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Local knowledge and treatment of malaria in Agusan del Sur, The Philippines
PERGAMON
Social Science & Medicine 48 (1999) 607±618
Local knowledge and treatment of malaria in Agusan del Sur, The Philippines Cynthia A. Miguel a, *, Veronica L. Tallo a, Lenore Manderson b, Mary Ann Lansang c a
Department of Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Alabang, Muntinlupa, Metro Manila, Philippines b Tropical Health Program, Australian Centre for International and Tropical Health and Nutrition, The University of Queensland, Herston Road, Herston, QLD 4006, Australia c Clinical Epidemiology Unit, College of Medicine, University of the Philippines/Philippine General Hospital, Ermita, Metro Manila, Philippines
Abstract Information about local knowledge of malaria, its transmission, treatment and prevention were gathered at the outset of a Malaria Control Program in order to incorporate this information into community interventions. Data were collected using focus groups and indepth interviews with caretakers of children who had had a recent episode of malaria. These were supplemented as baseline data through a survey and the ongoing participation of researchers in the intervention. Local knowledge of malaria was in¯uenced by clinical diagnosis and was based on the coexistence of signs of illness. People conventionally self-medicated or used herbs for symptomatic relief prior to seeking clinical diagnosis and treatment, with treatment delay in¯uenced by the logistic diculties within the region, direct and indirect costs associated with treatment seeking, and delays in the return of results once a blood ®lm for diagnosis was made. People were familiar with mosquito control activities conducted by the Malaria Control Service and, as a result, most respondents associated malaria with mosquitos. However, the role of the mosquito as the sole vector, and the means by which malaria was transmitted, were not well appreciated. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: The Philippines; Malaria; Rapid assessment procedures; Community etiology; Diagnosis; Treatment
1. Introduction Malaria remains a major threat to health and hinders the economic development of local communities and nations. Almost half of the world's population is at risk from the disease which causes an estimated 300±500 million clinical cases and 1.5±2.7 million deaths each year (WHO, 1996). In the Philippines, 86,000 cases of malaria were con®rmed in 1991, 110,000 in 1992 and 65,000 in 1993 and the most
* Corresponding author. Tel.: +63-2-842-2245/809-7599; fax: +63-2-842-2245; e-mail: [email protected].
aected regions and provinces were Eastern Mindanao, the Sulu Archipelago, Palawan, Mindoro, North and South Eastern Luzon, Camarines, KalingaApayao and the Ifugao provinces (WHO, 1996). One of the provinces plagued by malaria is Agusan del Sur (ADS), located in the northern part of Mindanao and the focus of this paper. Previous research work of the Research Institute for Tropical Medicine (RITM) on community-based malaria control programs showed promise in the utilization of community volunteers (CV) for the early detection and treatment of malaria patients. In a major multidisciplinary study in Morong, Bataan, the Philippines, malaria control volunteers were recruited
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to undertake early case diagnosis, thereby substantially increasing the identi®cation of cases in areas distant from ®xed health posts. Medication was provided only to microscopically-con®rmed cases, but prompt delivery of drugs following con®rmation appears to have helped reduce malaria transmission, and in the years since the commencement of this project there has been a substantial decrease in cases (Espino et al., 1997). The possible role of the community malaria volunteer program in malaria control does not discount the impact of the continuing control eorts of the Malaria Control Service, nor of other factors which might have aected endemicity and infection. However, the data suggest the value of involving the community and local health services. Similar research conducted in Tayabas (Quezon, the Philippines) again has drawn attention to the value of involving barangay (village) members in community-wide activities for malaria control. Both Morong and Tayabas experiences provided the impetus to test similar strategies in ADS. The Agusan del Sur-Malaria Control and Prevention Program (ADS-MCP), funded by the Australian International Development Agency (AusAID), was conceived as a community health intervention program that utilizes strategies of community participation to motivate members of the community to become actively involved in installing, patronizing and sustaining malaria control mechanisms and to be involved in ensuring accessible, locally organized and locally delivered services. The major strategies of the project consist of (1) institutional strengthening through capability building exercises for local government and service units; (2) the recruitment and use of volunteer workers, with the main responsibility of early case detection and prompt treatment of cases; (3) community-wide health education programs for malaria control and prevention and (4) initial capitalization of microenterprises or alternative means of income generation to sustain the volunteer program. The project covers 10 out of the total 14 municipalities of the province. After a year of operation, at time of writing, the project had been able to forge partnerships with incumbent political ocials from provincial to barangay level, with the health service sector of the government and with other government service units such as agriculture. The project design allowed for the delivery of health education material to supplement the direct activities of the community volunteers, with the aim of increasing knowledge of malaria, its transmission and the importance of early diagnosis and treatment. In an intervention project like this, health education strategies need to be implemented at the earliest possible time, to inform the community about the structures that will be established and to ensure their appropriate utilization. Hence, relevant baseline data had to be collected early. Rapid assessment procedures (RAP) pro-
vide the most appropriate approach to data collection for this purpose and a RAP was designed to get a `culture-speci®c map' of beliefs and behaviors relevant to the program (Manderson et al., 1996). The primary methods utilized in this project were interviews and focus group discussions (FGD), with focus groups having the advantage of stimulating discussion among participants and providing the researchers with considerable contextual data in addition to diseasespeci®c information (Dawson et al., 1993). 2. Background information 2.1. The study area Agusan del Sur (ADS) was chosen as the study area of the community-based malaria control program because the province is one of the most depressed and underserved communities in the Mindanao region, which historically is said to have received the least support and attention from the national government. ADS is the seventh largest out of the total 76 provinces and autonomous regions of the Philippines (see Fig. 1). It has a very rugged terrain with pronounced maximum rain periods. It is predominantly an agricultural province with farming as the main means of livelihood. It is endowed with natural resources including mines and wide forest areas. Logging is a common source of wage labour for local inhabitants and some of the municipalities derive a large part of their income from logging concessions. Infrastructure, social facilities and services in the province are inadequate. Only 49% of the barangays have electricity and access to telephone communication is limited. The road network provides a road density of only 0.4027 km per km2 of land area. Movement within the province is provided by public transportation like jeepneys, single motorbikes and pumpboats. However, fares can be very expensive, ranging from 10±100 pesos for single motorbikes and 15±200 pesos (US$1 = 25 pesos), depending on distance, for pumpboats. Because of constant rain, roads are poorly maintained, so that the single motorbike (locally called `skylab') has become the most viable means of transport in ADS. However, roads are often muddy, waterlogged or ¯ooded, rendering them impassable to light vehicles and at times negotiable only to water bualo. This has particular impact on riverine communities, some of which are located several hours by boat (or road, when feasible) from the nearest ®xed health post. Health services are provided by 14 health centers, 105 barangay health stations (BHS), 7 private hospitals and 6 government hospitals. The Malaria Control Service (MCS) at the provincial level is primarily responsible for all control activities and is run by 2 pro-
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Table 1 Annual parasite index (API) and slide positivity rate (SPR), Agusan del Sur, 1992±1994
1992 1993 1994
API
SPR
22.2/1000 9.2/1000 9.6/1000
13.3 11.2 14.6
Source: Malaria Control Service, Agusan del Sur.
3. Methods and results 3.1. Data gathering strategies
Fig. 1. Map of Agusan Del Sur and Philippines.
vincial malaria coordinators (PMC), 8 rural malaria coordinators (RMC) and 3 microscopists. The team is headed by a physician-malariologist. 2.2. Malaria in ADS According to the 1990 report of the MCS, the malaria morbidity rate was high at 277.4/100,000 while the mortality rate was 5.8/100,000. Other malaria indicators like the annual parasite index (API) and slide positivity rate (SPR) are set out in Table 1. Another indicator recently used by the MCS is the strati®cation of areas into geographic zones of endemicity. Thus there are malarious A (corresponding to API of >10), malarious B (5±10), MEPA (malaria epidemic-prone area, <5) and malaria free areas (API of 0). In 1994, the distribution of barangays according to this strati®cation system was as shown in Table 2. Only 24% of the barangays are free from malaria. In all other barangays there is at least some transmission and while there is some seasonality with the highest prevalence from January to April, cases occur throughout the year (Fig. 2). The highest prevalence is in the towns of Bayugan and Esperanza (Fig. 3) and those aged 14 and below appear to be at highest risk of infection (Fig. 4).
