The results are presented under six broad themes that are largely a priori and encompass participants’ perspectives on: (1) the prevalence of malaria, (2) their understanding of the causes of malaria, (3) their attitudes towards seeking healthcare for malaria (including traditional medicine), (4) their opinions on government interventions for malaria control, (5) their personal practices for preventing or managing malaria, and (6) the influence of cultural beliefs and perceptions of good health. The themes largely reflect community perspectives documented at the village level through FGD. Provider perspectives documented through IDI are presented briefly at the end of each section when relevant.
Perspectives on malaria prevalence
This theme presents participant awareness of malaria disease burden and reasons for changes. Most participants in FGD across the three districts expressed that malaria incidence has declined over the years. Around 74 participants from WKH, 81 participants from WJH, and 98 participants from SGH verbally indicated a reduction in malaria cases. While many participants conveyed their thoughts verbally, others communicated non-verbally through actions such as nodding or shaking their heads. The numbers indicated in the results count only those who made explicit statements, which is often an underestimation of the numbers as it does not consider those who conveyed the message by non-verbal means or remained non-responsive.
In the FGD, the perceived reduction was attributed primarily to government interventions such as the distribution of LLINs and application of indoor residual spraying (IRS) as well as improved access to diagnostic and treatment facilities. These findings align with interviews with healthcare providers/personnel and traditional healers who reported similar improvements.
“I just want to tell you that, 20 years earlier, I had also suffered from malaria. When one is infected with malaria, the palms and feet appear yellow in colour, and it takes time to get cured. When we go for a check-up in Shillong (capital city), we get medicines, we take them, and then we get cured. But if we look at the generation now, malaria is not much of a problem as compared to the years before. Because now there are people here who do blood tests, provide us medicines, and also give us injections that can cure malaria. I feel that it is very accessible now. In our village now, very few people get malaria; they only get other kinds of infections.” – R2_FGD_OM_WKH
While most FGD participants expressed that malaria had declined, a small number of participants reported that malaria is still a problem because of inadequate intervention measures available outside their homes, particularly in the agricultural fields. Participants further expressed that they are largely farmers by trade who spend considerable time outdoors, working in the fields or moving in forests or places with dense vegetation where they are frequently in contact with mosquitoes and are at a higher risk of contracting malaria.
‘It is really still a problem as we cannot protect ourselves from mosquito bites. If at home we use bed nets to protect ourselves from mosquitoes, when we go for our work in the forest, we roam around here and there…there are many mosquitoes that bites us…that might be infected and can cause malaria’ – R4_FGD_OM_WKH
Participants expressed that malaria is more prevalent in rural settings compared to urban areas where forests are less abundant. In the IDI, similar views on malaria prevalence were shared by providers. Both healthcare personnel in the public sector and traditional healers pointed out that malaria still persists in the area, and they believed that it could be attributed to the villages being surrounded by forests.
Knowledge about malaria aetiology
This theme explored participants’ knowledge and understanding of the causes or origins of malaria, and it delved into their awareness of the role of mosquitoes as vectors, the transmission cycle, and other factors contributing to the spread of malaria. Most participants demonstrated awareness of how malaria is transmitted and could identify common signs and symptoms such as body aches, chills, fever, and sweating. Participants who had encountered malaria themselves or observed cases within their families were able to provide more detailed information about their experiences. About 70 participants from WKH, 73 from WJH, and 71 from SGH acknowledged that mosquitoes play a role in transmitting malaria. They believed that mosquito bites alone could cause malaria and that infected mosquitoes could transmit the disease to healthy individuals through subsequent bites.
The majority of participants were aware of one or more common signs and symptoms of malaria. The scope of symptoms reported included fever, shivering, headache, body ache, chills, joint pain, weakness, body swelling, tingling sensation, and flu like symptoms. The majority of participants stated that they would rely on blood tests to confirm a diagnosis of malaria; however, a small number of participants expressed the belief that they could identify malaria based on the signs and symptoms alone, by observation, without conducting any confirmatory test.
“The sign and symptoms that we usually see from a person who have malaria are fever, chills, weakness of the body, and also the tingling sensation….that’s what I know.”-R1_FGD_OM_WKH
In addition to observing the common signs and symptoms of fever and chills, participants reported that traditional healers also examine a person’s urine, eyes, and palms as part of their diagnostic method. The traditional healers that were interviewed explained that examining urine for changes in colour, consistency, or odour can be indicative of certain diseases or conditions, including malaria.
