Local terminologies and illness perceptions
Malaria was locally known as ‘meleria’, a term derived from the biomedical nomenclature and there was no vernacular name. ‘Meleria’ included a cluster of symptoms closely resembling the biomedical presentation of malaria. All respondents ranked malaria as the most common disease or health condition in their locality. It was further reinforced by the healthcare providers and other key informants. Other perceived common ailments were diarrhoea, common cold, skin diseases, typhoid, and tuberculosis.
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Nowadays wherever you go, you would see ‘meleria’ patients. Whatever fever a person suffers from, the doctor tells it is ‘meleria’. [Male FGD participant, Sundargarh]
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Malaria is the common illness in this area [Block medical officer, Mayurbhanj]
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The participants reported multiple causes of malaria. As shown in Table
2, although there were diverse responses, two represented the majority, i.e., dirty (contaminated) water and mosquitoes. Consuming unboiled or unfiltered water is thought to cause malaria. People who venture into the forest to collect firewood and forest produce are perceived to contract malaria through bathing and drinking water from forest rivulets. Participants who reported mosquitoes to be the cause had differences of opinions on how the mosquitoes spread the disease. Many opined that malaria was transmitted through mosquito bites. For some it was through exposure to food and water contaminated with infected mosquito eggs.
Table 2
Reported causes of malaria by the focus group discussion participants
1. contaminated water | A. Drinking | 22 (91.7) |
B. Bathing in forest rivulets | 14 (58.3) |
C. Drinking water from open well without boiling | 15 (62.5) |
2. Mosquitoes | A. Sucking blood | 16 (66.7) |
B. Sitting on food and water | 6 (25) |
C. Laying eggs on food and water | 3 (12.5) |
3. Environmental and personal sanitation and hygiene | Garbage | 12 (50) |
4. Stale food | Eating | 11 (45.8) |
5. Fatigue | Hard physical work and lack of rest | 10 (41.7) |
6. Housefly | Brings germs from garbage to food | 9 (37.5) |
7. Eating habit | Untimely eating | 6 (25) |
8. Untreated common cold | Unexplained | 5 (20.8) |
9. Change of season | Unexplained | 4 (16.7) |
10. Mother to baby | Unexplained | 2 (8.3) |
11. Blood | Transfusion of infected blood | 1 (4.2) |
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When we go to the forest, we have to drink water and take bath in the streams and rivulets. Upon our return we develop ‘meleria’. [Male FGD participant, Mayurbhanj]
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Villagers do not cover the food items. When mosquitoes and flies sit on it, they contaminate the food. If one eats that food, it causes ‘meleria’. [Female FGD participant, Mayurbhanj]
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As discerned through the KII, health-care providers were aware of community perceptions and attributed the misconceptions regarding disease transmission to their low level of literacy and superstitions. A few informants were sceptical of the effectiveness of the current behaviour-change campaigns on community behaviour.
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You see…people here are illiterate and superstitious. Their level of awareness is very low. They have their own ideas for the aetiology of every disease, for instance, they say drinking contaminated water leads to malaria. [Medical Officer, Sundargarh]
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We have been conducting so many awareness sessions in the community. Despite that we don’t see much improvement. [Malaria laboratory technician, Sundargarh]
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The FGD participants reported a higher incidence of malaria during the rainy season and the least during the dry period. Some could relate rains leading to more mosquito breeding sites and hence more malaria.
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In the rainy season we cultivate paddy. Water accumulates in the farms and we have plenty of mosquitoes. More mosquitoes mean more ‘meleria’. [Male FGD participant, Mayurbhanj]
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‘Meleria’ in the locality was characterized by a combination of symptoms, closely resembling the clinical presentation of malaria. The FGD participants identified malaria as a febrile illness associated with severe shivering and headache (Table
3). All participants were able to state the symptoms. The majority perceived feeling cold, shivering, fever, intermittent fever, vomiting, and headache as malaria symptoms. Vomiting as a symptom was reported to be more commonly associated with childhood malaria. The female participants reported more malaria-specific symptoms than the men and the children. Participants were able to differentiate other fevers from malaria by the absence of its periodicity and shivering. Almost all participants reported the treatment by a physician at the primary health centre to be the more effective than any community-based provider.