A social and demographic pro®le of the province was compiled through interviews and review of records. For the rapid ethnographic studies, two main data gathering strategies were utilized: (1) focus group discussions (FGD) with members of the community, rural health unit (RHU) sta and barangay health workers (BHW) and (2) indepth interviews of mothers of children/adolescents who had had a recent episode of malaria. A total of 29 FGDs were conducted: 15 among community members, 9 with RHU sta and 5 with BHWs. The number of participants in a focus group ranged from 8±20, with a total of 237 participants. The FGDs focused on illness terms and their corresponding manifestations; levels of severity associated with illness or its manifestations; perceptions of causation; action taken with emphasis on the healthcare seeking behaviors and beliefs regarding preventive and control measures. Indepth interviews with mothers followed the same foci as the FGD with the added enrichment of information obtained from actual cases. The cases were obtained from recent records of positive blood smears at the RHU. Mother-respondents were randomly chosen from the list. To select the barangays, a list of barangays with the number of positive blood smears for the past 2 consecutive years was made, and those barangays that consistently showed high numbers were chosen. For each municipality, 2 barangays were selected. Table 2 Strati®cation of barangays by endemicity Strati®cation
Total barangays Total population
Malarious A 27 Malarious B 77 Malaria-endemic prone area 128 Malaria free 73
16,137 62,137 190,781 269,246
Source: Malaria Control Service, Agusan del Sur.
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Fig. 2. Percent distribution of positive malaria smears by month, Agusan del Sur, 1995.
Fig. 3. Percent distribution of positive malaria smears by municipality, Agusan del Sur, 1995.
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Fig. 4. Explanatory model for malaria.
3.2. Pro®les of participants The age of focus group participants and indepth interviewees ranged from 14±70 years, in terms of mean age, the interviewees were younger (27.7 years) than FGD participants (36 years). In both groups, the majority were married, had 1 to 6 years of schooling and a median household size of 6. The majority of FGD participants were housewives (52%), while 53.8% of indepth interviewees were actively engaged in farming (Table 3). 3.3. Description of symptoms and illness terms Malaria is commonly known as malarya, although sometimes as takig (chills). The symptoms most commonly associated with malaria are chills (kurog or takig) and hilanat (fever) and were considered as the primary signs of malaria from all focus group participants and interviewees. Other symptoms included constant thirst (kanunay giuhaw) which some women associated it with febrile chills and recurrent fever (magbalik-balik ang lagnat) which occurred at a regular time each day. Another term used is malignant, probably adapted from the medical term `malignant', to indicate cerebral malaria, which is contrasted with natural na malarya when the brain is not aected. Malignant is usually characterised by severe headache (sakit kaayo ang ulo) and is considered to be especially
serious and potentially fatal, because it may lead to magsalimuang/mabuang (a condition resembling epileptic convulsion, although literally the term connotes mental disorder). Women's explanation of this condition is that the malaria `germ' (kagaw) goes to the brain, causing the disorder. Conditions considered as indicative of severe malaria are `eyes rolled up' (sulirap ang mata), locked jaw and darkening of nails (lagum ang kuko). Malaria fever was dierentiated from other fever on the basis of its persistence even after the administration of paracetamol or the application of herbal treatment. The majority of mothers also believed that a child de®nitely had malaria if he or she presented with high fever at the same time everyday after feeling cold ( panugnawon) and shivering. On the other hand, some would suspect malaria on the basis of chills only and some regarded chills and malaria as the same disease entity. Mothers recognized a `pattern' of the presentation of the complex of signs (cf. Gomez et al., 1984). What is described below is one complex of signs and the progress of the disease, although not all respondents would agree with this sequence of signs and symptoms for all cases: First the child feels cold, the hands and feet are very cold, he would be shivering so badly that he would need to be wrapped in a blanket. Then the chill disappears and the shivering stops, but this is
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C.A. Miguel et al. / Social Science & Medicine 48 (1999) 607±618 Table 3 Socio-demographic pro®le of focus group and interview participants, Agusan del Sur, 1995 Focus group participants, No. (%)
Interviewees, No. (%) adults (26)
Age 1±5 6±10 11±14 15±19 20±24 25±29 30±34 35±39 > = 40
11 37 34 37 37 80
(4.7) (15.7) (14.4) (15.7) (15.7) (33.9)
4 5 4 5 3 5
(15.4) (19.2) (15.4) (19.2) (11.5) (19.2)
Occupation Farming Housewife Barangay oc. Government service Self-employed Unemployed Others No data
85 (36.0) 124 (52.5) 6 (2.5) 4 (1.7) 3 (1.3) 12 (5.1) 3 (1.3)
14 (53.8) 6 (23.1)
No school years attended None 1±6 7±10 > = 10 No data
10 (4.2) 169 (71.3) 46 (19.4) 12 (5.1)
0 19 (73.1) 5 (19.2)
Civil status Never married Married Widowed
9 (3.8) 211 (89.8) 15 (6.4)
2 (7.7) 22 (84.6) 2 (7.7)
Household size 1±3 4±6 7±10 > = 11
36 (15.2) 108 (45.6) 83 (35.0) 10 (4.2)
2 (7.7) 14 (53.8) 8 (30.8) 2 (7.7)
followed by his body getting hot with a high fever. In a few cases, this is accompanied by severe headache and convulsions. This pattern recurs at the same time the following day, so that if the fever appears at 9 o'clock today, it will recur at exactly the same time tomorrow. Another sequence is: At the start, you'll feel cold then it will progress to shivering followed by fever. Sweating follows and you'll feel well again. Sometimes there will be head-
child patient (38) 13 (34.2) 15 (39.5) 10 (23.3)
2 (7.7) 4 (15.4)
30 (78.9) 7 (18.4) 1 (12.6)
2 (7.7)
0 18 (47.4) 20 (52.6) 0
ache, this can be very painful. If it's the malignant type, there will be no shivering, just coldness and a steady fever. Then there will be severe headache and then delirium. The patient may then die. Whereas focus group participants frequently referred to headache, this was not mentioned as often by mothers of children who had con®rmed malaria and only 40% of the mothers recalled that their child had had headache. It is possible, of course, that this was because of the inability of young children to verbalize the condition.
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The symptoms recognized within the community are usually clinical manifestations of malaria. Those symptoms that they associate with malignant and consider as severe are the same as those with P. falciparum infection. This is the predominant species of malaria in the Philippines where according to latest reports, 73.6% of malaria cases are due to P. falciparum (WHO, 1996). In ADS, the proportion is slightly higher, 83.6% (unpublished data, 1995). In general, respondents had a clear understanding of the manifestations of malaria, and this could potentially guide them to act appropriately in the event of illness within the household. 3.4. Perceptions of severity Notwithstanding the reported perception that severe malaria could be fatal, respondents did not perceive malaria to be a serious public health problem. This apparent lack of concern relates in part to people's knowledge of the ready availability of antimalarials which are believed to be fast-acting and eective and their con®dence that one will be cured of malaria if she or he takes the drug, although contrarily, respondents also considered malaria to be self-limiting. In general, they regarded childhood diseases like diarrhoea and measles as most serious, especially the former because it could be immediately fatal and is a common occurrence. Another reported health priority was schistosomiasis, known locally as `shisto' and described as a disease causing enlargement of the stomach and other body parts; primary cause of concern for this disease is the disability resulting from it. At the same time however, other circumstantial factors clearly in¯uenced perception of severity and action. As noted, in ADS barriers to early treatment include topography (mountainous areas), lack of roads or usable roads, lack of transport able to negotiate poor road conditions, infrequent public transport services, distance from sitio (hamlet) to RHU and delays that occur between the collection of a blood smear and feedback regarding diagnosis and treatment. Respondents also often lacked adequate funds to pay for transportation, other indirect costs and treatment costs (although in fact, through the RHU, there is no charge) (cf. Jayawardene, 1993). These factors all discouraged the use of local health facilities and contributed to people feeling that they could manage illness within the domestic domain. 3.5. Etiology and transmission Knowledge of the etiology of malaria varied widely. Peoples' knowledge combined various concepts of infection, often confusing the etiology of various microbiological and parasitic infections and other ill-