The majority of participants were unaware of diseases other than malaria that can be transmitted by mosquitoes. Participants occasionally categorised malaria with other conditions such as typhoid. When such views were expressed usually none of the other participants contested them. Some participants correctly mentioned other diseases that they believed could be spread by mosquitoes, such as Japanese Encephalitis and dengue fever. However, some conditions like diarrhoea and HIV/AIDS were incorrectly associated with mosquitoes. There were variations in the perceptions of mosquito-borne diseases among participants from different districts. For instance, younger men in SGH associated mosquitoes with skin infections and dengue fever, while younger women in the same district linked mosquitoes to stomach ache and joint pain.
“According to what I have heard malaria is the main disease spread by the mosquito bite but in my knowledge, I think typhoid might also be, and even diarrhoea because sometimes if we happen to consume the foods which are being infected by the mosquito, we can get typhoid and also diarrhoea.”-R1_FGD_OM_SGH
Practices and attitudes towards seeking care for malaria
This theme presents participants' reported behaviours and attitudes when it comes to seeking healthcare for malaria. Participant's practices in terms of community preferences for treatment and utilizing healthcare services, such as visiting health facilities (and if so, public or private sector) or seeking care from traditional healers, were probed.
The majority of participants indicated they preferred seeking care for malaria from public healthcare institutions, such as PHCs, while a smaller number of participants reported a preference for seeking healthcare from private healthcare providers. Most participants reported having shifted their health-seeking behaviour from traditional healing practices to services at public health facilities. This transition is partly due to their belief that timely and effective treatment for malaria was available in the public health system. In the three districts, the participants and healthcare providers had expressed how the frontline health workers are now equipped with basic rapid diagnostic tests (RDT) for malaria and can promptly identify malaria cases, thereby ensuring more timely referral for appropriate treatment that improves outcomes and reduces the risk of complications.
“ Before, when either me or any of my family members were being infected by malaria I will directly rush to the hospital or the PHC but now we can go to the ASHA because she also has the equipment which can run the test of malaria.” – R1_FGD_OM_WKH
Some participants described occasions where they received contradictory test results from different healthcare providers, including initial negative results from the ASHA. Such experiences contributed to reduced confidence in the testing equipment used by the ASHAs, and some participants said they would now prefer to go to the PHC directly for malaria testing.
“So…From my side I used to do the same as he had already told you, but there are chances that if we do the test with the ASHA it’s showing that there is no malaria detected but when we do the test in PHC it’s showing that malaria parasite is there in our body, so it was due to this reason that I never rely on ASHA test, I used to go directly to the PHC.” -R8_FGD_OM_WJH
In SGH, participants shared that it was problematic when it comes to visiting the health centre as it is located further from the village and there are no proper roads or public transportation to reach the facility. In keeping with this sentiment, the providers interviewed confirmed that villagers visit the health centre(s) with complaints of malaria, but the symptoms have sometimes subsided so they are unable to detect the parasite, especially when people self-medicate before seeking professional help. The providers indicated that this makes it difficult for doctors to accurately diagnose and appropriately treat the disease.
“We are living in rural areas, and people over here suffer a lot, especially due to financial constraints, and if we get malaria, we have to go to the doctor two to three times, and that too does not help cure the patient, and within two to three months there is relapse.”– R8_FGD_OM_WKH
While PHCs were mentioned as the preferred choice for most participants, health personnel did indicate that community members also visit traditional healers for treatment. Only a few participants from WKH and WJH stated that they would seek malaria treatment from traditional healers. The reasons offered for seeking traditional healers' care included the perceived effectiveness of traditional healing methods, the limitations of modern medicine in certain scenarios, the (in) accessibility of healthcare services, and personal preferences. Traditional healers were often seen as providing quick care, and their services were said to be cheaper than those practicing modern medicine. The distance between someone's village and the nearest PHC was also reported to influence the preference for traditional treatment since traditional healers are often located within or near the community, making them more easily accessible. This reduces the cost of travel and waiting time that would be associated with visiting a PHC.
