Malaria treatment-seeking behaviour and related factors of Wa ethnic minority in Myanmar: a cross-sectional study
Malaria treatment-seeking behaviour and related factors of Wa ethnic minority in Myanmar: a cross-sectional study
Jian-Wei Xu 0
Qi-Zhang Xu 2
Hui Liu 0
Yi-Rou Zeng 1
0 Yunan Institute of Parasitic Diseases , Puer 665000 , China
1 Mengmao County Hospital , Shan Special Region II , Myanmar
2 People's Hospital of Taikang County , Henan Province , China
Background: In Southeast Asia, data on malaria treatment-seeking behaviours and related affecting factors are rare. The population of the Wa ethnic in Myanmar has difficulty in accessing formal health care. To understand malaria treatment-seeking behaviour and household-affecting factors of the Wa people, a cross-sectional study carried out in Shan Special Region II, Myanmar. Methods: The two methods, questionnaire-based household surveys to household heads and in-depth interviews to key informants, were carried out independently. The proportion of treatment-seeking patterns was calculated. Logistic regression was used to determine affecting factors of treatment-seeking. Qualitative data were analysed by using Text Analysis Markup System. Results: Overall, 87.5% of the febrile population sought treatment, but only 32.0% did so within 24 hours. The proportion accessing the retail sector (79.6%) was statistically significant higher (P<0.0001) than accessing the public sector (10.6%). Multivariable logistic regression analysis identified family income, distances from a health facility, family decision and patient characteristics being independently associated with delayed malaria treatment. Conclusion: Malaria treatment-seeking behaviour is not appropriate, and affecting factors include health service systems, social and cultural factors in Wa State of Myanmar.
Malaria; Treatment-seeking behaviour; Wa ethnic; Household survey
There were an estimated 216 million episodes of malaria
and 655,000 malaria deaths worldwide in 2010 .
Malaria is a major cause of poverty and slows economic
growth by up to 13% per year in endemic countries .
Early diagnosis and effective treatment of all malaria
cases is an essential component to reduce the burden of
malaria. This requires appropriate infrastructure and
resource, and also active engagement and participation of
communities . Data on malaria treatment-seeking
behaviours and household-affecting factors are rare in
Southeast Asia [4,5]. The Wa ethnic minority lives
across the China-Myanmar border and its total
population is around 1.2 million (740,000 in Myanmar side,
and 460,000 in China) . Malaria control among the
population of ethnic minorities is being challenged by
treatment-seeking behaviours and accessibility to health
service . In Myanmar, Wa people mainly live in Shan
Special Region II (locally called Wa State or UWSA
territory). Malaria is one of the major public health
problems among the population. An active detection found
60% (270/453) of parasite rates among febrile patients
and of them 90.74% (245/270) was Plasmodium
falciparum . In Wa State, most residents have difficulty in
accessing formal health care. Data and information
concerning malaria treatment for them are insufficient. This
investigation could assist in understanding
treatmentseeking behaviour and related household factors.
Study area and period
A cross-sectional study was conducted between 1 October
and 31 December 2009 in Gelongba and Mandong
Figure 1 The study site, Shan Special Region II (UWSA territory), Myanmar (Burma).
districts, Mengmao County, Wa State (Figure 1). The
two districts in Salween River Valley were purposely
selected based on their malaria endemicity and prevalence.
This area experiences year-round malaria transmission
with a peak during the rainy season from September to
November. Health care is provided by a community health
centre, two NGO health posts by Aide Medical
International (AMI) and two private clinics. Drugs are provided
by two drug shops and market stalls. All these facilities of
health care and pharmacy are located the two main
villages: Gelongba and Mandong.
Household survey design and implementation
The study population included people who had
signs/symptoms of malaria in the previous two weeks. The investigation
was carried out by household survey (HHS) as a quantitative
method and semi-structured in-depth interviews (SDI) to
key informants as the qualitative [8,9].
The data collection tools (questionnaires and interview
guidelines) were developed in Chinese because Wa
language is only a speaking language. One of researchers
who can understand both Wa and Chinese Language
conducted the interviews in Wa language and then filled
out the questionnaires in Chinese. The sampling frame
for the survey covered all 64 villages of the districts of
Gelongba and Mandong, which have an approximate
total population of 18,940. Households were the units of
sampling. A sample size of 350 households was required
by using desired 5% of precision, estimated 35% of
febrile patients in the previous two weeks who sought
treatment within 24 hours and 95% of confidence limits.