613
nesses. Understanding of malaria as contagious, related to the importance of a human reservoir to maintain infection, was rarely articulated compared with other ideas of contagion, although people did associate to some degree infection in others and their own risk. The mechanisms of transmission of malaria, as explained in FGDs and interviews, were: 1. Predisposing factors: these included a perception that malaria was due to pasmo, a condition characterized by headache and fever due to skipping meals or not having meals on time: ``having missed meals, they become weak and lose resistance to infection, thus they become prone to illness''. In addition, `weak blood', low resistance and malnutrition were considered to increase an individual's likelihood of getting malaria. These beliefs are associated with those relating to the importance of humoral balance, which is in¯uenced by thermal conditions, diet, particular foods and other illnesses (Hart, 1969). 2. Transmission by the vector: malaria was attributed to mosquitoes (lamok) either directly, by being bitten by them, or indirectly, by drinking water contaminated with mosquito larvae or in other ways polluted. The majority of FGD participants mentioned mosquitoes in relation to malaria. The vast majority (36 of 38) of caretakers of children who had had malaria regarded mosquitos as a single or a contributing cause. 3. Germs or kagaw were also reported to cause malaria; sharing the same bed, the same utensils and even the same bathing material (towels, soap, etc.) could transmit the disease. This is not an uncommon response in other parts of the world; HelitzerAllen et al. (1993), for example, made similar observations in Malawi of people's association of malaria with germs, contagion and personal contact. In Agusan del Sur, people did not dierentiate among germs that could cause disease and, hence, food, air and water were all possible sources of contagion. Flies were also believed to be carriers, with a person becoming ill if she or he ate food where ¯ies had landed after coming from faecal matter. 4. Situational factors: a very common perception within all focus groups (but not from mothers) also was that individuals involved in logging or other upland or forest activities were at greatest risk of getting malaria, either by being bitten by mosquitoes, drinking polluted water, or getting hungry and missing meals. Perceptions that malaria is transmitted in the forest rather than in or around the village is not uncommon (cf. Tang et al., 1995), but is not consistent with vector behaviour and habitat,
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nor patterns of transmission in this area of the Philippines. Although mothers of sick children and focus group participants shared a general understanding of malaria, in fact, as indicated in Table 4, the majority of the mothers attributed malaria to mosquitos in some way and these perceptions appear to associate stream clearance and the reduction of larvae with decline in infection, consistent with the belief that the ingestion of larvae will cause malaria (these beliefs are held elsewhere in the Philippines, e.g. Espino et al., 1997). In general, except for pasmo, concepts related to disease transmission could also have been learned from health educational material delivered by clinic or malaria control service (MCS) sta. 4. Action when confronted with illness Initially, a person sick with fever takes no action: ``As long as I can still carry on, I'll not take anything yet''. She or he will ®rstly observe and monitor progress and only if the fever persists or the condition deteriorates will the person take either paracetamol or herbal medicine: ``I'll try this medicine ®rst, it might work in this episode''. Paracetamol is the preferred drug if these are tablets in the house or if money were
available to purchase it (most commonly under the brand name Biogesic). Consistent use of the same drug by an individual is attributed to nakasanayan or hiyang, familiarity with a drug on the basis of its previous successful use. If people have no money, they will take herbal medicine, and herbs are freely available. Herbs like herba buena, kalabo and oregano are used to relieve fever, through a decoction made from boiling the leaves in water to make a drink. Other bitter-tasting leaves or roots like marbelosa, dita, tubatuba and ubod ng pasan are believed to be remedies speci®cally for malaria; again their leaves are boiled and the infusion is given to the patient to drink. Our opinion is that the association of their bitter taste with the bitterness of antimalarials such as chloroquine may have in¯uenced people's perception of the eectiveness of herbs against malaria, although respondents were not asked about this. Herbs are also used when it is believed that the illness is due to pasmo and respondents mentioned their accessibility and the fact that they do not cost anything, they can be picked at any site or corner in the vicinity, as an attractive treatment alternative. Herbs are commonly used to treat illness (McNee et al., 1995) and this is encouraged by midwives during mothers' classes at the RHU for symptomatic relief for health problems such as respiratory infections (Simon et al., 1996). Women perceive herbal
Table 4 Caregiver's knowledge of the cause of malaria Causes of malaria
No. (n = 38)
Mosquito-related Drinking water from open sources which contain eggs of mosquitoes Mosquitos carrying malaria germs which they get from dirty surroundings Bite of a mosquito which had just bitten someone with malaria Mosquitos n.e.c.
36 10 14 5 7
Food-related Eating sweet `cold' food or drinking cold coconut water on an empty stomach Pasmo-skipping meals
10 4 6
Sanitation practices Dirty surroundings Not washing hands before eating
7 6 1
Weather-related Cold climate
1 1
Others Piang Inadequate nutrition
3 1 2
Source: In-depth interviews with mothers of children who had malaria, Agusan del Sur, 1995.
C.A. Miguel et al. / Social Science & Medicine 48 (1999) 607±618
therapy as a sanctioned treatment for various illnesses, and do not necessarily discriminate the advice according to symptoms and possible diagnosis. If the fever does not subside after a day or so, the caregiver will either buy an antimalarial (Aralen (chloroquine) or Fansidar) locally, or go to the health centre, depending on the relative costs. Agusan del Sur is geographically vast, often with considerable distances between the barangay and the poblacion (township) where health facilities are located: distances range from 10±30 km (with extreme distances of up to 127 km), with one-way fares of 20±50 pesos (but up to 500 peso in extreme cases). As already noted, if the transportation cost to the health centre is greater than the cost of buying antimalarials from a small retail stores within the barangay, or if transport is infrequently available, then people will self-medicate. The free drugs from the health centre are not seen to be an attractive option if people have to spend money on a fare or if the travel to the health centre is dicult or complicated, like having to take both a motor bike and a connecting pumpboat ferry. In addition, depending on their experience of RHU services, people are not always con®dent of the availability when they arrive of health workers (doctors, nurses or midwives). Hence a variety of factors encourage self-medication. Antimalarials are well known in the community because of the high endemicity of malaria and people do not consider it necessary to have their blood examined ®rst to con®rm the diagnosis or to determine appropriate medication. They know that blood examination (`blood test') should be done ®rst, but since they are familiar with the names of the antimalarials already, they go directly to the drug store. Aralen (chloroquine) costs an average of 7 pesos (US$0.27) per tablet while Fansidar costs an average of 22 pesos (US$0.84) a unit. Both drugs are available over the counter. People's con®dence in the eectiveness of the drug is reinforced by their previous experiences with it or reports from other people. Usual drug intake is a single dose or one tablet per day for 1±3 days, most often one day unless otherwise indicated. People say, ``after one day, we are usually cured, we don't have fever anymore'', so they stop taking the drugs. The drugs are ``so bitter, I won't take it longer than I have need for it''. Although local herbs are used, resort to traditional healers is not common. Gamot na binisaya (herbalists) are rarely consulted because their skill is considered more appropriate for buyag (evil eye) or piang (sprain), although if fever is initially thought to be caused by buyag or piang, then such consultation might take place. If the symptoms did not improve and chills occurred, they would suspect malaria and this would then lead to a change in treatment seeking behaviour.
