A mixed methods study on health-seeking behaviors in a malaria endemic district in Lao People's Democratic Republic

概要

Background
　In the Greater Mekong Subregion (GMS) including Lao People’s Democratic Republic (PDR), the emergence of artemisinin-resistant Plasmodium falciparum malaria parasites threatens to reverse the gains made after the failure of the global eradication campaign. In response to this threat, the GMS countries aim to eliminate malaria from the GMS by 2030. Talks of global malaria eradication by 2050 have also resurfaced. Considering this ambitious goal, studies using social medicine approaches could synergize the elimination efforts to accelerate progress towards the goal. I conducted this study to provide evidence which will accelerate the progress towards malaria elimination in Lao PDR as well as the GMS. This thesis comprises four parts. The objective for each part is as follows:
　1) To identify the major clinical manifestations of glucose-6-phosphate dehydrogenase (G6PD) deficiency in the GMS.
　2) To find the prevalence of G6PD Viangchan variant in Lao PDR.
　3) To analyze the progress in malaria research and to identify existing research gaps.
　4) To explore the health-seeking behaviors of the villagers and the perceptions of the healthcare workers in Buttaphan and Napasad villages in Thapangthong district, Savannakhet Province, Lao PDR.

Methods
　In Part 1, I conducted a systematic review to identify the major clinical manifestations of G6PD deficiency in the GMS. I systematically searched for original research of all study designs that reported the clinical symptoms of G6PD deficiency in the GMS.
　In Part 2, I conducted a genetic analysis to find the prevalence of G6PD Viangchan variant in Lao PDR. I collected 2043 blood samples from Phongsaly, Savannakhet, and Champasak provinces in Lao PDR and sequenced exon 9 of the G6PD gene to detect G6PD Viangchan mutation.
　In Part 3, I conducted a scoping review to analyze the progress in malaria research and to identify existing research gaps.
　In Part 4, I conducted a convergent mixed methods study in Buttaphan and Napasad villages in Thapangthong district, Savannakhet Province, Lao PDR. In the quantitative part of Part 4, I used a pretested questionnaire which consisted of seven parts: health-seeking behaviors, knowledge on malaria and modern medicine, perceived susceptibility, perceived benefits, self-efficacy, clinical vignettes, and socioeconomic characteristics. I collected data from 313 villagers from the two villages in the quantitative part. In the qualitative part, I conducted ten focus group discussions among villagers and seven in-depth interviews among healthcare workers. I conducted multiple logistic regressions to identify the factors associated with individual beliefs. I used thematic analysis to obtain the qualitative results and combined the quantitative and qualitative results in joint displays to arrive at a deeper understanding of the health- seeking behaviors in the mixed methods part.

Results
　In Part 1, I found that in addition to the major clinical manifestations of G6PD deficiency such as hemolytic anemia and hemoglobinurea, G6PD deficiency also affected the clinical presentations of infectious diseases such as typhoid fever and dengue fever, which are common in this region.
　In Part 2, the prevalence of G6PD Viangchan variant ranges from 1%-12% in villages in Savannakhet and Champasak provinces, but I did not find any G6PD Viangchan variant in Phongsaly province.
　In Part 3, I found that although we have made so much gains in malaria elimination, there was still a lack of human-centered research focusing on vulnerable populations such as those living in malaria endemic areas of Lao PDR.
　In Part 4, the quantitative result revealed that 256 out of 313 villagers (81.8%) responded that they would first go to the health center or the district hospital to seek treatment whenever someone in the family was sick. Regarding the knowledge on malaria, some villagers attributed the cause of malaria to something else other than mosquito bites such as drinking dirty water (Buttaphan, 14.9%; Napasad, 24.3%). In the clinical vignettes, more than 90% of villagers in both villages mentioned that they would go to the public healthcare workers such as the village health volunteer, nurse at the health center, or nurse or doctor at the district hospital immediately for conditions such as hemolytic anemia, malaria, tuberculosis, acute respiratory infection, or diarrhea.
　Qualitative data revealed that the villagers faced problems such as lack of medicines and medical equipment. Despite this, the villagers still preferred to seek treatment at the health center as the National Health Insurance (“Kor Por Sor”) was introduced. In the focus group discussions, some villagers still attributed the cause of malaria to drinking dirty water or evil spirits. Moreover, the healthcare workers also mentioned that they would like to receive more training to improve their skills. When both quantitative data and qualitative data were combined in a joint display, I obtained a more comprehensive interpretation of the situation. Although going to the public healthcare workers was the first choice in many situations such as malaria and other illnesses such as acute respiratory infection or diarrhea, the evidence from the qualitative data showed that the current situation should be further improved if the high usage was to be maintained.

Conclusions
　Malaria elimination is a complicated process that transcends the provision of antimalarials and insecticides. In the case of primaquine, drug safety and adverse effects for people with G6PD deficiency must be seriously considered. In Lao PDR, the village health centers are not adequately equipped to handle complications from primaquine toxicity such as hemolysis. This points to the need to improve the quality at the village health centers throughout Lao PDR in order to prevent the unnecessary loss of life.
　The usage of public health facilities in this study was high due to the introduction of the National Health Insurance (“Kor Por Sor”). However, high usage by the villagers alone is not enough to achieve the elimination goal. In addition, in the qualitative part, both the villagers and healthcare providers expressed dissatisfaction with and the desire to improve the quality of the public healthcare facilities. Therefore, it is essential to improve the quality of the healthcare services such as providing more training to the staff and supplying enough medicines and equipment.
　Although malaria is endemic in this district, many villagers in this study did not understand the basic transmission route of malaria. Moreover, many villagers still described common illnesses using local terminologies and beliefs. Having knowledge will not necessarily result in the desired outcome, however, having knowledge on malaria could enable the villagers to make a better decision in protecting themselves from malaria. Hence, suitable education materials and campaigns conforming with the local contexts should be conducted in these villages to equip the villagers with the necessary knowledge to protect themselves from malaria. This is an important step towards achieving the malaria elimination goal.
　In conclusion, public health facility usage was very high but barriers such as lack of medicines and medical equipment existed. Malaria elimination is not impossible, and effective policies and enabling environments such as the introduction of the National Health Insurance (“Kor Por Sor”) could help accelerate the progress towards the malaria elimination goal. Moreover, the benefits of introducing effective policies and enabling environments could go beyond the context of malaria.