Table 3
Reported symptoms of malaria by the focus group discussion participants
Thanda lagiba
| Feeling cold | 8 | 8 | 8 |
Deha thariba
| Shivering | 8 | 5 | 4 |
Banti haba
| Vomiting | 8 | 2 | 6 |
Deha batha
| Body ache | 8 | 6 | 1 |
Munda batha
| Headache | 8 | 3 | 4 |
Jara
| Fever | 6 | 6 | 5 |
Pali jara
| Intermittent fever | 6 | 5 | 3 |
Munda bulei haba
| Dizziness | 2 | 2 | 1 |
Durbala lagiba
| Weakness | 2 | 2 | 0 |
Bhoka na heba
| Loss of appetite | 1 | 2 | 1 |
Patala jhada
| Diarrhoea | 0 | 0 | 4 |
Kasa
| Cough | 0 | 0 | 1 |
Nakaru pani bohiba
| Running nose | 0 | 1 | 0 |
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In ‘meleria,’ when the temperature goes up, the patient shivers, head becomes heavy and aches, whole body aches and vomiting takes place with the loss of appetite. The fever comes and goes on alternate days. [Female FGD participant, Sundargarh]
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Most respondents opined that malaria, if not treated timely will lead to jaundice, typhoid, brain meleria (cerebral malaria) and eventually death. The reported timeframe for developing these complications varied from six to seven days for typhoid, and to 12 to 14 days for jaundice and cerebral malaria.
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If a ‘meleria’ patient does not take medicines, the fever climbs up to the head and he behaves like mad. This is brain ‘meleria’, my father has told. [Female school student, Mayurbhanj]
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Reported prevention modalities
Malaria prevention methods were reported to revolve around maintaining personal and environmental hygiene and drinking safe water.
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To prevent ‘meleria’, clothes should be clean, water should be covered and hands should be clean. [Female FGD participant, Sundargarh]
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If we drink boiled water then we will not suffer from ‘meleria’. [Female school student, Sundargarh]
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The communitymembers perceived mosquitoes as a nuisance. All of them were reported to adopt some method of protection from mosquitoes during the rainy season when the vector is more prevalent. Among these methods, fumigating the house in the evenings with dried leaves, husk, straw, or firewood was reported to be the most common way of avoiding mosquitoes. Other reported prevention modalities were application of repellent oils out of neem (Azadirachta indica) and karanja (Pongammia glabra) seeds and burning anti-mosquito coils.
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We burn neem leaves and bark, cow dung cakes, dried leaves, grain husk to smoke away mosquitoes when they are too much. [Female FGD participant, Sundargarh]
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We fumigate the house before we go to bed. Who cares after you are asleep? [Male FGD participant, Mayurbhanj]
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Though most were aware that mosquito nets can prevent malaria, only a few respondents used them regularly. The reported reasons for irregular use were the lack of adequate nets in the household due to unaffordablity, old or torn nets, a feeling of suffocation or heat inside the nets, exhaustion or intoxication at night that prevents proper use, and a preference to use nets for something else. FGDs respondents reported about using bed nets for fishing, filtering rice beer, setting traps to catch edible insects, and collecting sal leaves (Shorea robusta) to stitch leaf plates.
