Background
Methods
Study site and population
Data collection and sampling
Data analysis
Results
Study participants
Occupational profile | N |
---|---|
Private health providers | 4 |
VMWs | 2 |
Traditional healers | 4 |
Community leaders | 4 |
Public health staff | 3 |
Seasonal workers | 2 |
Total | 19 |
Participant characteristics | IDIs | FGDs | Total | |
---|---|---|---|---|
Gender | Male | 10 | 26 | 36 |
Female | 16 | 23 | 39 | |
Age | 15–30 | 9 | 12 | 21 |
30–45 | 6 | 20 | 26 | |
45–60 | 11 | 17 | 28 | |
Literacy | Literate | 18 | 16 | 34 |
Illiterate | 8 | 33 | 41 | |
Ethnicity | Khmer | 39 | 26 | 65 |
Kuy | 6 | 23 | 29 | |
Provenance | Chhaeb | 15 | 31 | 46 |
Chey Saen | 11 | 18 | 29 |
Illness aetiologies
Supernatural realm
R: Sometimes the [malaria] patient says it is maybe a ghost that attacked [him], such as the deity of the forest or mountain!I: And for the case of your grandchild, she just got sick for 2 or 3 days and then she died?R: Yes, after two days she died. […] Some people said she was defeated by the ancestral spirit, she had convulsions and said something without thinking. (Interview with a middle-aged male farmer)
People say: ‘a person who is useless and [has] fights with others, risks to [be attacked by] ‘ampeu’ (i.e. sorcery)’. But as I’ve never started problems with anyone […] no one has ever done [sorcery] against me. […] If we do something wrong to them, they will do [it] back to [us]. (Interview with a young male farmer)
Natural causes of illness
Sometimes, [when] we get better, we [have to] follow a diet. If we don’t follow the diet [we] will be sick again. For ‘krun chan’ (malaria) people cannot eat tamarind and papayas; both mixed papayas and sour papayas. [We] cannot eat noodles either. If we don’t follow this diet and still eat everything, we will get sick again, [but then it will be] more serious. (Interview with a middle-aged female farmer)
[…] if the ‘dey low’ (i.e. the land on which the house is built) of each of us [has] [puddles of] water, like these ones there, [as we] don’t take time to clear it, [they will become] shelters of mosquitoes, isn’t that right? […] As mosquitoes have a lot of places to stay, the ‘krun’ (fever) [can happen] anywhere. [We have to] clean the whole house and its surroundings. (Interview with a middle-aged male farmer)
During the first years, when I just arrived here, I never went into the forest, [so] I never had ‘krun chan’ (malaria). [But since] the last three, four years, when I went to work on the farm, [I] began to [have] ‘krun’ [chan] (malaria). (Interview with a middle-aged female farmer)
Double causality
It is like my younger sister, last month. […] As [she] had convulsions—[her] eyes were rolling upwards, [her] mouth was twisting—my parents became very worried about [their] child, so [they] asked [the medical staff] to take [her] out of the hospital. […] [They] went straight to the […] indigenous healer in the provincial capital. […] He said she was possessed by 3 or 4 ancestor spirits. We did the ‘saen’ (the offering for the spirits) and they left her body. She recovered and survives until this day. (Respondent in a focus group discussion with female farmers)
Illness perceptions
R1: Now, [after] my nephew had a blood test, [he] didn’t have ‘krun chan’, but ‘krun vivak’. […] Then [the village malaria worker] asked [us] to go to the referral hospital in the provincial capital. If it is only ‘krun chan’ or no serious ‘krun chan’, [we can] recover by the treatment provided in the district, but when it is ‘krun vivak’, they won’t allow [us] to keep [the patient here]. They send us to the referral hospital.R2: If it is ‘krun chan’, [they will] call the ambulance to take [the patient]. If [it’s] ‘vivak’, [we will] buy medicines here.R3: If [it’s] ‘chan’ and ‘vivak’ together, they cannot give treatment here, [so we have to] take [the sick person] to the referral hospital.R4: If [someone has] ‘krun chan’ from the start, [he can] get better [easily], but now [people] mostly have ‘krun vivak’ or ‘krun che’, [so] it is not easy to get better. (Four respondents in focus group discussion with female farmers)
Treatment options for malaria
Home-based self-treatment
Condition | Treatment | Examples of local treatment options |
---|---|---|