615
If fever or other symptoms persist or recur, people may reconsider seeking medical advice, although only if they have money. Otherwise, they will just `bear' the illness, hope for improvement or recovery, and wait until they have enough money to seek professional help. The occurrence of delirium (magsalimuang) or a deterioration in the patient's condition (`too sick to move') will lead to changes in treatment seeking and medication, initially by use of herbal medicine except when the patient lives within 5 km radius of the RHU, in which case they are more likely to go to the RHU. Hence the picture that emerges is that determinants of health action are strongly in¯uenced by immediate economic circumstances, other situational factors and/ or experience with drugs, health workers and health facilities. Self-medication is a common action for many ailments in the Philippines, the consequence of the ready availability of pharmaceuticals, the aggressive promotion by pharmaceutical companies and the weak control of drug supplies by government (Hardon, 1987; Carpenter et al., 1996). Outcome of the illness is not a consideration in the sense that it is not the fear of worst possible outcome that dictates peoples' action. Rather, people react in response to each prior action. They consult a doctor only if the illness does not improve, rather than consulting a doctor because they are worried that the illness might not improve. People did not perceive malaria as having serious consequences and were not worried by being sick with malaria. Their health action is on the basis of `trial and error', `shopping' around from one action to another until they ®nd one to cure them of symptoms. 4.1. Diagnostic protocol Malaria control and treatment services are provided mainly by malaria control program workers, although the health centres provide supplementary services for this program. The RMCs are consulted if they are in the area when a patient is sick. Consultation consists of blood examination and drug dispensation free of charge. With just one RMC for every municipality, these workers are infrequently seen in the barangay, especially those which are located beyond 5 km of the town center. Most RMCs live in the town centre. The alternative health providers in these remote areas are the midwives and barangay health workers (BHW). The midwives are responsible for speci®c catchment areas consisting of more than 2 barangays and again are infrequently seen in areas far from their residence. As a result, the most available service provider is the BHW. BHWs have been trained to make blood smears and some have been given antimalarials for dispensing. However, most often, antimalarials are available only
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from the RMCs, whose usual practice is to prioritize their ®eld visits to areas with reported `¯are-ups' or sudden increases in malarial patients. An RMC will visit other areas if he has a follow-up to do, that is, if a patient's blood smear is positive and the patient needs a complete treatment regimen. The policy at the moment is for the RMC to give presumptive treatment at ®rst and complete medication when the result of the blood smear examination is available. We tried to determine the length of time from when the blood smear was taken, to the administration of medication. Depending on logistics, weather, stang and other factors, it is possible to take as long as four weeks for the patient to receive the microscopy result and be given the appropriate medication if health providers adhere to the policy of providing only presumptive treatment. If midwives or RMCs are available, however, the turn around time can be as short as one day. Strict adherence to the policy of presumptive treatment only therefore was not enforced by the MCS in Agusan del Sur because of delays in receiving results. It was left to the RMC to determine how many drugs would be given to the patient and frequently, radical treatment was practiced especially if the patient came from a barangay known to be endemic with malaria. Presumptive treatment is supposed to be a 3-day course to be completed or discontinued depending on the results of the blood smear examination; radical treatment is a 5-day full course. The antimalarial dose given to a patient suspected to have malaria is set out in Table 5. 5. Prevention and control Motivation to undertake preventive action is in¯uenced by etiological beliefs held by individuals. Although, as illustrated above, people held a wide range of beliefs about the cause of malaria, they included mosquitos in their model of transmission. Mosquitoes were said to live and breed in slow, ¯owing waters, in trash receptacles like coconut husks with water collected in them, in grassy or tree-®lled areas,
and in any dark and dirty place. Thus, the pervading preventive behaviors were to clean the surroundings, get rid of empty receptacles which could contain water, cover drinking water containers (mosquitoes might lay their eggs in these) and other foods (¯ies might land on these), boil drinking water and adhere to other sanitation-related actions (Helitzer-Allen et al., 1993, report a similar confusion between hygiene, sanitation and malaria prevention practices transmitted by various health and agricultural extension ocers among Malawi residents). People were also familiar with other malaria control measures advocated by the malaria control program, such as the use of insecticide-impregnated bed nets and residual house spraying. Bed nets were used mainly to ward nuisance mosquitoes rather than for protection from malaria. Children are the usual persons who sleep under nets, although adults may join them if space permits. Few had had their bed nets impregnated with insecticide for a variety of reasons: they were away when the impregnation was done; it was raining and they were afraid that the bed net might not be dry enough to be used the same evening; or they were embarrassed because their net was homemade from sack cloth. Those who had used insecticide-impregnated bed nets were generally positive about the procedure and were not bothered by smell or any skin irritation. People were also familiar with house spraying preventive measures, and some had had their houses sprayed. Others did not because they were out of the house during the period of spraying; spraying was a nuisance because lots of other insects (like cockroaches) fell down dead (hence making a mess); or children got skin irritations or some other illness when exposed to the insecticide. There was also a prevailing opinion that the eectiveness of these insecticides were shortlived. Immediately after spraying, people agreed that mosquitos were driven away, but within a week or so, they were back. Another negative comment on house spraying was that the insecticides left a foul odor and caused discolouration of the walls, so that they would prefer that spraying be done only on the
Table 5 Antimalarial protocol (drug dosage/age group) Age group
Chloroquine
Primaquine (No. of tablets daily 14 days)
> = 16 12±15 7±11 4±6 1±3 <1
4, 4, 2 3, 3, 2 2, 2, 1 112, 112, 12 1, 1, 12 1 1 1 2, 2, 4
1 14 days = 14 tablets 1 14 days = 14 tablets 3 1 414 days = 102 tablets 1 14 days = 7 tablets 2 1 1 414 days = 32 tablets should not give medication
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outside of the house. This could limit the eectiveness of the insecticide to the extent that anopheline mosquitos in the area, on the basis of human-biting rates from entomological work conducted with the project, appear to be both exophagic and endophagic (3:2) (Torres, personal communication). Others preferred to use mosquito coils at nighttime to drive mosquitos away. People were also familiar with stream clearing as a means of vector control. This activity was left to malaria control program workers or barangay ocials, primarily through fear of going into the water because of `shisto' (schistosomiasis).
6. Conclusion Because of the high level of endemicity relative to other areas of the Philippines, people in Agusan del Sur are familiar with the clinical presentation of malaria and to a lesser degree, are aware of an association between mosquitoes and infection. Knowledge of clinical manifestations of malaria and of treatment regimens indicate people's exposure to information from health workers and their own exposure to the disease. However, the general view is that malaria is relatively benign and that a sick individual can easily be treated if given the correct remedy. People often delay treatment and are not concerned with the possibility of progression of the illness because of delayed action. The presence of untreated and infected individuals is the likely reason for the continued transmission and relatively high endemicity of malaria in this region. Both to reduce serious morbidity and mortality, and to reduce transmission by reducing sources of infection in the community, early detection of malaria cases and prompt treatment are important. As noted, self-medication is common in this area, almost inevitably because of the inaccessibility of health services. The practice has the potential, however, to increase the risk of drug resistance. Community members are well aware of the standard procedure of taking blood smears for the diagnosis of malaria. They can go to the RMC, midwife or even BHWs for this. However, the same problems of access and availability of these people prevents compliance with this standard procedure, and people resort to self-medication immediately if they think that a household member is 1 A quick diagnostic tool\kit that requires no microscopic examination, especially one that a BHW can do and is therefore practical in the ®eld, could be used. Such a kit, ParaSight F (Becton and Dickenson, USA) is being ®eld tested by the ADS-MCP Project. At this stage its major disadvantage is cost compared with the cost of microscopy.
617
suering from malaria. Diagnostic tests for the presence of malarial parasite is still an important procedure prior to medication and is the only known practical step to prevent the resurgence of drug resistant strains of parasites. Mechanisms to promote diagnostic testing of suspected patients need to be explored to reduce the time it takes for the patient to ®nd out the result of the blood smear examination. A possible mode here is to involve motorbike owners or operators in the transport of blood ®lms and results between the patient and the main health centres where the microscopists are usually stationed1. People's perceptions surrounding causes and transmission of malaria confuses factors associated with a variety of infections. Although respondents associated malaria transmission with mosquitos, they were unclear about the mechanisms of this. A predominant belief was that malaria could be transmitted by drinking water contaminated by mosquito's eggs. Perceptions of contagion are further extended to include social contact, such as sharing a bed, utensils, etc. In this, the role of mosquito as vector is lost. Community understandings of malaria transmission and treatment can be incorporated into health education material to reinforce control eorts in the community. Acknowledgements We are grateful to the sta of the Agusan del SurMalaria Control and Prevention (ADS-MCP) Program; Mila-Fulache, Paz Demonteverde, Tina Villarama and Earl L. Alcala and the community organizers; the RHU sta of the 10 municipalities covered by this study, the Rural Malaria Coordinators of the Provincial Malaria Control Service and members of the communities who provided us with valuable assistance and information. The research on which this paper is based was conducted as part of the Agusan del Sur Malaria Control and Prevention Program: implementation and evaluation of a self-sustaining, community-based malaria control program in a hyperendemic area (PI: M.A.L.), funded by AusAID (Australian International Development Agency) and involving the Research Institute of Tropical Medicine, The Philippines, The University of the Philippines, the Department of Health-Malaria Control Service and the Australian Centre for International and Tropical Health and Nutrition, The University of Queensland. References Carpenter, H., Manderson, L., Janabi, M., Kalmayem, G., Simon, A., Waidubu, G., 1996. The politics of drug distri-
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bution in Bohol, the Philippines. Asian Studies Review 17, 35±52. Dawson, S., Manderson, L., Tallo, V.L., 1993. A Manual for the Use of Focus Groups. International Nutrition Foundation for Developing Countries, Boston, MA. Espino, F., Manderson, L., Acuin, C., Domingo, F., Ventura, E., 1997. Perceptions of malaria in a low endemic area of The Philippines: transmission and prevention of disease. Acta Tropica 63 (4), 221±239. Gomez, M., Espino, F.E., Abaquin, J., Realon, C., Salazar, N.P., 1984. Symptomatic identi®cation of malaria in the home and in the primary health care clinic. Bulletin of the World Health Organization 72 (3), 383±390. Hardon, A.P., 1987. The use of modern pharmaceuticals in a Filipino village: doctor's prescriptions and self-medication. Social Science and Medicine 25, 277±292. Hart, D.V., 1969. Bisayan Filipino and Malayan Humoral Pathologies: Folk Medicine and Ethnohistory in Southeast Asia. Data Paper No. 76. Department of Asian Studies Southeast Asia Program, Cornell University, Ithaca, NY. Helitzer-Allen, D.L., Kendall, C., Wirima, J.J., 1993. The role of ethnographic research in malaria control: an example
from Malawi. Research in the Sociology of Health Care 10, 269±286. Jayawardene, R., 1993. Illness perception: social cost and coping-strategies of malaria cases. Social Science and Medicine 37, 1169±1176. McNee, A., Khan, N., Dawson, S., Gunsalam, J., Tallo, V.L., Manderson, L., Riley, I., 1995. Responding to cough: Boholano illness classi®cation and resort to care in response to childhood ARI. Social Science and Medicine 40, 1279± 1289. Manderson, L., Agyepong, I., Aryee, B., Dzikunu, H., 1996. Anthropological methods for malaria interventions. Practicing Anthropology 18 (3), 32±39. Simon, A., Janabi, M., Kalmayem, G., Waidubu, G., Galia, E., Pague, L., Manderson, L., Riley, I., 1996. Caretakers' management of childhood ARI and the use of antibiotics, Bohol, The Philippines. Human Organisation 55 (1), 76±83. Tang, L.H., Manderson, L., Deng, D., Wu, K.C., Cai, X., Lan, C., Gu, Z., Wang, K.A., 1995. Social aspects of malaria in Heping, Hainan. Acta Tropica 59 (1), 41±53. World Health Organization, 1996. World malaria situation in 1993. WHO Weekly Epidemiological Records 6, 41±48.