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Mosquito nets keep the mosquitoes away when we sleep and hence “meleria”. But, one big net (double size) costs 200 rupees (US$ 4) and we need many nets for a house as we are too many. From where shall we get this much money? [Male FGD participant, Mayurbhanj]
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Alcoholism is a major problem in this region, which is an additional burden on the poverty. Here both men and women drink, though men more. They would borrow to drink than buying a mosquito net. When they are drunk they forget to hang the net at home, even they lie down on the road if they are too much drunk. [NGO staff, Mayurbhanj]
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Mosquito nets have been given to them and they are not using it by telling it is too hot inside. Some even catch fish from the canals during the rains. [Female health worker, Mayurbhanj]
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If nets are few in a household, there is a preference for the children (at times with their mothers) to sleep under it. The reported use of bed nets was higher among children and women than men. There was no difference observed between the participants in both districts. The possessed nets were reported to be either never treated with an insecticide or treated at least a year ago. Around half of the participants were sceptical about the efficacy of nets to prevent malaria as they perceived mosquitoes were not the only cause and mosquitoes also bite during the non-sleeping hours. During the summer season, reported net use was less as it was hot and humid inside the nets. Most of the adult men slept out in the open, where it was difficult to hang the nets.
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What kind of protection do these nets give? Even with the nets hung, mosquitoes enter through the holes or suck blood from outside. When I wake up in the morning I see a lot of mosquitoes in my net with their bellies full of blood. Despite sleeping under the nets, my two children got ‘brain meleria’ six months back. [Male FGD participant, Mayurbhanj]
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Reported care seeking for febrile illnesses
Despite developing fever and malaria-like symptoms, the majority of adult participants reported that care is not immediately sought for themselves. Rather they wait for a few days and engage in home remedies like consuming bitter herbal concoctions or a paste made from neem leaves. If the situation worsens they seek care from the local traditional healer.
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If we feel feverish, we think it might be weakness due to hard work. We wait and watch for two to three days. [Male FGD participant, Mayurbhanj]
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Immediately they don’t come to me; suppose fever comes today then they won’t come today. If it continues further, they come to me after a couple of days. [ASHA, Sundargarh]
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The village-based traditional healers are not full-time professional health-care providers and most of them inherit the skills from their forefathers. In the locality, there were two types of traditional healers: ‘gunia’ (faith healer) and ‘baidya’ (herbalist). A ‘gunia’ resorted to sorcery and ritual blowing to ward off evil spirits. The ‘baidya’ on the other hand, cured ailments using roots, tubers, leaves and their concoctions. Some traditional healers used both principles. Care seeking from these healers is more of a reflection of faith and some even rely on them while simultaneously seeking care from other providers.
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First they go to ‘gunia’, perform ‘jhada-phunka’ (ritual blowing) and come to me after five to seven days. [Less qualified provider, Sundargarh]
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People consume tablets and visit the ‘gunia’ at the same time; despite knowing that the tablet works. They have a faith that they should be treated by him (faith healer) at any cost. [ASHA, Mayurbhanj]
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Afterwards, depending upon the progression of disease and perceived severity, care is sought from other health care providers or facility, such as the community health worker, multipurpose village grocery shops stocking antipyretics (paracetamol), analgesics, and anti-malarials (chloroquine); less qualified provider (locally known as ‘private doctor’), and very rarely the primary health centre.
Care seeking for women and elderly, in general, was reported to be delayed. However, immediate care is sought for infants and children from the public health centres as there is a perceived notion of seriousness of their situation and inability of the local providers’ methods to ensure complete cure.
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Children are more vulnerable to malaria. We take our children immediately to the health centre when they get fever. ‘Private Doctors’ don’t have good medicines for the children; we can’t take risk by treating children at home through them. [Female FGD participant, Mayurbhanj]
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Care seeking from the less qualified providers (LQP) is very common considering their geographic vicinity, use of modern medicine and flexibility in modes of payment. Most LQPs are unqualified (without any education or training in medicine or allied health sciences), or less qualified (some education or training in allied health science), but legally are not allowed to practise modern medicine. Though the participants expressed their dissatisfaction with the providers’ attitude and cost of care, their choice of a more convenient alternative was limited. The majority of the participants felt the LQPs are overprescribing medicines for their own profit without considering the villagers’ financial hardship.