“I go wherever suits me because when I take allopathic (modern) medicine it is not effective. If I go to doctors, I’ll have to spend a lot of money in the medication. But when I go to traditional healers, the minimum charge will be hundred (Indian) rupees” – R10_FGD_YM_WJH
Participants from WKH shared experiences of what they termed 'yellow malaria' for which they not only depended on traditional medicine but also sought confirmation and diagnosis through medical tests at PHCs. These participants also expressed a willingness to combine both traditional healing practices and modern medicine for treatment because they valued the confirmation and diagnosis from modern medical professionals and were less confident in diagnosis by traditional healers alone.
“It ("yellow malaria") is similar to malaria but it affects a person differently, the person looks pale and the skin turns yellow and there is swelling. This is the effect of yellow malaria and we take medicines from the traditional healers, there are times where it does not help then we go to the hospital but there are also times when it does not help even after the treatment from hospitals so we go to the traditional healers. We also have to take serious precautions and visit the doctor for any illness and not only depend on the traditional healers.” – R7_FGD_YM_WKH
Some participants from WKH described that their primary reason for choosing traditional healers was a perceived lack of effectiveness of modern medicine. When individuals reported feeling that the medication prescribed by doctors was not helping them, they turned to traditional healing practices as an alternative solution. Further, there were instances reported where healthcare services were not readily available or accessible, such as when doctors were unavailable or when hospitals failed to respond adequately to the health needs of patients. In such situations, community members felt that they had no other option but to resort to traditional healing practices to address their health concerns. From the FGDs, the unavailability and inaccessibility of medical specialists contribute to the community members' reliance on traditional healing practices, which represents their only viable choice for treatment.
“Yes…..we do go, because when we suffer from fever. Let’s say its Monday. The doctor will not be there. At night even if we come looking for help at the hospital we won’t be receiving any. So there are traditional healers we used to go who give local (Dawai Khasi) medicine…I had malaria in the past and had taken modern medicine from a medical practitioner and I did not get cured; so I tried from the traditional healers and from that time I drank medicines from them. I drank medicines for three times and was cured and I feel I received help from them.” – R6_FGD_YM_WKH
Participants from WJH shared their experiences of shifting between modern medicine and traditional medicine when they do not get cured. In cases where modern medicine fails to provide their expected outcome(s), they turn to traditional medicine as an alternative. Participants from WJH reported using both traditional and modern medicines to treat malaria. They believe that using both types of medicine provides them with benefits, and some participants reported that they saw no reason to not use traditional medicine alongside modern medicine.
“Yes, we also take herbal medicines as it does not have any side effects and cause no harm if we take along with modern medicine” – R2_FGD_YM_WJH
In contrast participants from SGH district reported that community members have largely stopped seeking traditional healers' help for malaria treatment as their awareness of diagnostic tests, treatments, and services in PHCs or hospitals has increased. The availability of diagnostic tools, such as those used by the village ASHA and ANM in the health sub-centres, has contributed to the villagers' preference for seeking help from these healthcare providers.
Traditional healers from WJH and SGH shared their traditional practices for diagnosing and treating malaria. Briefly, they employ various methods of preparing medicines, use different types of remedies, and assess the perceived effectiveness based on the reported experiences of clients. A traditional healer from WJH described a practice specifically for treating malaria that has been passed down through generations in his family whereby he infuses a thread spun from fibres of a particular plant with oil, turmeric and garlic that the patient is instructed to wear.
A traditional healer from SGH provided insights into his practice and the preparation of his medicines according to the patient's specific ailment. He said gathering the required herbs is often time-consuming, as he needs a full day of travel to the forest to collect them. The healer acknowledged that not all patients will be cured by his treatments. He explained that the effectiveness of certain herbs depends on the individual's body, and that different patients may have different preferences for treatment, including seeking assistance from other traditional healers or opting for modern medicine. His treatment involves mixing herbs with warm water and instructing patients to drink the mixture. For headaches, he recommends the use of "Poron" which refers to ground herbs that are used as a poultice on the patient's head.
Attitudes towards government implemented malaria control interventions
This theme explored participants' perceptions and attitudes on the malaria control interventions implemented by the government (e.g., IRS and LLIN) and assessed their opinions on the effectiveness, accessibility, and overall quality of these interventions. Overall, the community members acknowledged a lower acceptance of IRS compared to LLINs which appeared to be attributable to perceived ineffectiveness and inconvenience of IRS.