A household was defined as all those eating from the
same cooking pot. Sampling of households was
restricted to those with a fever patient in the previous
The survey started from Gelongba, one of two main
villages. The first household was randomly selected. The
researchers visited the subjects village by village and
house by house. A household with a fever patient in the
previous two weeks was selected for the survey, until the
desired sample size was reached. The household head
was selected on behalf of the entire household to answer
the questionnaires. The questionnaire included
structured questions on respondent and household
characteristics, details of the treatment-seeking behaviours and
malaria-related knowledge [10,11]. In order to reduce
recall bias, households without fever in the last two weeks
were just interviewed for socio-demographic
characteristics but for treatment-seeking and other related factors.
Details of the youngest one were collected if there was
more than one person who had had fever in a household
in last two weeks.
To collect information in detail for exploring malaria
treatment-seeking, the SDIs were conducted in the same
villages sampled for HHS. According to the
recommendation of household heads, 23 village heads and 13
village health workers were selected as key informants for
interview. The issues discussed with key informants were
local health service, peoples perception of malaria,
treatment-seeking behaviours and related socioeconomic
All health facilities were visited and their staffs were
interviewed on health service in the two districts. An
outlet survey of anti-malarial drugs was also conducted
and the survey included interviewing medical sellers on
their knowledge of drugs.
Both quantitative and qualitative data analysis was
carried out by two senior researchers (J-W & H L).
Quantitative Data were first checked manually for
completeness and then double-entered and validated in
EpiData version 3.1 . Epi Info 2000 was used for data
processing and analysis. Bivariate analysis between
dependent and independent variables was performed
using binary logistic regression. To control the effect of
confounding variables, multivariate logistic regressions
were done. Adjusted OR and 95% CI were used to
interpret the findings. Qualitative data were analysed by using
Text Analysis Markup System (TAMS). The data were
encoded on the basis of emerging themes and a
codebook was progressively elaborated. Trends in the data
were identified by producing matrices allowing for
Table 1 Socio-demographic characteristics of respondents in Gelongba and Mandong Districts, Shan Special Region II,
Households with fever patients
in previous 2 weeks (n=369)
combination and comparison of information from the
different key informants.
According to the Helsinki Declaration, ethical approval
for the study was granted by the Ethics Committees of
Yunnan Institute of Parasitic Diseases, China. The
purpose of the study was explained to the local health
authority and the study participants and informed consent
Sociodemographic characteristics of respondents
A total of 718 households were visited and a total of
3,678 people lived in the households. The mean family
size was 5.8 (range 113) persons per household. 369
heads of households with fever patients in previous two
weeks were interviewed. Sociodemographic
characteristics were similar (P>0.05) between households visited
and households with fever patients, except resident
altitude. This might be because people living at low altitude
contract malaria more readily (Table 1). The mean age
of respondents was 35.6 (SD 13.5) years, 240 (65.0%)
were male. Most households mainly live on growing dry
field rice, and a few households have a member working
in rubber plantation. The mean age of the 36 key
informants was 32.7 (SD 17.5) years, and all 23 village
heads were male, seven village health workers were male
and five female.
Table 2 Malaria treatment-seeking behaviour of fever
patients in previous two weeks in Gelongba and
Mandong Districts, Shan Special Region II, Myanmar
Overall 87.5% (323) of the febrile sought treatment;
32.0% (118) sought it within 24 hours, 6.5% (24) within
2448 hours and 49.2% (181) after 48 hours. Of the 323
fever patients who sought treatment, 79.6% (257) went
to the retail sector (drug peddlers, shops and market
stalls); 8.4% (31) sought from village health workers (the
lowest level public health facility); 2.2% (eight) went to
community health centres; 7.3% (27) sought advice or
treatment from other sources such as a traditional
healer, a friend or relative (Table 2). The proportion
accessing the retail sector was statistically significantly
higher than accessing the public sector (P<0.0001). Of
the 46 who stayed at home, 73.9% (34) already had drugs
in the house; 67.4% (31) sought help from supernatural
spirit. The proportion of fever patients who received
laboratory-based diagnosis was low (20.08% for
microscopy and 8.1% for RDT, respectively) (Table 2). Of 104
febrile who received laboratory-based diagnosis, 7.7%
(eight) received it at the community health centre and
92.3% (96) in outreach service of NGOs. Of the 257 who
sought treatment in the retail sector, 65.8% (169)
received under-dosed paraquin; 13.0% (42/323) took
herbs and 3.4% (11/323) took only a febrifuge, such as
Factors related to treatment-seeking
The results from interviewing key informants, public
health facilities and their service were very limited in
Wa State. The central government of Myanmar only
runs hospitals and clinics in main towns in Wa State;
they hardly provide any health service at community
level. The local government of special region had a
community health centre (CHC) in Gelongba. Despite there
being six staff in the CHC, none of the staff had
professional training in health or medicine in formal school.