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With whatever fever we go to the ‘private doctor’, he tells it is ‘meleria’ and you have to take high potency injections. We don’t know much about the disease, so we have to obey him. [Male FGD participant, Mayurbhanj]
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The LQPs almost uniformly narrated the treatment for fever and malaria-like illness with an anti-malarial injection (arteether), an antibiotic, paracetamol, iron and multivitamin syrups. There is a perceived advantage of injections in the community as they think more pain during the treatment will give them a more effective cure. Also, the community perceives that the injection directly delivers the medicine in their blood stream, so it will give them quick relief and they will be able to resume their work early. On the other hand, the oral formulations would reach the blood through the stomach and some have prior experience of side effects like dizziness, vomiting, or tinnitus with tablets. That is why, in certain cases, the patients demand injections.
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Villagers believe that the more they have to undergo pain during treatment, the more effective it is. Though the tablets are cheaper; still the people are prepared to pay more for the injections. [Less qualified provider, Mayurbhanj]
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With one injection it needs a day to recover as it goes directly to my blood, but consuming tablets will take at least two to three days. How my family will eat if I don’t go to work for those days? We don’t want to get into more trouble (drug side effects) by consuming tablets. [Male FGD participant, Sundargarh]
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The treatment for an episode of fever in this fashion costs around INR 300 to 700 (US$ 7–15), and in case of complicated malaria it can reach up to INR 2,000 to 3,000 (US$ 45–65). This level of health-care expenditure can severely burden an average rural family with one breadwinner engaged in subsistence farming or wage labour. The peak malaria transmission season (June to September) coincides with the “lean” period when income is at a seasonal low. At times households have to borrow from a moneylender with high interest rates or sell scarce assets such as land, jewellery, or livestock to arrange for the treatment. The growing presence of microfinance–related, women’s self-help groups have helped to alleviate this burden, but not reduced the cost of expenditure.
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If a card (rapid diagnostic test) test is done, followed by three injections of EMAL (arteether) and an antibiotic, the cost comes to Rs.350.Only the card and malaria tablets would cost around Rs.150, with the antibiotic it will cost a bit more. However, we have to inject most patients as they demand it. [Less qualified provider, Sundargarh]
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When we realise that one of us needs money for medical purpose, we loan from our group (self-help group) at nominal interest with flexible repayment period. Like this we have supported many of us. [Female FGD participant, Mayurbhanj]
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On the other hand, LQPs have certain natural advantages because of their geographical proximity and flexibility in modes of payment, which can be paid in kind or in instalments. Visiting a far-off government health centre can be time consuming, expensive and inconvenient if regular transport facilities are not available. In contrast, LQPs would visit the household on receiving a phone call. There are community health workers in the villages or in the neighbourhoods providing care free of cost, but they hardly get recognized as they do not use RDT or ‘inject’ medicines.
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By realizing our financial condition, he (LQP) receives the payment when we can afford. This payment takes place within two to three days when he visits us for the injection. At times he allows us a month or two. We arrange money by borrowing from the neighbours or the moneylender at 5% interest rate. Some mortgage or sell their goats, bullocks and even land. [Male FGD participant, Sundargarh]
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Here more people get treated in credit and repay the amount within two to three months. [Less qualified provider, Mayurbhanj]
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You see…the ASHA in the village does not have card test (RDT) and injections. How can we expect quick cure if you don’t have these? [Male FGD participant, Mayurbhanj]
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The choice of providers is driven by faith and convenience (proximity, flexible payment modes, and perceived quick relief). Although most villages have a community health worker, the community does not have faith in them. The CHW does not have community’s acceptance for treatment of fever and malaria-like illnesses as there are frequent drug stock-outs.
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Whenever we go to them (CHW), they would tell that medicines are not there, so we do not go to them nowadays. [Male FGD participant, Sundargarh]
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