Social Science & Medicine 48 (1999) 607±618
Local knowledge and treatment of malaria in Agusan del Sur, The Philippines Cynthia A. Miguel a, *, Veronica L. Tallo a, Lenore Manderson b, Mary Ann Lansang c a
Department of Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Alabang, Muntinlupa, Metro Manila, Philippines b Tropical Health Program, Australian Centre for International and Tropical Health and Nutrition, The University of Queensland, Herston Road, Herston, QLD 4006, Australia c Clinical Epidemiology Unit, College of Medicine, University of the Philippines/Philippine General Hospital, Ermita, Metro Manila, Philippines
Abstract Information about local knowledge of malaria, its transmission, treatment and prevention were gathered at the outset of a Malaria Control Program in order to incorporate this information into community interventions. Data were collected using focus groups and indepth interviews with caretakers of children who had had a recent episode of malaria. These were supplemented as baseline data through a survey and the ongoing participation of researchers in the intervention. Local knowledge of malaria was in¯uenced by clinical diagnosis and was based on the coexistence of signs of illness. People conventionally self-medicated or used herbs for symptomatic relief prior to seeking clinical diagnosis and treatment, with treatment delay in¯uenced by the logistic diculties within the region, direct and indirect costs associated with treatment seeking, and delays in the return of results once a blood ®lm for diagnosis was made. People were familiar with mosquito control activities conducted by the Malaria Control Service and, as a result, most respondents associated malaria with mosquitos. However, the role of the mosquito as the sole vector, and the means by which malaria was transmitted, were not well appreciated. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: The Philippines; Malaria; Rapid assessment procedures; Community etiology; Diagnosis; Treatment
1. Introduction Malaria remains a major threat to health and hinders the economic development of local communities and nations. Almost half of the world's population is at risk from the disease which causes an estimated 300±500 million clinical cases and 1.5±2.7 million deaths each year (WHO, 1996). In the Philippines, 86,000 cases of malaria were con®rmed in 1991, 110,000 in 1992 and 65,000 in 1993 and the most
* Corresponding author. Tel.: +63-2-842-2245/809-7599; fax: +63-2-842-2245; e-mail: [email protected].
aected regions and provinces were Eastern Mindanao, the Sulu Archipelago, Palawan, Mindoro, North and South Eastern Luzon, Camarines, KalingaApayao and the Ifugao provinces (WHO, 1996). One of the provinces plagued by malaria is Agusan del Sur (ADS), located in the northern part of Mindanao and the focus of this paper. Previous research work of the Research Institute for Tropical Medicine (RITM) on community-based malaria control programs showed promise in the utilization of community volunteers (CV) for the early detection and treatment of malaria patients. In a major multidisciplinary study in Morong, Bataan, the Philippines, malaria control volunteers were recruited
0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 9 8 ) 0 0 3 5 2 - 9
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to undertake early case diagnosis, thereby substantially increasing the identi®cation of cases in areas distant from ®xed health posts. Medication was provided only to microscopically-con®rmed cases, but prompt delivery of drugs following con®rmation appears to have helped reduce malaria transmission, and in the years since the commencement of this project there has been a substantial decrease in cases (Espino et al., 1997). The possible role of the community malaria volunteer program in malaria control does not discount the impact of the continuing control eorts of the Malaria Control Service, nor of other factors which might have aected endemicity and infection. However, the data suggest the value of involving the community and local health services. Similar research conducted in Tayabas (Quezon, the Philippines) again has drawn attention to the value of involving barangay (village) members in community-wide activities for malaria control. Both Morong and Tayabas experiences provided the impetus to test similar strategies in ADS. The Agusan del Sur-Malaria Control and Prevention Program (ADS-MCP), funded by the Australian International Development Agency (AusAID), was conceived as a community health intervention program that utilizes strategies of community participation to motivate members of the community to become actively involved in installing, patronizing and sustaining malaria control mechanisms and to be involved in ensuring accessible, locally organized and locally delivered services. The major strategies of the project consist of (1) institutional strengthening through capability building exercises for local government and service units; (2) the recruitment and use of volunteer workers, with the main responsibility of early case detection and prompt treatment of cases; (3) community-wide health education programs for malaria control and prevention and (4) initial capitalization of microenterprises or alternative means of income generation to sustain the volunteer program. The project covers 10 out of the total 14 municipalities of the province. After a year of operation, at time of writing, the project had been able to forge partnerships with incumbent political ocials from provincial to barangay level, with the health service sector of the government and with other government service units such as agriculture. The project design allowed for the delivery of health education material to supplement the direct activities of the community volunteers, with the aim of increasing knowledge of malaria, its transmission and the importance of early diagnosis and treatment. In an intervention project like this, health education strategies need to be implemented at the earliest possible time, to inform the community about the structures that will be established and to ensure their appropriate utilization. Hence, relevant baseline data had to be collected early. Rapid assessment procedures (RAP) pro-
vide the most appropriate approach to data collection for this purpose and a RAP was designed to get a `culture-speci®c map' of beliefs and behaviors relevant to the program (Manderson et al., 1996). The primary methods utilized in this project were interviews and focus group discussions (FGD), with focus groups having the advantage of stimulating discussion among participants and providing the researchers with considerable contextual data in addition to diseasespeci®c information (Dawson et al., 1993). 2. Background information 2.1. The study area Agusan del Sur (ADS) was chosen as the study area of the community-based malaria control program because the province is one of the most depressed and underserved communities in the Mindanao region, which historically is said to have received the least support and attention from the national government. ADS is the seventh largest out of the total 76 provinces and autonomous regions of the Philippines (see Fig. 1). It has a very rugged terrain with pronounced maximum rain periods. It is predominantly an agricultural province with farming as the main means of livelihood. It is endowed with natural resources including mines and wide forest areas. Logging is a common source of wage labour for local inhabitants and some of the municipalities derive a large part of their income from logging concessions. Infrastructure, social facilities and services in the province are inadequate. Only 49% of the barangays have electricity and access to telephone communication is limited. The road network provides a road density of only 0.4027 km per km2 of land area. Movement within the province is provided by public transportation like jeepneys, single motorbikes and pumpboats. However, fares can be very expensive, ranging from 10±100 pesos for single motorbikes and 15±200 pesos (US$1 = 25 pesos), depending on distance, for pumpboats. Because of constant rain, roads are poorly maintained, so that the single motorbike (locally called `skylab') has become the most viable means of transport in ADS. However, roads are often muddy, waterlogged or ¯ooded, rendering them impassable to light vehicles and at times negotiable only to water bualo. This has particular impact on riverine communities, some of which are located several hours by boat (or road, when feasible) from the nearest ®xed health post. Health services are provided by 14 health centers, 105 barangay health stations (BHS), 7 private hospitals and 6 government hospitals. The Malaria Control Service (MCS) at the provincial level is primarily responsible for all control activities and is run by 2 pro-
C.A. Miguel et al. / Social Science & Medicine 48 (1999) 607±618
609
Table 1 Annual parasite index (API) and slide positivity rate (SPR), Agusan del Sur, 1992±1994
1992 1993 1994
API
SPR
22.2/1000 9.2/1000 9.6/1000
13.3 11.2 14.6
Source: Malaria Control Service, Agusan del Sur.
