.2) 2+(1.4) 2-8 (1.5) 2.0 (0.9) a (-) 2-5(1.3)
aMeans (standard deviations in parentheses). Preventive
measures
In 23% of families one or more members used bed nets at a cost of approximately rupees 600-700 per double net. Families with a yearly income of more than the median, rupees 12 900, used significantly more bed nets than the poorer families (&2=4.00, eO.045). Another common preventive measure was burning mosquito coils during the rainy season. An average of 6.3 coils per week, costing rupees 2.50 per coil, were used by 54% of the families. Traditional smokes were used by 69% of the families. Most of the households burned leaves and
HOUSEHOLD
RESPONSES TO MALARIA
seeds of the neem tree (A.aadiruchta in&u) in clay pots during the evening and night to keep mosquitoes away. Another strategy was roasting cashew nut shells in charcoal. As part of the entomological work in the study area, it was noted that only a very few families actively tried to eliminate mosquito breeding sites around their homesteads or elsewhere in the village. Two hundred of the surveyed houses had been visited by the Anti-Malaria Campaign in the previous 6 months, and almost all of the families had their homes sprayed with the insecticide FenitrothionTM. Discussion
Despite the awareness of malaria, with early diagnosis and treatment, and high acceptance of residual spraying, the impact of malaria on this study population was considerable. Knowledge regarding the disease was high, especially compared with other countries (FUNGLADDA, 1991; AWNS et al., 1994). After taking paracetamol at home, people normally sought prompt diagnosis and treatment at a ‘western-type’ health facility, mainly in a government establishment. In this study, Kekirawa Hospital was the most popular facility, probably because this was the only permanent facility where the- patient could get an immediate diagnosis. -Mobile clinics of the Anti-Malaria Camuainn also nrovided immediate blood film examination, -contributing to the very high blood film confirmation rate. This high use of ‘western-type’ facilities for suspected malaria and the awareness of the importance of blood examination has been reported from other rural areas of Sri Lanka (RAMASAMY et al., 1992; ANONYMOUS, 1993). This is in marked contrast to reports from Africa and other Asian countries such as Thailand and Nepal, where self-treatment with antimalarial drugs is common and where shops play an important role in their distribution (RAUYAJIN,
1991; SNOW et al., 1992; FOSTER, 1995). It
is likely that the most important factors encouraging people to seek prompt treatment were their high knowledge, the perceived seriousness of the disease, and the relativelv _ good transport facilities in the area. Despite the high awareness, people often confused side effects of antimalarial drugs with symptoms of the disease. This has also been described from other areas of Sri Lanka. and was found to be a reason for poor patient complii ante ~A~AWARDENE, 1993; PINIKAHANA, 1993). It is notable that not a single case made use of ayurvedic or indigenous physicians, despite the close proximity of 2 functioning ayurvedic hospitals. While ayurvedic treatment is still popular for other conditions, it seems to be a general trend that, for high fever, ‘western-type’ health facilities are used (WOLFFERS, 1989). However, the high expenditure on special food for malaria patients in Sri Lanka reflects the belief that both the disease and the modern antimalarial drugs have a ‘heating’ effect, which should be neutralized by special foods. Household expenditure on special diet for the malaria patient is most often not included in studies on the economic impact of malaria. Mobile clinics were a frequently used alternative to permanent health facilities. These provided blood tests, reduced the cost of transport, and saved time and money that would normally be spent on food while awaiting treatment. A survey approach such as the one used in this study has some methodological difficulties. One of the weaknesses was related to the long recall period. To assess possible recall bias the cases that occurred in the 2 weeks just before the survey were compared with the cases that had occurred more than 2 months earlier. The 2 groups showed no significant difference in the number of days between onset of symptoms, treatment behaviour, and expenditure pattern. Also, obtaining reliable income figures from the households was difficult. Although the interviewers were experienced in calculating income and expenditure figures from rural households with a diverse set of income generating activities,
129
