Improving malaria knowledge and practices in rural Myanmar through a village health worker intervention: a cross-sectional study

Malaria causes approximately 500 million infections and about 650,000 deaths every year worldwide[1, 2]. In Myanmar, an estimated 37 million people live in malaria endemic areas, where 70% of malaria-risk people live in rural areas[2]. Late diagnosis and inappropriate treatment of malaria can lead to complications and death[3, 4]. Early diagnosis and effective treatment can be improved through the use of health workers. Numerous programmes in low- and middle-income countries that utilized trained health workers in rural settings demonstrated improvements in rural populations’ access to accurate diagnosis and treatment[5‐11]. Since 2004, community-based malaria control projects have gained popularity in Myanmar. For example, village health volunteers in 160 remote villages provided insecticide-treated mosquito nets (ITNs) and early diagnosis and appropriate treatment, resulting in reported positive health impacts[6, 12].

Health workers help to improve early diagnosis and effective treatment for malaria by increasing access to and provision of quality services and products such as RDTs (rapid diagnostic test kits) and ACT (artemisinin-based combination therapy). RDTs provide an easy and accurate confirmation of symptomatic diagnosis of malaria in resource-poor settings[9, 10, 13]. In several studies conducted in Thailand, Ethiopia, and Uganda, community-based malaria care services combined with RDT use have been shown to reduce malaria transmission and lower malaria morbidity and mortality in rural populations[10, 14, 15]. ACT is the most effective for uncomplicated malaria cases, using RDT to correctly diagnose patients reduces presumptive treatments, limiting the overuse of ACT, lowering programme costs, and delaying the emergence of drug resistance[10, 13, 16, 17].

In total, 1,040 participants were included in the study, with 321 respondents in communities that received an SPH and 719 respondents living in communities that did not have the intervention. Analyses of basic demographic characteristics suggest that there were no statistically significant differences between SPH and non-SPH communities. Approximately 32% of the study sample was between 15–35 years, 33% between the ages of 35–50 years, 28% between 50–65 years, and 7% older than 65 years (see Table 1). There was no statistically significant difference in age between SPH and non-SPH communities (p = 0.694). The majority of respondents had at least a middle school education or higher (approximately 75%), while 28.6% reported having no schooling. The majority of respondents in both the SPH and non-SPH communities were female (73.2% vs. 67.6%, respectively, p = 0.07). Overwhelmingly, respondents reported working in manual labor (88.3%), followed by owning a business/shopkeeper (8.7%), retired (2.3%), and less than 1% reported being in higher management (see Table 1).

Across a number of malaria knowledge and treatment-related questions, SPH communities scored higher compared to non-SPH communities. Respondents living in SPH communities were more likely to correctly identify using ITN as prevention of malaria (33.3% vs. 25.7%, p > 0.05), and more likely to have ever heard of RDTs for malaria (68.5% vs. 61.2%, p = 0.023). Moreover, respondents in communities with SPH providers were also more likely to be treated from a trained provider compared to those without a SPH provider (79.1% vs. 69.5%, p > 0.05). Respondents in non-SPH communities, on the other hand, were more likely to buy and take medicine from drug stores or take treatment at home compared to respondents in SPH communities (23% vs. 19%, p < 0.01) (see Table 2).

The study found a dose–response effect -the longer the time the intervention had been in place in communities, the greater the malaria knowledge and treatment behaviours across a number of indicators (i.e. knowledge of mosquitoes as causes of malaria, ITN use, treatment with trained provider). For example, communities with a longer intervention period (2009) reported almost 49% knowledge of ITN use compared to only 15.6% of respondents with the shortest intervention period (2011). The two-year time period of the intervention increased the knowledge score by more than three times. This was the case across practically all knowledge and treatment indicators (see Figure 2).

This study was the first to evaluate the impact of the Sun Primary Health (SPH) intervention on malaria knowledge and behaviours among rural populations in Myanmar. The study found that the presence of a SPH provider in the community is associated with increased malaria knowledge, such as knowledge of use of ITN and RDT, and higher likelihood of going to trained providers for fevers. Lack of statistically significant differences in basic demographic characteristics between SPH and non-SPH groups strengthens the finding that there is an association between a SPH provider and higher knowledge levels. Furthermore, the study also found that communities with a longer duration of intervention (intervention introduced in 2009) had better knowledge score and treatment behaviours compared to communities with more recent introduction of providers (in 2011).

There are a number of limitations to the study. First, the study was not able to assess characteristics regarding patient-provider relationship, such as the quality of the providers, the frequency of visiting providers, or whether respondents interacted with SPH providers. Future studies should examine the quality of health workers and how that relates to patient practices and knowledge levels. Second, because the study uses cross-sectional data, the study cannot infer causality. However, these analyses take advantage of the stepped design of the intervention and examine dose–response, a criteria for causal inference.

Despite the limitations, this study demonstrates the critical and potential role of health workers in improving health in rural Myanmar. There is a dearth of studies on promising interventions in Myanmar, particularly in rural areas, and this study not only demonstrates a change in knowledge score between SPH and non-SPH communities, but also suggests that there are cumulative effects over time. Future studies should concentrate on a better understanding of the direct and indirect effects of SPH providers, how training impacts the quality of health workers, and explore whether greater frequency and contact with SPH providers result in better health outcomes. Moreover, future studies should concentrate on the health impact of communities, going beyond knowledge indicators to measure malaria prevalence, incidence, morbidity, and mortality. This study highlights the opportunity to engage with rural health workers in improving malaria knowledge, care, and practices.

Written informed consent was obtained from the patient’s guardian/parent/next of kin for the publication of this report and any accompanying images.