Patient Knowledge on Malaria Symptoms Is a Key to Promoting Universal Access of Patients to Effective Malaria Treatment in Palawan, the Philippines

<div><p>Introduction</p><p>Palawan, where health care facilities are still limited, is one of the most malaria endemic provinces in the Philippines. Since 1999, microscopists (community health workers) have been trained in malaria diagnosis and feasibility of early diagnosis and treatments have been enhanced throughout the province. To accelerate the universal access of malaria patients to diagnostic testing in Palawan, positive health seeking behavior should be encouraged when malaria infection is suspected.</p><p>Methods</p><p>In this cross-sectional study, structured interviews were carried out with residents (N = 218) of 20 remote malaria-endemic villages throughout Palawan with a history of suspected malaria from January to February in 2012. Structural equation modeling (SEM) was conducted to determine factors associated with appropriate treatment, which included: (1) socio-demographic characteristics; (2) proximity to a health facility; (3) health seeking behavior; (4) knowledge on malaria; (5) participation in community awareness-raising activities.</p><p>Results</p><p>Three factors independently associated with appropriate treatment were identified by SEM (CMIN = 10.5, df = 11, CFI = 1.000, RMSEA = .000): “living near microscopist” (<i>p</i> < 0.001), “not living near private pharmacy” (<i>p</i> < 0.01), and “having severe symptoms” (<i>p</i> < 0.01). “Severe symptoms” were positively correlated with more “knowledge on malaria symptoms” (<i>p</i> < 0.001). This knowledge was significantly increased by attending “community awareness-raising activities by microscopists” (<i>p</i> < 0.001).</p><p>Conclusions</p><p>In the resource-limited settings, microscopists played a significant role in providing appropriate treatment to all participants with severe malaria symptoms. However, it was considered that knowledge on malaria symptoms made participants more aware of their symptoms, and further progressed self-triage. Strengthening this recognition sensitivity and making residents aware of nearby microscopists may be the keys to accelerating universal access to effective malaria treatment in Palawan.</p></div

Map of Annual Parasite Incidence (API) (confirmed infections/1,000 population at risk) by municipalities, 2010.

<p>This map was constructed by the authors based on the data of provincial health report 2010 [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0127858#pone.0127858.ref005" target="_blank">5</a>].</p

Nominal socio-economic status variables of participants with respect to first treatment sought.

<p>¹Fisher’s exact test between first treatment sought.</p><p>Nominal socio-economic status variables of participants with respect to first treatment sought.</p

Correlation matrix.

<p>* Significant difference (0.01 < <i>p</i> < 0.05),</p><p>** Significant difference (0.001 < <i>p</i> < 0.01),</p><p>*** Significant difference (<i>p</i> < 0.001).</p><p>Correlation matrix.</p

Knowledge on malaria of participants with respect to first treatment sought.

<p>¹ANOVA between first treatment sought.</p><p>^aIndicates the combination of two places of first treatment sought that were significantly different by Tukey-Kramer test.</p><p>*Significant difference (0.01 ≤ <i>p</i> < 0.05)</p><p>Knowledge on malaria of participants with respect to first treatment sought.</p

Determinants of appropriate treatment.

<p>N = 216, CMIN = 10.5, df = 11, CFI = 1.000, RMSEA = 0.000. <i>* p</i> < 0.05, ** <i>p</i> < 0.01, *** <i>p</i> < 0.001. Since the two participants who first sought treatment from a traditional healer (Tagalog: Albalaryo) made a very unusual choice, the authors analyzed them separately and did not include them in the SEM model.</p

Conceptual framework.

<p>The authors hypothesize that an association exists between “appropriate treatment” and the following multi-directional variables: “socio-demographic status,” “proximity to health facility,” knowledge on malaria,” and “participation in community awareness-raising activities for malaria prevention.” Sub-variables of each variable are in the circles of the conceptual framework.</p

Proximity to health facility, symptoms, and awareness-raising activities of the participants with respect to first treatment sought (multiple answers allowed).

<p>¹Fisher’s exact test between first treatment sought.</p><p>*Significant difference (0.01 ≤ <i>p</i> < 0.05),</p><p>**Significant difference (0.001 ≤ <i>p</i> < 0.01),</p><p>***Significant difference (<i>p</i> < 0.001).</p><p>Proximity to health facility, symptoms, and awareness-raising activities of the participants with respect to first treatment sought (multiple answers allowed).</p

Continuous socio-economic status variables of participants with respect to first treatment sought.

<p>¹ANOVA between first treatment sought.</p><p>²This scale scores from 1–8 points, with 1 point each for each of the following: electricity, radio, television, refrigerator, bicycle, motorcycle, bike-car, and tin or cement wall.</p><p>Continuous socio-economic status variables of participants with respect to first treatment sought.</p