Krun chan (malaria) |
Tnam Khmer (herbal medication) | Take twigs of a sdaw tree, peel them, mix with three cups water and boil until one cup remains, resulting in a very bitter mixture. A variant is to soak the twigs in water instead of boiling, although the mixture is then believed to be less effective Eat 10–20 chillies per day as prevention to krun chan
Take bon-dole-pek (a kind of winder), the bark of the sdaw tree and the bark of the kdol tree. Cut it into pieces and clean it with water. Then you can either boil it or soak it in water, before drinking. If you boil it, you take tree cups of water and boil it until one cup is left. Repeat this procedure for another two times, adding water each time. Then add rice flour (msaw) to the mixture, stir it, and when it is well mixed, make round pills of it to swallow. To make these pills, often a bamboo layer is used |
Tnam Pet (biomedical medication) | Paracetamol (para) Antibiotics such as amoxicillin and ampicillin Antimalarials such as artesunate-mefloquine (malarine), quinine, chloroquine, tetracycline Often sold in a ready-made mix (psom tnam) | |
Kjol (discomfort) | Manual therapy | Coin-rubbing (kos kjol): a very popular self-care technique among the Khmer, during which neck, chest, back shoulders and upper arms are vigorously rubbed with the edge of a coin, spoon or cover of a small tin box, lubricated with Tiger Balm or other types of heat rub, until the scraped areas turn red. The darker the red, the more effective the procedure is perceived to be Cupping (chup kjol): another practice to relief internal pressure linked to kjol, which refers to placing heated small cups on the part of the body that is troubling the person. This can be the chest, the back, the upper arms or the forehead. Bad air (kjol) is perceived to be sucked out of the skin when the air inside the cup cools down and a vacuum is built. Red circular marks are left on the skin, which will remain for several days (see Fig. 2) Pulling hair strand (dork sork), all around the head, by short twitches, causing a feeling of svaang (relief)
Chaab kjol, a specific type of massage which is considered as the most painful of all the techniques to relieve the bad air, as it produces bruising, by pinching and releasing skin folds repeatedly over the same site while applying Tiger Balm, thereby increasing the circulation of blood to the area |
Kob sorsaai (blockage of meridian) |
Tnam sorsaai (herbal medication) | Take the bark of the bom-pong chong-krom tree and boil it Take the roots of the sdaw tree and ang kroang plant and boil these together with leaves of the sdoal tree in water |
Manual therapy | Massage of the sorsaai (chaab sorsaai, kes kaay (i.e. “dig up”) or tver sorsaai) | |
Krun kdaw (fever that feels hot) | Manual therapy | Showering Fanning (bork) Wiping or covering the person with a krama soaked in water or with slices of traw-larch (winter melon) Coin-rubbing (kos kjol) Cupping (chup kjol) |
Tnam trawjak (herbal medication reducing high body temperature) | Pile bitter melon leaves and sav mov leaves together, add sugar, and mix it with water, which results in a very better mixture Mix the roots of three kinds of plants, sbaw plaeng, pkaah-yok and chkaeh sreng, together and boil it with water Take the barks of the trees kagn-jes and roh-lork, and mix it with 3 cups of water. Boil it until only one cup is left. Add water and repeat this procedure for another two times | |
Tnam pet (biomedical medication) | Mostly paracetamol (para)
| |
Krun njeak (fever with shivering) |
Tnam Khmer (herbal mediciation) | Take the roots or bark of the trom kmoach and ampov kmao dai darch trees and boil them in water together with the skin of a ripe coconut for around half an hour. It is also a remedy against digestion related problems. |
Cheu kbaal (headache) |
Tnam Khmer (herbal mediciation) | Take the leaf traw-jeak chruk, grind it and put it in water. |
Manual Therapy | Coin-rubbing (kos kjol) | |
Fatigue | Manual Therapy | Coin-rubbing (kos kjol) |
Malaise | Manual Therapy | Coin-rubbing (kos kjol) |
[We] boil water [and when] it’s hot, we take it, [soak the ‘krama’ in it] and we wipe it all over the body. After, we cover [the body] for a while. [Then] we turn [the sick person on its back], we soak [the krama] again and wipe it all over the body again. […] Then the ‘kdaw’ (hotness) will leave [the body] and the body becomes ‘traw-jak’ (normal temperature). (Interview with a young female farmer)
