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Evaluation of the user-provider interface in malaria control programme: The case of Jepara District, Central Java Province, Indonesia
Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
2002 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Early detection and case management remain the main strategies in malaria control programme (MCP) in a low endemic area such as in Java Island, Indonesia. These strategies require an understanding of the community’s care-seeking behaviour in relation to the various health services. Since most malaria cases in Java are diagnosed at home by the village malaria workers (VMWs), this study aimed to examine the user-provider interface in early detection and case management of malaria, particularly the interaction between the clinical malaria patients and the VMWs.

Methods: The number of blood slides examined and the laboratory results over a 20-year period were retrieved from the routine malaria surveillance system. The population at risk of malaria and the rainfall data were obtained from secondary sources. In addition, age, sex, malaria species, types of drugs, drug and dosage and time lapse between slides taken and examined were recorded from the malaria registers at the three endemic health centres from 1994-1998. The quality of diagnosis was examined by re-reading 153 slides at the Faculty of Medicine, Gadjah Mada University. Prior to using rapid assessment procedures (RAP), we proposed 11 criteria and applied these to 15 published RAP studies in health. For each of the papers, two authors assessed the adequacy of information provided independently. Using the criteria as a guideline for developing a protocol, a RAP study of malaria was thereafter carried out. Data were retrieved from 38 free-listings, 28 in-depth interviews, seven focus group discussions and unstructured observation. A qualitative thematic content analysis was applied. Finally, based on the RAP results, a one-year longitudinal study of care-seeking behaviour of all clinical malaria cases treated by the VMWs was conducted in Mlonggo II area. Age, sex, daily actions and date of consultations were recorded by all VMWs in a diary that covered prior all contacts between the patients and the VMWs. Also, 24 interactions between the VMWs and the patients were audiotaped.

Results: The incidence of malaria during the 1990s fluctuated, albeit at the lower level than that of the 1980s, and it reached a peak (3.5/1000 population) during an outbreak in 1996-97. There was no clear association between the El Nino phenomenon and incidence of malaria. The incidence was almost twice as high in children <15 years than in adults (15+ years). In <5 year old children the risk of P. vivax malaria was higher than the risk of P. falciparum. Comparisons between active and passive case detection (ACD and PCD) showed that almost 60% of 10, 493 confirmed malaria cases in Jepara were identified from ACD. ACD also detected significantly higher percentage of P. falciparum gametocyte infections than PCD (14.7% vs. 5.7%). The duration between slides taken to examination was however longer for ACD than for PCD (2.3 vs. 1.1 days). Applying the criteria to the published RAP studies, it was found that information was limited to address subjectivity, staff and ethics criteria. In Jepara, malaria (known as katisen or panas tis) was considered a common but minor illness. This was also reflected by the most common action taken by the patients, i.e. not doing anything. However, when the illness was perceived as important, the community had a good access to different health care providers. Eighty seven percent of cases had been treated by the VMWs on day four of the illness period. On day two, the proportion not treated was significantly higher in male than in female cases (60.7% and 54.6%; p 0.01) and in those <15 years of age compared with those 15+ years (71.3% and 56.9%; p<0.001). Insufficient understanding of malaria signs and symptoms likely leads to delay in illness recognition and treatment. Interactions between the VMWs and the patients were mostly focused on medical tasks, and low compliance with treatment was a common concern of the VMWs in the interaction.

Conclusion: El Nino phenomenon was not associated with an epidemic in Jepara. A possible association between age and the risk of P. vivax malaria needs further investigation. In this decentralised health care system, ACD should be continued in a focus endemic area and therefore, efforts to retain the VMWs should be considered. This research showed similar findings between the RAP study and the longitudinal study. A consistent gap was found between the common understanding and the biomedical description of malaria. The performance of the VMWs supports the MCP through early contact with clinical malaria patients. Visits of VMWs within four days of symptom recognition appear to be the ideal situation for both the programme and the community. If case management continues to be the main strategy in MCP in this low endemic area, the emic perspective of the people must be well integrated to improve home treatment. Likewise, simple interventions to strengthen the role of VMWs in home management should be conducted.

Place, publisher, year, edition, pages
Umeå: Epidemiology, Department of Public Health and Clinical Medicine, Umeå University , 2002. , 76 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 805
Keyword [en]
malaria control programme, early diagnosis, case management, rapid assessment procedures, user-provider interface, Indonesia
National Category
Medical and Health Sciences
Research subject
Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-11ISBN: 91-7305-293-0 (print)OAI: oai:DiVA.org:umu-11DiVA: diva2:140193
Distributor:
Epidemiologi och folkhälsovetenskap, 901 87, Umeå
Public defence
2002-10-11, Tandläkarhögskolan, Sal D, 9 tr., Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Available from: 2002-10-11 Created: 2002-10-11 Last updated: 2010-03-11Bibliographically approved
List of papers
1. Malaria morbidity trends in the Jepara District, Central Java, Indonesia, 1980-1999
Open this publication in new window or tab >>Malaria morbidity trends in the Jepara District, Central Java, Indonesia, 1980-1999
(English)Manuscript (preprint) (Other academic)
Keyword
Malaria, trend, low endemic areas
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Family Medicine
Identifiers
urn:nbn:se:umu:diva-2264 (URN)
Available from: 2002-10-11 Created: 2002-10-11 Last updated: 2015-04-29Bibliographically approved
2. Performance and role of active and passive case detection systems in Jepara District, Indonesia.
Open this publication in new window or tab >>Performance and role of active and passive case detection systems in Jepara District, Indonesia.
(English)Manuscript (preprint) (Other academic)
Keyword
malaria, low endemic area, active and passive case detection
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Family Medicine
Identifiers
urn:nbn:se:umu:diva-2265 (URN)
Available from: 2002-10-11 Created: 2002-10-11 Last updated: 2015-04-29Bibliographically approved
3. Appraising studies in health using Rapid Assessment Procedures (RAP): Eleven critical criteria
Open this publication in new window or tab >>Appraising studies in health using Rapid Assessment Procedures (RAP): Eleven critical criteria
2001 (English)In: Human Organization, ISSN 0018-7259, E-ISSN 1938-3525, Vol. 60, no 4, 390-400 p.Article in journal (Refereed) Published
Abstract [en]