The only available medical instruments were two
stethoscopes and three thermometers. Anti-malarial drugs had
been out of stock at the time of survey. This determined
why medical sellers were the most accessible and widely
used health resources. Most of the medical sellers did
not know precise chloroquine doses for children and
dosing information they gave was often inadequate,
however the patients prefer their services because they
satisfy their needs. For example, even if the retailers
were aware that an oral therapy would be appropriate,
they might sell injectable formulations if a client asked
or they knew that patients believed injections to be more
The results of multivariable logistic regression analysis
showed that five variables were independently associated
with delayed malaria treatment. Families with an average
yearly income per person more than US$200 were more
likely to seek treatment for malaria within 24 hours.
Households located more than 3 km from a health
facility were more likely to delay seeking malaria treatment.
Families, whose wives could make decisions or
codecisions, were more likely to seek treatment in time.
Families were more likely to seek treatment promptly if
patients were male, and for children under 15 years old
The health systems deficiencies play an important role
in the performance of the case management strategy of
global malaria control. The political divarication between
central government and local government led to the
national health system (NHS) not being able to effectively
cover the Wa State. Since cease-fire between the central
Mandong Districts, Shan Special Region II, Myanmar
government and local government in 1988, the central
government has established three hospitals in main
towns and the local government was trying to establish a
health service network but is short of investment in
human resources and basic facilities, and some
international NGOs were running some health programmes,
however all three efforts have not established an
effective public health service system.
A large proportion of febrile patients sought advice or
treatment, however most of them sought treatment from
medical sellers, so a high proportion of the febrile was
only diagnosed by clinical symptoms for malaria, and
most of the microscopy or RDT were given by outreach
service of NGOs. In the neighbouring region (Yunnan
Province of China), 82% of malaria patients chose
township community hospitals first . The literature
regarding treatment seeking in Myanmar and other countries
of Greater Mekong subregion is rare. The situation
seems similar that in sub-Saharan Africa; medicine
sellers are widely used for fever and malaria treatment .
Despite the drug seller market being extremely informal,
it is the most available and stable provider. The Roll
Back Malaria (RBM) Partnership had set a target for
80% to receive appropriate treatment within 24 hours by
2010 . However, this study found it was far away
from that target. WHO now advocates strategies to
improve home-based management of malaria, with retailer
interventions being seen as one possible channel [16,17].
At present, this could be one of strategies addressing
timely and appropriate treatment of malaria for the Wa
Wa State is an endemic area of falciparum malaria.
Patients should seek treatment within 24 hours, however
less than one third of patients to do so. Of 12.5% (46/
369) of febrile patients who never sought treatment
outside the home, 67.4% (31/46) of them sought help from
supernatural spirit. In the culture of Wa ethnics, people
believe in everything has its soul, so they might seek
help from spirit when they are ill. A study done in
Burkina Faso showed that literacy level of the heads of the
households was the main factor to bring children within 24
hours to the health facility for the treatment of malaria
. In this study, 96.7% (357/369) of respondents were
illiterate. Studies carried out in Ethiopia  and southern
Ghana  showed that knowledge of respondents is not
associated with malaria treatment-seeking . Knowledge
itself is not equal to behaviour. Peoples perception,
knowledge and awareness, assured material supply and enabling
environment are necessary for behaviour development .
Family income and distances from a health facility can solve
accessibility in economics and geography respectively, so
the two factors are associated with treatment seeking in the
study. In Wa tradition, men are usually more respectable
and powerful than women ; on the other hand, mothers
are usually child carers and housework undertakers, so wife
or co-decision can increase timely treatment seeking, and
male patients and children are more likely to be assisted in
In the study design, the hypothesis is no difference in
treatment-seeking between households in which there
was someone with fever in the last two weeks compared
to households without. In order to reduce recall bias,
the households without fever in the last two weeks were
just interviewed for socio-demographic characteristics,
but for treatment-seeking and other related factors. In
true-life, there may be differences in fever frequency and
treatment-seeking pattern between the two household
groups. This limitation may affect the results of the
study. However the population of the two districts is
estimated at 18, 940, but 718 households with 19.4% (3,
678) of the total population was visited. This can reduce
sample bias caused by the difference.
Malaria treatment-seeking behaviour is not effective, and
factors affecting this include health service systems,
social and cultural features in the Wa State of Myanmar.
The authors declare that they have no competing interests.
J-WX, Q-ZX and HL designed the study and developed the protocol,
analyzed and interpreted the data. HL supervised the field survey. Q-ZX, Y-R
Z and HL conducted HHs survey, SDI, health facility visits and the outlet
survey, and entered the data. J-WX and Q-ZX wrote the first draft of the
paper. All authors read and approved the final manuscript.