3. Methods and results 3.1. Data gathering strategies
Fig. 1. Map of Agusan Del Sur and Philippines.
vincial malaria coordinators (PMC), 8 rural malaria coordinators (RMC) and 3 microscopists. The team is headed by a physician-malariologist. 2.2. Malaria in ADS According to the 1990 report of the MCS, the malaria morbidity rate was high at 277.4/100,000 while the mortality rate was 5.8/100,000. Other malaria indicators like the annual parasite index (API) and slide positivity rate (SPR) are set out in Table 1. Another indicator recently used by the MCS is the strati®cation of areas into geographic zones of endemicity. Thus there are malarious A (corresponding to API of >10), malarious B (5±10), MEPA (malaria epidemic-prone area, <5) and malaria free areas (API of 0). In 1994, the distribution of barangays according to this strati®cation system was as shown in Table 2. Only 24% of the barangays are free from malaria. In all other barangays there is at least some transmission and while there is some seasonality with the highest prevalence from January to April, cases occur throughout the year (Fig. 2). The highest prevalence is in the towns of Bayugan and Esperanza (Fig. 3) and those aged 14 and below appear to be at highest risk of infection (Fig. 4).
A social and demographic pro®le of the province was compiled through interviews and review of records. For the rapid ethnographic studies, two main data gathering strategies were utilized: (1) focus group discussions (FGD) with members of the community, rural health unit (RHU) sta and barangay health workers (BHW) and (2) indepth interviews of mothers of children/adolescents who had had a recent episode of malaria. A total of 29 FGDs were conducted: 15 among community members, 9 with RHU sta and 5 with BHWs. The number of participants in a focus group ranged from 8±20, with a total of 237 participants. The FGDs focused on illness terms and their corresponding manifestations; levels of severity associated with illness or its manifestations; perceptions of causation; action taken with emphasis on the healthcare seeking behaviors and beliefs regarding preventive and control measures. Indepth interviews with mothers followed the same foci as the FGD with the added enrichment of information obtained from actual cases. The cases were obtained from recent records of positive blood smears at the RHU. Mother-respondents were randomly chosen from the list. To select the barangays, a list of barangays with the number of positive blood smears for the past 2 consecutive years was made, and those barangays that consistently showed high numbers were chosen. For each municipality, 2 barangays were selected. Table 2 Strati®cation of barangays by endemicity Strati®cation
Total barangays Total population
Malarious A 27 Malarious B 77 Malaria-endemic prone area 128 Malaria free 73
16,137 62,137 190,781 269,246
Source: Malaria Control Service, Agusan del Sur.
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Fig. 2. Percent distribution of positive malaria smears by month, Agusan del Sur, 1995.
Fig. 3. Percent distribution of positive malaria smears by municipality, Agusan del Sur, 1995.
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611
Fig. 4. Explanatory model for malaria.
3.2. Pro®les of participants The age of focus group participants and indepth interviewees ranged from 14±70 years, in terms of mean age, the interviewees were younger (27.7 years) than FGD participants (36 years). In both groups, the majority were married, had 1 to 6 years of schooling and a median household size of 6. The majority of FGD participants were housewives (52%), while 53.8% of indepth interviewees were actively engaged in farming (Table 3). 3.3. Description of symptoms and illness terms Malaria is commonly known as malarya, although sometimes as takig (chills). The symptoms most commonly associated with malaria are chills (kurog or takig) and hilanat (fever) and were considered as the primary signs of malaria from all focus group participants and interviewees. Other symptoms included constant thirst (kanunay giuhaw) which some women associated it with febrile chills and recurrent fever (magbalik-balik ang lagnat) which occurred at a regular time each day. Another term used is malignant, probably adapted from the medical term `malignant', to indicate cerebral malaria, which is contrasted with natural na malarya when the brain is not aected. Malignant is usually characterised by severe headache (sakit kaayo ang ulo) and is considered to be especially
serious and potentially fatal, because it may lead to magsalimuang/mabuang (a condition resembling epileptic convulsion, although literally the term connotes mental disorder). Women's explanation of this condition is that the malaria `germ' (kagaw) goes to the brain, causing the disorder. Conditions considered as indicative of severe malaria are `eyes rolled up' (sulirap ang mata), locked jaw and darkening of nails (lagum ang kuko). Malaria fever was dierentiated from other fever on the basis of its persistence even after the administration of paracetamol or the application of herbal treatment. The majority of mothers also believed that a child de®nitely had malaria if he or she presented with high fever at the same time everyday after feeling cold ( panugnawon) and shivering. On the other hand, some would suspect malaria on the basis of chills only and some regarded chills and malaria as the same disease entity. Mothers recognized a `pattern' of the presentation of the complex of signs (cf. Gomez et al., 1984). What is described below is one complex of signs and the progress of the disease, although not all respondents would agree with this sequence of signs and symptoms for all cases: First the child feels cold, the hands and feet are very cold, he would be shivering so badly that he would need to be wrapped in a blanket. Then the chill disappears and the shivering stops, but this is
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C.A. Miguel et al. / Social Science & Medicine 48 (1999) 607±618 Table 3 Socio-demographic pro®le of focus group and interview participants, Agusan del Sur, 1995 Focus group participants, No. (%)
Interviewees, No. (%) adults (26)
Age 1±5 6±10 11±14 15±19 20±24 25±29 30±34 35±39 > = 40
11 37 34 37 37 80
(4.7) (15.7) (14.4) (15.7) (15.7) (33.9)
4 5 4 5 3 5
(15.4) (19.2) (15.4) (19.2) (11.5) (19.2)
Occupation Farming Housewife Barangay oc. Government service Self-employed Unemployed Others No data
85 (36.0) 124 (52.5) 6 (2.5) 4 (1.7) 3 (1.3) 12 (5.1) 3 (1.3)
14 (53.8) 6 (23.1)
No school years attended None 1±6 7±10 > = 10 No data
10 (4.2) 169 (71.3) 46 (19.4) 12 (5.1)
0 19 (73.1) 5 (19.2)
Civil status Never married Married Widowed
9 (3.8) 211 (89.8) 15 (6.4)
2 (7.7) 22 (84.6) 2 (7.7)
Household size 1±3 4±6 7±10 > = 11
36 (15.2) 108 (45.6) 83 (35.0) 10 (4.2)
2 (7.7) 14 (53.8) 8 (30.8) 2 (7.7)
followed by his body getting hot with a high fever. In a few cases, this is accompanied by severe headache and convulsions. This pattern recurs at the same time the following day, so that if the fever appears at 9 o'clock today, it will recur at exactly the same time tomorrow. Another sequence is: At the start, you'll feel cold then it will progress to shivering followed by fever. Sweating follows and you'll feel well again. Sometimes there will be head-
child patient (38) 13 (34.2) 15 (39.5) 10 (23.3)
2 (7.7) 4 (15.4)
30 (78.9) 7 (18.4) 1 (12.6)
2 (7.7)
0 18 (47.4) 20 (52.6) 0
ache, this can be very painful. If it's the malignant type, there will be no shivering, just coldness and a steady fever. Then there will be severe headache and then delirium. The patient may then die. Whereas focus group participants frequently referred to headache, this was not mentioned as often by mothers of children who had con®rmed malaria and only 40% of the mothers recalled that their child had had headache. It is possible, of course, that this was because of the inability of young children to verbalize the condition.