In recent years, rapid assessment procedures (RAP) have resulted in many descriptive health studies of potential utility to the wider social science community. However, as RAP departs from the in-depth, more holistic style of qualitative research, it is important to develop criteria for judging the quality of individual studies. In this paper we propose 11 criteria and apply them to published RAP studies, taking into consideration the limitations inherent in RAP studies and common methodological problems. The criteria cover important aspects from preparation to presentation of findings. We found that authors typically do not include adequate information to address all criteria. We suggest that greater attention to these issues would enhance the strengths of RAP studies as contributions to social science.

Place, publisher, year, edition, pages
The Society for Applied Anthropology, 2001
Keyword
rapid assessment procedures, health, critical criteria, appraisal
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Family Medicine
Identifiers
urn:nbn:se:umu:diva-2266 (URN)
Available from: 2002-10-11 Created: 2002-10-11 Last updated: 2017-12-14Bibliographically approved
4. Rapid assessment procedures of malaria in low endemic countries: Community perceptions in Jepara District, Indonesia
Open this publication in new window or tab >>Rapid assessment procedures of malaria in low endemic countries: Community perceptions in Jepara District, Indonesia
2003 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 56, no 4, 701-712 p.Article in journal (Refereed) Published
Abstract [en]

Most studies on community perceptions toward malaria have been undertaken in high-endemic countries, and studies from low-endemic countries have only recently been published. Similar information is also needed for hypoendemic countries such as Indonesia, to cope with the persistence of foci-endemic malaria in these regions. An applied qualitative method, Rapid Assessment Procedures, was employed during a 3-month intensive data collection period in Jepara district, Central Java province. Data were retrieved from 38 free-listings, 28 in-depth interviews, seven focus group discussions and unstructured observation. Qualitative thematic content analysis was applied. In this community, malaria (known as katisen or panas tis) was considered a common but minor illness. Insufficient understanding of malaria signs and symptoms in the subvillages likely leads to delay in illness recognition and treatment; not surprisingly self-treatment is common and the dosage most likely below the recommended dose. The health center was used but when it did not work, most people would shift back to traditional services due to cost considerations. Low understanding and acceptance of the causal link between the mosquito and malaria, likely leading to poor comprehension of preventive activities, as well as confusion of malaria with dengue fever, were identified. In conclusion, this study highlights a consistent gap between the common understanding and the biomedical description of malaria. If case management continues to be the main strategy in malaria control program, the emic perspective of the people must be well-integrated into the program. Likewise, interventions to improve home-treatment should also be developed.

Place, publisher, year, edition, pages
Elsevier, 2003
Keyword
Rapid assessment procedures (RAP), Malaria, Community perception, Indonesia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-2267 (URN)10.1016/s0277-9536(02)00066-7 (DOI)
Available from: 2002-10-11 Created: 2002-10-11 Last updated: 2017-12-14Bibliographically approved
5. Interactions between malaria workers and clinical malaria patients in Jepara District, Indonesia.
Open this publication in new window or tab >>Interactions between malaria workers and clinical malaria patients in Jepara District, Indonesia.
Show others...
2007 (English)In: The Southeast Asian journal of tropical medicine and public health, ISSN 0125-1562, Vol. 38, no 6, 959-70 p.Article in journal (Refereed) Published
Abstract [en]

In a one-year longitudinal study of all clinical malaria cases treated by the Village Malaria Workers (VMWs) during 1999-2000, data on health-seeking behavior during a seven-day illness period were collected using a diary; 24 interactions were audiotaped. The results showed that 87% of cases had been treated by the VMWs on day four of the illness period. On day two, the percentage not treated was significantly higher in male as compared with female cases (p = 0.01) and in those below 15 years of age as compared with those 15 years and older (p < 0.001). "Not doing anything" and "using VMWs only" were the two most common actions. Interactions between the VMWs and the patients focused on medical tasks, and low compliance with treatment was a common concern of the VMWs. The concept of preventive measures and the role of mosquitoes were lacking in the interactions.

Place, publisher, year, edition, pages
?, 2007
Keyword
Interactions, malaria workers, low endemic, Indonesia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-25324 (URN)18613535 (PubMedID)
Available from: 2009-08-12 Created: 2009-08-12 Last updated: 2015-04-29Bibliographically approved

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