We thank the fifth grant to China of the Global Fund to fight AIDS,
Tuberculosis and Malaria (GFATM) for financial sponsor. We are grateful to Dr
Chun-Fu Li, Dr Xing-Liang Li and Ren-Hua Nie from Yunnan Institute of
Parasitic Disease (YIPD) involvement of field work. We thank participants and
local health sector for their collaboration in field survey. The opinions
expressed are those of the authors and do not necessarily reflect those of
YIPD and GFATM.
1. World Health Organization: World malaria report: 2011 . Geneva: WHO ; 2011 .
2. Sachs J , Malaney P : The economic and social burden of malaria . Nature 2002 , 415 : 680 - 685 .
3. WHO: Global Malaria Control and Elimination: report of a technical review, World Health Organization Global Malaria Programme . Geneva: WHO ; 2008 .
4. Wangroongsarb P , Satimai W , Khamsiriwatchara A , Thwing J , Eliades JM , Kaewkungwal J , Delacollette C : Respondent-driven sampling on the Thailand-Cambodia border. II. Knowledge, perception, practice and treatment-seeking behaviour of migrants in malaria endemic zones . Malar J 2011 , 10 : 117 .
5. Yeung S , Van Damme W , Socheat D , White NJ , Mills A : Cost of increasing access to artemisinin combination therapy: the Cambodian experience . Malar J 2018 , 7 : 84 .
6. Xu JW : Community-based malaria control for ethnic minority groups: malaria control progress of a Wa ethnic community at China-Myanmar border . World J Inf 2009 , 9 : 218 - 223 .
7. Liu H , Nie RH , Li CF , Sun YH , Li GS : Active detection of malaria cases in Myanmar Wa ethnical villages of China-Myanmar border (abstract in English) . Parasitol Infect Dis 2009 , 7 : 6 - 8 .
8. Xu JW , Xia M , Petlueng P , Tao H , Zhong YC , Wu XH , Liu SM , Wen ZD , Liu H : Current situation, affordability and obstacles on treatment-seeking of Wa ethnic in Ximeng , Yunnan. China Trop Med 2004 , 4 : 937 - 939 .
9. Xu JW , Xia M , Petlueng P , Tao H , Zhong YC , Wu XH , Liu SM , Wen ZD , Liu H : Current situation, attitudes and scaling up obstacles toward usage of bednets in Wa ethnic . China Trop Med 2004 , 4 : 319 - 321 .
10. Henderson RH , Sundaresan T : Cluster sampling to assess immunization coverage: a review of experience with a simplified sampling method . Bull World Health Organ 1982 , 60 : 253 - 260 .
11. Smith L , Bruce J , Gueye L , Helou A , Diallo R , Gueye B , Jones C , Webster J : From fever to anti-malarial: the treatment-seeking process in rural Senegal . Malar J 2010 , 9 : 333 .
12. Wen L , Lieber E , Wan D , Hong YH : A qualitative study about selfmedication in the community among market vendors in Fuzhou, China . Health Soc Care Community 2011 , 19 : 504 - 13 .
13. Lauritsen J : EpiData Data Entry , Data management and basic Statistical Analysis System Version 3 .1. Odense , Denmark: EpiData Association ; 2000 .
14. Goodman C , Brieger W , Unwin A , Mills A , Meek S , Greer M : Medicine sellers and malaria treatment in sub-saharan africa . AmJTrop Med Hyg 2007 , 77 (Suppl): 203 - 218 .
15. WHO: RBM Global Strategic Plan: Roll Back Malaria 2005-2015 . Geneva: Roll Back Malaria Partnership, World Health Organization ; 2005 .
16. WHO: Scaling up home-based management of malaria . Geneva: Roll Back Malaria Department/UNICEF/UNDP/World Bank/TDR WHO/HTM/MAL/ 2004 .1096; 2004 .
17. WHO: The Roll Back Malaria Strategy for Improving Access to Treatment through Home Management . Geneva: WHO/HTM/MAL/2005 .1101; 2005 .
18. Tipke M , Louis RV , Y M : Access to malaria treatment in young children of rural Burkina Faso . Malar J 2009 , 8 : 266 .
19. Getahun A , Deribe K , Aare Deribew A : Determinants of delay in malaria treatment seeking behaviour for under-five children in south-west Ethiopia: a case control study . Malar J 2010 , 9 : 320 .
20. Ahorlu CK , Koram KA , Ahorlu C , de Savigny D , Weiss MG : Socio-cultural determinants of treatment delay for childhood malaria in southern Ghana . Trop Med Int Health 2006 , 11 : 1022 - 103 .
21. Xu JW , Wu XH , WEI C , Petlueng P , Tao H , Lin H , Xia: A pilot study on strengthening malaria control for ethnic minorities (abstract in English) . Chin J Vector Biol Control 2010 , 21 : 527 - 530 .