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The symptoms recognized within the community are usually clinical manifestations of malaria. Those symptoms that they associate with malignant and consider as severe are the same as those with P. falciparum infection. This is the predominant species of malaria in the Philippines where according to latest reports, 73.6% of malaria cases are due to P. falciparum (WHO, 1996). In ADS, the proportion is slightly higher, 83.6% (unpublished data, 1995). In general, respondents had a clear understanding of the manifestations of malaria, and this could potentially guide them to act appropriately in the event of illness within the household. 3.4. Perceptions of severity Notwithstanding the reported perception that severe malaria could be fatal, respondents did not perceive malaria to be a serious public health problem. This apparent lack of concern relates in part to people's knowledge of the ready availability of antimalarials which are believed to be fast-acting and eective and their con®dence that one will be cured of malaria if she or he takes the drug, although contrarily, respondents also considered malaria to be self-limiting. In general, they regarded childhood diseases like diarrhoea and measles as most serious, especially the former because it could be immediately fatal and is a common occurrence. Another reported health priority was schistosomiasis, known locally as `shisto' and described as a disease causing enlargement of the stomach and other body parts; primary cause of concern for this disease is the disability resulting from it. At the same time however, other circumstantial factors clearly in¯uenced perception of severity and action. As noted, in ADS barriers to early treatment include topography (mountainous areas), lack of roads or usable roads, lack of transport able to negotiate poor road conditions, infrequent public transport services, distance from sitio (hamlet) to RHU and delays that occur between the collection of a blood smear and feedback regarding diagnosis and treatment. Respondents also often lacked adequate funds to pay for transportation, other indirect costs and treatment costs (although in fact, through the RHU, there is no charge) (cf. Jayawardene, 1993). These factors all discouraged the use of local health facilities and contributed to people feeling that they could manage illness within the domestic domain. 3.5. Etiology and transmission Knowledge of the etiology of malaria varied widely. Peoples' knowledge combined various concepts of infection, often confusing the etiology of various microbiological and parasitic infections and other ill-
613
nesses. Understanding of malaria as contagious, related to the importance of a human reservoir to maintain infection, was rarely articulated compared with other ideas of contagion, although people did associate to some degree infection in others and their own risk. The mechanisms of transmission of malaria, as explained in FGDs and interviews, were: 1. Predisposing factors: these included a perception that malaria was due to pasmo, a condition characterized by headache and fever due to skipping meals or not having meals on time: ``having missed meals, they become weak and lose resistance to infection, thus they become prone to illness''. In addition, `weak blood', low resistance and malnutrition were considered to increase an individual's likelihood of getting malaria. These beliefs are associated with those relating to the importance of humoral balance, which is in¯uenced by thermal conditions, diet, particular foods and other illnesses (Hart, 1969). 2. Transmission by the vector: malaria was attributed to mosquitoes (lamok) either directly, by being bitten by them, or indirectly, by drinking water contaminated with mosquito larvae or in other ways polluted. The majority of FGD participants mentioned mosquitoes in relation to malaria. The vast majority (36 of 38) of caretakers of children who had had malaria regarded mosquitos as a single or a contributing cause. 3. Germs or kagaw were also reported to cause malaria; sharing the same bed, the same utensils and even the same bathing material (towels, soap, etc.) could transmit the disease. This is not an uncommon response in other parts of the world; HelitzerAllen et al. (1993), for example, made similar observations in Malawi of people's association of malaria with germs, contagion and personal contact. In Agusan del Sur, people did not dierentiate among germs that could cause disease and, hence, food, air and water were all possible sources of contagion. Flies were also believed to be carriers, with a person becoming ill if she or he ate food where ¯ies had landed after coming from faecal matter. 4. Situational factors: a very common perception within all focus groups (but not from mothers) also was that individuals involved in logging or other upland or forest activities were at greatest risk of getting malaria, either by being bitten by mosquitoes, drinking polluted water, or getting hungry and missing meals. Perceptions that malaria is transmitted in the forest rather than in or around the village is not uncommon (cf. Tang et al., 1995), but is not consistent with vector behaviour and habitat,
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nor patterns of transmission in this area of the Philippines. Although mothers of sick children and focus group participants shared a general understanding of malaria, in fact, as indicated in Table 4, the majority of the mothers attributed malaria to mosquitos in some way and these perceptions appear to associate stream clearance and the reduction of larvae with decline in infection, consistent with the belief that the ingestion of larvae will cause malaria (these beliefs are held elsewhere in the Philippines, e.g. Espino et al., 1997). In general, except for pasmo, concepts related to disease transmission could also have been learned from health educational material delivered by clinic or malaria control service (MCS) sta. 4. Action when confronted with illness Initially, a person sick with fever takes no action: ``As long as I can still carry on, I'll not take anything yet''. She or he will ®rstly observe and monitor progress and only if the fever persists or the condition deteriorates will the person take either paracetamol or herbal medicine: ``I'll try this medicine ®rst, it might work in this episode''. Paracetamol is the preferred drug if these are tablets in the house or if money were
available to purchase it (most commonly under the brand name Biogesic). Consistent use of the same drug by an individual is attributed to nakasanayan or hiyang, familiarity with a drug on the basis of its previous successful use. If people have no money, they will take herbal medicine, and herbs are freely available. Herbs like herba buena, kalabo and oregano are used to relieve fever, through a decoction made from boiling the leaves in water to make a drink. Other bitter-tasting leaves or roots like marbelosa, dita, tubatuba and ubod ng pasan are believed to be remedies speci®cally for malaria; again their leaves are boiled and the infusion is given to the patient to drink. Our opinion is that the association of their bitter taste with the bitterness of antimalarials such as chloroquine may have in¯uenced people's perception of the eectiveness of herbs against malaria, although respondents were not asked about this. Herbs are also used when it is believed that the illness is due to pasmo and respondents mentioned their accessibility and the fact that they do not cost anything, they can be picked at any site or corner in the vicinity, as an attractive treatment alternative. Herbs are commonly used to treat illness (McNee et al., 1995) and this is encouraged by midwives during mothers' classes at the RHU for symptomatic relief for health problems such as respiratory infections (Simon et al., 1996). Women perceive herbal
Table 4 Caregiver's knowledge of the cause of malaria Causes of malaria
No. (n = 38)
Mosquito-related Drinking water from open sources which contain eggs of mosquitoes Mosquitos carrying malaria germs which they get from dirty surroundings Bite of a mosquito which had just bitten someone with malaria Mosquitos n.e.c.
36 10 14 5 7
Food-related Eating sweet `cold' food or drinking cold coconut water on an empty stomach Pasmo-skipping meals
10 4 6
Sanitation practices Dirty surroundings Not washing hands before eating
7 6 1
Weather-related Cold climate
1 1
Others Piang Inadequate nutrition
3 1 2
Source: In-depth interviews with mothers of children who had malaria, Agusan del Sur, 1995.
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therapy as a sanctioned treatment for various illnesses, and do not necessarily discriminate the advice according to symptoms and possible diagnosis. If the fever does not subside after a day or so, the caregiver will either buy an antimalarial (Aralen (chloroquine) or Fansidar) locally, or go to the health centre, depending on the relative costs. Agusan del Sur is geographically vast, often with considerable distances between the barangay and the poblacion (township) where health facilities are located: distances range from 10±30 km (with extreme distances of up to 127 km), with one-way fares of 20±50 pesos (but up to 500 peso in extreme cases). As already noted, if the transportation cost to the health centre is greater than the cost of buying antimalarials from a small retail stores within the barangay, or if transport is infrequently available, then people will self-medicate. The free drugs from the health centre are not seen to be an attractive option if people have to spend money on a fare or if the travel to the health centre is dicult or complicated, like having to take both a motor bike and a connecting pumpboat ferry. In addition, depending on their experience of RHU services, people are not always con®dent of the availability when they arrive of health workers (doctors, nurses or midwives). Hence a variety of factors encourage self-medication. Antimalarials are well known in the community because of the high endemicity of malaria and people do not consider it necessary to have their blood examined ®rst to con®rm the diagnosis or to determine appropriate medication. They know that blood examination (`blood test') should be done ®rst, but since they are familiar with the names of the antimalarials already, they go directly to the drug store. Aralen (chloroquine) costs an average of 7 pesos (US$0.27) per tablet while Fansidar costs an average of 22 pesos (US$0.84) a unit. Both drugs are available over the counter. People's con®dence in the eectiveness of the drug is reinforced by their previous experiences with it or reports from other people. Usual drug intake is a single dose or one tablet per day for 1±3 days, most often one day unless otherwise indicated. People say, ``after one day, we are usually cured, we don't have fever anymore'', so they stop taking the drugs. The drugs are ``so bitter, I won't take it longer than I have need for it''. Although local herbs are used, resort to traditional healers is not common. Gamot na binisaya (herbalists) are rarely consulted because their skill is considered more appropriate for buyag (evil eye) or piang (sprain), although if fever is initially thought to be caused by buyag or piang, then such consultation might take place. If the symptoms did not improve and chills occurred, they would suspect malaria and this would then lead to a change in treatment seeking behaviour.