About 601 participants across the districts felt that IRS acceptance was low. Key reasons that participants shared for low acceptance of IRS was the perceived temporary nature, as effects diminish over time, requiring repeated applications. Pregnant women were concerned about the potential effects of the insecticide on their health and the health of their unborn child. It was reported that the IRS solution had a strong odour and caused dizziness, especially for pregnant women and children. Some community members perceived IRS as making their houses dirty due to the residue left behind by the insecticide. Community members expressed feelings that the IRS solution was not prepared well and of the possibility that excess water was added, thus reducing its effectiveness.
Most participants across the districts were of the viewpoint that LLINs are more effective compared to IRS. This aligned with interviews with healthcare providers who also highlighted the benefits of government-distributed LLINs for the community members. Specifically, they mentioned that most villagers face financial constraints and cannot afford to purchase bed nets, particularly if they have large families. Further, LLINs were stated to be helpful during the summer season when individuals tend to sleep without covering themselves with blankets or shawls. Some of the participants indicated that bed nets help to protect not only from mosquitoes but also from other insects.
“Yes, what I believe is that the use of bed nets was of prime importance. Since they do not agree to spray on the areas that we want, it (IRS) is useless because they want to spray indoors when there are more mosquitoes around the pig sty....” – R3_FGD_OW_WJH
A few of the participants expressed that the number of bed nets provided to them was insufficient for big families. Affordability was also cited as a major challenge by the participants as well as healthcare providers, as families found it difficult to purchase extra bed nets beyond what the government supplied free of charge.
Personal malaria prevention practices
This theme focused on the individual behaviours and practices adopted by participants to prevent malaria both inside and outside their homes, as well as when they are working in their agricultural fields. It examines the range of preventive measures individuals employ to protect themselves from malaria. Participants reported that they use bed nets, mosquito repellents like coils, vaporisers and creams inside their homes, and they keep their windows and doors closed in the evening to help minimize the entry of mosquitoes into the house. Some participants also described keeping the veranda lights on, as they believe it reduces mosquito entry into the house.
“The first prevention measure is bed nets, the second is using smoke or repellents and the third is to leave the light open but in the fields, nothing can be done in the end the mosquito gets the advantage.” – R10_FGD_YM_WJH
Participants reported implementing personal preventive practices to reduce the risk of malaria transmission, especially outside their homes where there were fewer preventive options. Community members described burning leaves, straw, wood, egg trays, jute bags, and carton boxes outside their homes. They also reported boiling water before drinking it, and taking action to ensure proper drainage around their homes to prevent the accumulation of stagnant water.
The farmers involved in Jhum cultivation and forest dwelling participants reported increased risk of malaria due to their occupational and living conditions. Some participants also indicated that they would wear long overalls and apply oil when working in agricultural fields to prevent mosquito bites. However, some participants expressed concerns about the effectiveness of these personal protection measures.
“As farmers we cannot escape our work and will have to work day and night, we will have to bear mosquitoes bite that is the main reason we become ill.” – R10_FGD_YM_WKH
Additionally, some community members practiced self-treatment using readily available medications such as paracetamol, which can be obtained from local shops without a prescription. Participants shared that they practiced home remedies and self-medication whenever they started to experience symptoms of malaria because it is less expensive and easily available. Participants shared that they prefer self-medication as it saves travel time to the health centre and avoids losing time at work, as most are daily labourers.
Other practices reported include using steam inhalation from lemon leaves, bamboo leaves, and yam stems; drinking lemon water with honey for symptom relief; and applying oil or honey on the body to keep warm during chill episodes.
Cultural beliefs and perceptions of good health
During the FGDs, participants provided an overview of their understanding and perceptions of what they considered to be 'good health.' Many participants started with comments on physical health and the absence of illness but then went on to include a more holistic state of being that included various aspects of a person's life. As the conversations progressed, some participants delved into the cultural beliefs and practices related to health that prevail in their communities.
Participants shared how they and their fellow community members relied on local beliefs and performed specific rituals to treat health ailments. They explained, however, that attitudes and practices towards malaria have changed over the past decade. For example, there was a time when villagers did not know about cerebral malaria (referred to as ‘brain disease’ in WKH), and assumed that it was mental illness caused by evil spirits. After seeking bedical diagnosis and treatment from healthcare professionals, they accepted that this was a more severe type of malaria with the same underlying cause. With the passage of time and changes in the community's attitude and healthcare seeking behaviour, certain cultural practices regarding malaria have also changed. Of note, some community members still seek help from traditional healers depending on the ailment, even though most of the community members have largely shifted to modern medicine for treatment of malaria.