My child has had ‘krun chan’ recently. His grandmother took care of him, as he got severe ‘njeak’ (shivering). [He] was given a few ‘para’ (i.e. tablets of paracetamol) and one tablet of this [because he was] seriously ‘kdaw’ (i.e. feeling hot) and ‘njeak’ (shivering). (Respondent in a focus group discussion with female farmers)
Biomedical treatment outside of the home
[We] make decisions together… [It] is decided by husband [and] wife, yes. […] Sometimes, there are relatives [or] neighbours coming over to listen, to offer ideas. […] Yes, [it’s] like exchanging ideas. […] Sometimes, the person who is taking care of the illness is so worried about the child that, [he/she] doesn’t think clearly anymore. (Respondent in a focus group discussion with male farmers)
I don’t do the blood test, you know. I only know [someone has ‘krun chan’], when they come here to see me. This morning, [someone] came here and described the symptoms as shivering, then fever, and afterward [he] started to sweat. (Interview with a male ‘village doctor’)
If the pills are too slow to kill the illness, we take the child for an injection)! (Interview with a middle aged male forest worker)
There is only one private practitioner here, that sells ‘tnam pet’ (‘biomedical drugs’). Anybody who is staying at his house, they give injections. […] An injection is more effective than pills. (Interview with a middle-aged male farmer)
Counter-sorcery
When I was not well, I went first to private practitioner to check my ‘kraw peah pos vean’ (illness related to the digestive system). […] I came back [home] and I took medicines, but I still couldn’t recover. I went to buy ‘serum’ (IV therapy), which was not effective at all. [I thought I] was going to die. […] [Finally, I] decided to try [with the indigenous healer]. [When I] arrived, he asked [me] to prepare a ‘bae sey’ of two or three layers (i.e. a small square tray of banana stems and leaves, often decorated with flowers and)[…], ‘sdos’ (treatment consistent of spitting) and ‘chak teuk’ (treatment consisting of pouring of blessed water) three times a day. […] Because the indigenous healer did the ‘chak teuk’ I could recover and stay alive until today. (Respondent in a focus group discussion with female farmers)
Factors determining provider choice
Financial situation
I have spent millions each year to get injections. For several years I had no energy and was [often] sick, so I went to the private practitioner. [I was said to have] ‘roh-leak tom rong nom’ (i.e. kidney inflammation) and ‘roh-leak dai sbon’ (i.e. uterus inflammation). I bought a lot of medicine to take, injections, and ‘serum’ (IV fluid therapy) too, but [I] could not see any improvement. My family never experienced nice food and a happy family life [during these years], because [I] was always in need of money to pay [the treatment costs]. [This went on] for three years, until [I] went to see an indigenous healer in Stung Treng. It was there I could recover, until today. (Respondent in a focus group discussion with female farmers)
Accessibility
R1: [When we are] sick, it is not always the case that we go to the health centre right away. Mostly [we] try first to find ‘tnam’ (i.e. biomedicines) from here and there, to swallow. [We] are unwilling to go [to the health centre], as it is far away and [to get there] it costs money too.R2: [It’s] not a matter of unwillingness, but [we just] don’t have money. (Two respondents in a focus group discussion with female farmers)
Trust
When there is no NGO (‘angkar’) nearby, the health centre staff ignores us, they pay no attention to us. […] It’s like a father hitting his child; the child does not have any right. They are the father; whatever they say, [people] have to believe it. (Interview with a middle aged male farmer).I didn’t trust [them]… I was really unwell, but [they] didn’t do anything. […] I was waiting a half morning, until almost noon, and still [they] didn’t receive me. [At the end, they] just gave me one pill of medicine. [They] didn’t do anything. (Interview with a middle aged female farmer)