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If fever or other symptoms persist or recur, people may reconsider seeking medical advice, although only if they have money. Otherwise, they will just `bear' the illness, hope for improvement or recovery, and wait until they have enough money to seek professional help. The occurrence of delirium (magsalimuang) or a deterioration in the patient's condition (`too sick to move') will lead to changes in treatment seeking and medication, initially by use of herbal medicine except when the patient lives within 5 km radius of the RHU, in which case they are more likely to go to the RHU. Hence the picture that emerges is that determinants of health action are strongly in¯uenced by immediate economic circumstances, other situational factors and/ or experience with drugs, health workers and health facilities. Self-medication is a common action for many ailments in the Philippines, the consequence of the ready availability of pharmaceuticals, the aggressive promotion by pharmaceutical companies and the weak control of drug supplies by government (Hardon, 1987; Carpenter et al., 1996). Outcome of the illness is not a consideration in the sense that it is not the fear of worst possible outcome that dictates peoples' action. Rather, people react in response to each prior action. They consult a doctor only if the illness does not improve, rather than consulting a doctor because they are worried that the illness might not improve. People did not perceive malaria as having serious consequences and were not worried by being sick with malaria. Their health action is on the basis of `trial and error', `shopping' around from one action to another until they ®nd one to cure them of symptoms. 4.1. Diagnostic protocol Malaria control and treatment services are provided mainly by malaria control program workers, although the health centres provide supplementary services for this program. The RMCs are consulted if they are in the area when a patient is sick. Consultation consists of blood examination and drug dispensation free of charge. With just one RMC for every municipality, these workers are infrequently seen in the barangay, especially those which are located beyond 5 km of the town center. Most RMCs live in the town centre. The alternative health providers in these remote areas are the midwives and barangay health workers (BHW). The midwives are responsible for speci®c catchment areas consisting of more than 2 barangays and again are infrequently seen in areas far from their residence. As a result, the most available service provider is the BHW. BHWs have been trained to make blood smears and some have been given antimalarials for dispensing. However, most often, antimalarials are available only
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from the RMCs, whose usual practice is to prioritize their ®eld visits to areas with reported `¯are-ups' or sudden increases in malarial patients. An RMC will visit other areas if he has a follow-up to do, that is, if a patient's blood smear is positive and the patient needs a complete treatment regimen. The policy at the moment is for the RMC to give presumptive treatment at ®rst and complete medication when the result of the blood smear examination is available. We tried to determine the length of time from when the blood smear was taken, to the administration of medication. Depending on logistics, weather, stang and other factors, it is possible to take as long as four weeks for the patient to receive the microscopy result and be given the appropriate medication if health providers adhere to the policy of providing only presumptive treatment. If midwives or RMCs are available, however, the turn around time can be as short as one day. Strict adherence to the policy of presumptive treatment only therefore was not enforced by the MCS in Agusan del Sur because of delays in receiving results. It was left to the RMC to determine how many drugs would be given to the patient and frequently, radical treatment was practiced especially if the patient came from a barangay known to be endemic with malaria. Presumptive treatment is supposed to be a 3-day course to be completed or discontinued depending on the results of the blood smear examination; radical treatment is a 5-day full course. The antimalarial dose given to a patient suspected to have malaria is set out in Table 5. 5. Prevention and control Motivation to undertake preventive action is in¯uenced by etiological beliefs held by individuals. Although, as illustrated above, people held a wide range of beliefs about the cause of malaria, they included mosquitos in their model of transmission. Mosquitoes were said to live and breed in slow, ¯owing waters, in trash receptacles like coconut husks with water collected in them, in grassy or tree-®lled areas,
and in any dark and dirty place. Thus, the pervading preventive behaviors were to clean the surroundings, get rid of empty receptacles which could contain water, cover drinking water containers (mosquitoes might lay their eggs in these) and other foods (¯ies might land on these), boil drinking water and adhere to other sanitation-related actions (Helitzer-Allen et al., 1993, report a similar confusion between hygiene, sanitation and malaria prevention practices transmitted by various health and agricultural extension ocers among Malawi residents). People were also familiar with other malaria control measures advocated by the malaria control program, such as the use of insecticide-impregnated bed nets and residual house spraying. Bed nets were used mainly to ward nuisance mosquitoes rather than for protection from malaria. Children are the usual persons who sleep under nets, although adults may join them if space permits. Few had had their bed nets impregnated with insecticide for a variety of reasons: they were away when the impregnation was done; it was raining and they were afraid that the bed net might not be dry enough to be used the same evening; or they were embarrassed because their net was homemade from sack cloth. Those who had used insecticide-impregnated bed nets were generally positive about the procedure and were not bothered by smell or any skin irritation. People were also familiar with house spraying preventive measures, and some had had their houses sprayed. Others did not because they were out of the house during the period of spraying; spraying was a nuisance because lots of other insects (like cockroaches) fell down dead (hence making a mess); or children got skin irritations or some other illness when exposed to the insecticide. There was also a prevailing opinion that the eectiveness of these insecticides were shortlived. Immediately after spraying, people agreed that mosquitos were driven away, but within a week or so, they were back. Another negative comment on house spraying was that the insecticides left a foul odor and caused discolouration of the walls, so that they would prefer that spraying be done only on the
Table 5 Antimalarial protocol (drug dosage/age group) Age group
Chloroquine
Primaquine (No. of tablets daily 14 days)
> = 16 12±15 7±11 4±6 1±3 <1
4, 4, 2 3, 3, 2 2, 2, 1 112, 112, 12 1, 1, 12 1 1 1 2, 2, 4
1 14 days = 14 tablets 1 14 days = 14 tablets 3 1 414 days = 102 tablets 1 14 days = 7 tablets 2 1 1 414 days = 32 tablets should not give medication
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outside of the house. This could limit the eectiveness of the insecticide to the extent that anopheline mosquitos in the area, on the basis of human-biting rates from entomological work conducted with the project, appear to be both exophagic and endophagic (3:2) (Torres, personal communication). Others preferred to use mosquito coils at nighttime to drive mosquitos away. People were also familiar with stream clearing as a means of vector control. This activity was left to malaria control program workers or barangay ocials, primarily through fear of going into the water because of `shisto' (schistosomiasis).
6. Conclusion Because of the high level of endemicity relative to other areas of the Philippines, people in Agusan del Sur are familiar with the clinical presentation of malaria and to a lesser degree, are aware of an association between mosquitoes and infection. Knowledge of clinical manifestations of malaria and of treatment regimens indicate people's exposure to information from health workers and their own exposure to the disease. However, the general view is that malaria is relatively benign and that a sick individual can easily be treated if given the correct remedy. People often delay treatment and are not concerned with the possibility of progression of the illness because of delayed action. The presence of untreated and infected individuals is the likely reason for the continued transmission and relatively high endemicity of malaria in this region. Both to reduce serious morbidity and mortality, and to reduce transmission by reducing sources of infection in the community, early detection of malaria cases and prompt treatment are important. As noted, self-medication is common in this area, almost inevitably because of the inaccessibility of health services. The practice has the potential, however, to increase the risk of drug resistance. Community members are well aware of the standard procedure of taking blood smears for the diagnosis of malaria. They can go to the RMC, midwife or even BHWs for this. However, the same problems of access and availability of these people prevents compliance with this standard procedure, and people resort to self-medication immediately if they think that a household member is 1 A quick diagnostic tool\kit that requires no microscopic examination, especially one that a BHW can do and is therefore practical in the ®eld, could be used. Such a kit, ParaSight F (Becton and Dickenson, USA) is being ®eld tested by the ADS-MCP Project. At this stage its major disadvantage is cost compared with the cost of microscopy.
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suering from malaria. Diagnostic tests for the presence of malarial parasite is still an important procedure prior to medication and is the only known practical step to prevent the resurgence of drug resistant strains of parasites. Mechanisms to promote diagnostic testing of suspected patients need to be explored to reduce the time it takes for the patient to ®nd out the result of the blood smear examination. A possible mode here is to involve motorbike owners or operators in the transport of blood ®lms and results between the patient and the main health centres where the microscopists are usually stationed1. People's perceptions surrounding causes and transmission of malaria confuses factors associated with a variety of infections. Although respondents associated malaria transmission with mosquitos, they were unclear about the mechanisms of this. A predominant belief was that malaria could be transmitted by drinking water contaminated by mosquito's eggs. Perceptions of contagion are further extended to include social contact, such as sharing a bed, utensils, etc. In this, the role of mosquito as vector is lost. Community understandings of malaria transmission and treatment can be incorporated into health education material to reinforce control eorts in the community. Acknowledgements We are grateful to the sta of the Agusan del SurMalaria Control and Prevention (ADS-MCP) Program; Mila-Fulache, Paz Demonteverde, Tina Villarama and Earl L. Alcala and the community organizers; the RHU sta of the 10 municipalities covered by this study, the Rural Malaria Coordinators of the Provincial Malaria Control Service and members of the communities who provided us with valuable assistance and information. The research on which this paper is based was conducted as part of the Agusan del Sur Malaria Control and Prevention Program: implementation and evaluation of a self-sustaining, community-based malaria control program in a hyperendemic area (PI: M.A.L.), funded by AusAID (Australian International Development Agency) and involving the Research Institute of Tropical Medicine, The Philippines, The University of the Philippines, the Department of Health-Malaria Control Service and the Australian Centre for International and Tropical Health and Nutrition, The University of Queensland. References Carpenter, H., Manderson, L., Janabi, M., Kalmayem, G., Simon, A., Waidubu, G., 1996. The politics of drug distri-
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