Some participants, particularly older men, mentioned rituals that were performed by their ancestors. One such ritual involved sacrificing a rooster and using eggs for health prediction(s). These rituals were believed to have a connection with health and were performed as a means of understanding and addressing illnesses, including malaria.
“When we talk about the disease, there are many types of diseases because there is this new disease that has the same symptoms as malaria, but this new disease "ngi phet biej" (literal translation in English could mean being in the wrong state of mind), so that’s why we need to go to the doctor. Many of the people out here, when they have this fever and cold, they usually "kren biej" (speak nonsense), so they thought it was due to witchcraft done by someone, because this type of disease affects the brain. But when they visited the doctor, they said... It is a disease of the brain. There are many people who get this brain disease. Oh… I remember it’s the brain malaria that the doctor mentioned...” – R8_FGD_OM_WKH
Participants and respondents placed significant emphasis on physical well-being as a primary indicator of health. Overall, their perspectives on physical health encompassed aspects such as physical fitness, freedom from illness, cleanliness, healthy habits, and socioeconomic implications. The participants considered physical fitness and freedom from illness as essential attributes of a healthy individual. They associated good health with the ability to perform daily tasks effectively, suggesting a positive correlation between physical well-being and productivity.
“Well Kong [common local name often referring to a woman], according to me if a person does not exercise or do any physical activity he/she will not be healthy. Even if they do not eat good food or maintain a good diet they will not be healthy” –R2_FGD_YW_WJH
The participant discussions emphasized the value of cleanliness, both at the household and locality levels, in maintaining good health. Clean surroundings and personal hygiene were viewed as essential factors for preventing diseases and promoting well-being. Many participants acknowledged the importance of healthy habits such as good diet, getting proper sleep, taking regular rest, and engaging in physical exercise. These behaviours were seen as crucial for preventing the need for frequent visits to healthcare facilities and expenditures on medication. The community members recognized a link between physical health and socioeconomic well-being. A healthy person was perceived as someone who could work, earn a living, and fulfil their familial responsibilities.
“Health is maintaining cleanliness, keeping our body clean, keeping our surroundings clean”. -R3_FGD_Women_SGH
The participants also spoke of the connections and interactions that individuals have with each other and with their communities, and the importance of social exchange and community involvement for overall well-being. Discussions included emphasis on the importance of the quality of relationships, social support networks, and the sense of belonging. The FGDs reflected participants' understanding of the socially interconnected nature of health. By acknowledging the social aspects of health, the participants highlighted the role of community and social relationships in promoting and maintaining overall health and enhancing their quality of life. The participants emphasized that socializing and engaging with others in the community positively impacts a person's well-being. Examples of community support and helping one another were shared, highlighting the mutual assistance and sense of belonging that contribute to well-being. Some participants explicitly recognized the interrelationships between physical, social, and mental aspects of health. They understood and articulated that when a person is physically fit and free from stress or tension, their ability to interact effectively within the community is enhanced. Good health was seen and explained as a foundation for maintaining communication and relationships with family, friends, and neighbours. Moreover, the participants acknowledged that being healthy enables individuals to actively contribute to society.
“We also need to have a good relation with our family members, neighbours, and friends because if we don’t get along with our friends, neighbours and families then we don’t feel good and our mind is also not at ease. So to have a good health we need to be aware and take care of ourselves” - IDI_CHV_051_SGH
Mental health, which involves an individual's psychological and emotional well-being, was recognized by some participants as affecting physical health, social relationships, and community engagement. The participants acknowledged that mental health has a profound influence in every aspect of a person's life and recognized that mental well-being can affect physical abilities, social interactions, and the overall functioning of a person. The discussions highlighted the participants' understanding that an individual's ability to engage in social relationships and community life can be disrupted if they do not have a clear and healthy mind. The participants expressed their belief that meeting people every day and engaging in social interactions is beneficial for mental health. They recognized the positive impact of socialization and specifically indicated that it provides opportunities for connection, support, and the exchange of ideas.
“Health is very important because we usually think that health is about being free from diseases but is also about having a healthy mind which is also very important.” R1_FGD_OW_WJH