it is still likely that a number of families were reluctant to provide full details of their income. It is possible that a few relatively wealthy families feared that, if they were registered as having a high income, they would lose out on future government food handouts. The ranking of malaria by almost all families as their most important health problem was probably influenced by the fact that the survey was undertaken during the peak malaria transmission period. In addition, as found in other studies (MILLS, 1994), it is difficult to assess the full impact of disease on household income or productive capacity since the economic impact is mediated by the extended family, which may both reduce and disguise the actual impact. Although total direct expenditure on a single malaria episode was less than US$3, it should be realized that malaria is likely to be clustered, as has been found in other studies in Sri Lanka (MENDIS et al.. 1990). and that some families are likely to experience a”large number of malaria episodes in a transmission season which places a substantial burden on the financial resources of the households. In addition, for a farming family, the time of occurrence of the malaria episode is very important. If the disease affects an agriculturally active member of the family for an extended period during the peak cultivation periods of land preparation and harvesting, it can lead to severe hardship. Early diagnosis and treatment are one of the main strategies of control of malaria (WHO, 1993). This study showed that the economic cost can still be considerable, even in a community where people comply with this strategy. Acknowledgements This study was a component of a continuing malaria research project and was supported by the Danish International and the Norwegian Agency Development Agency (DANIDA) for Develooment Co-oueration (NORAD). We thank MS Herath. MS Damavanthi. &lr Tavasena and MS Wanigadewa. Research Officers; who assisted-in carrying out the survey. We are also grateful for the secretarial support provided by Mala Ranawake. References Aikins, M. K., Pickering, H. & Greenwood, B. M. (1994). Attitudes to malaria, traditional practices and bednets (mosquito nets) as vector control measures: a comparative study in five West African countries. Journal of Tropical Medicine and Hygiene, 91, 81-86. Anonvmous (1993). Sri Lanka Nutrition and Health Status of Chz?dren. Battara’mulla, Sri Lanka: Ministry of Policy Planning and Implementation. Anonymous (1995). Anti-Malaria Campaign Annual Report for 1994. Colombo. Sri Lanka: Ministrv of Health Social Services and Highways. Foster, S. (1995). Treatment of malaria outside the formal health services. Journal of Tropical Medicine and Hygiene, 98, 29-34. Fungladda, W. (1991). Health behaviour and illness behaviour of malaria: a review. In: Social and Economic Aspects ofMalar; ia Control, Sornmani, S. & Fungladda, W. (editors). Bangkok, Thailand: Faculty of Tropical Medicine, Mahidol Umversity, pp. 84-99. Jayawardene, R. (1993). Illness perception: social cost and coping-strategies of malaria cases. Social Science and Medicine, 37, 1169-l 176. Mendis. C.. Gamaae-Mendis. A. C.. De Zovsa. A. I? K.. Abhayawardena, T. A., Carter; R., Herath, I’: R: J. & Mendis, K. N. (1990). Characteristics of malaria transmission in Kataragama, Sri Lanka: a focus for immuno-epidemiological studies. American Journal of Tropical Medicine and Hygiene, 42.298308. Mills, A. (1994). The economic consequences of malaria for households: a case-study in Nepal. Health Policy. 29, 209-227. Pinikahana, J. (1993). Illness behavior and preventive behavior of the people and malaria transmission in Sri Lanka. Mosquito-Borne Diseases Bulletin, 10, 12-20. Ramasamy, R., Subanesan, N:, Wljesundere, A., Fernando, N. K. & Ramasamy, M. S. (1992). Observations on malaria patients seeking treatment in hospitals in a rural and urban area of Sri Lanka. Indian Journal of Malariology, 29, 29-34.
F. KONFUDSEN ETAL.
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Rauyajin, 0. (1991). Factors affecting malaria related behavior: a literature review of behavioral theories and relevant research. In: Social and Economic Aspects of Malaria Control, Sornmani, S. & Fungladda, W. (editors). Bangkok, Thai~;-xg~lty ofTropical Medicine, Mahidol University, pp. Silva, K. T. (1991). Ayurveda, malaria and indigenous herbal tradition in Sri Lanka. Social Science and Medicine, 33, 153-160. Snow, R. W., Peshu, N., Forster, D., Mwenesi, H. & Marsh, K. (1992). The role of shops in the treatment and prevention of childhood malaria on the coast of Kenya. Transactions of the
Royal Society of Tropical Medicine and Hygiene, 86, 237-239. WHO (1993). A Global Strategy for Malaria Control. Geneva: World Health Organization. Wijesundera, M. (1988). Malaria outbreaks in new foci in Sri Lanka. Parasitology rOday, 4, 147-150. Wolffers, I. (1989).Traditional practitioners’ behavioral adaptations to changing patients’ demands in Sri Lanka. Social Science and Medicine, 29, 111 l-l 119. Received 26 June 1996; revised 22 October 1996; accepted for publication 22 October 1996
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