J Arthropod-Borne Dis, March 2019, 13(1): 94–103 K Soofi et al.: The Challenges of …

Original Article The Challenges of the Malaria Elimination Program in the South East of , a Qualitative Study

Khodamorad Soofi1; *Narges Khanjani2; Fatemeh Kamiabi3

1Department of Epidemiology and Biostatistics, Faculty of Health, Kerman University of Medical Sciences, Kerman, Iran 2Research Center for Environmental Health Engineering, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran 3Department of Environmental Health and Medical Entomology, Faculty of Health, Kerman University of Medical Sciences, Kerman, Iran

(Received 2 Nov 2015; accepted 30 Jan 2019)

Abstract Background: Despite all the efforts made to control and eliminate malaria in Iran, this disease is still considered as a priority health problem in the South East of Iran. We aimed to determine the cultural obstacles which have prevented the elimination of malaria in this region. Method: This study was carried out through qualitative content analysis. Purposeful sampling was done from people who had malaria or were involved with malaria patients in 2015, in City, Sistan and Baluchestan Province, Eastern Iran. Data were collected through interviews using open ques- tions and continued until data saturation. Results: The most important barriers in malaria prevention was delay in visiting health centers, delay in diagnosis and treatment due to superstitious beliefs, lack of information about the disease, misdiagnosis and fake doctors. Other obstacles were lack of trust and cooperation with interventions offered by the health system, lack of proper use of the available facilities to prevent malaria and commuting in the high-risk neighbor countries. Conclusion: Raising awareness in people, officials and health workers about malaria and preventive health interven- tions as well as health risks associated with fake doctors, following up and re-examination of peripheral blood smear in suspected cases, establishing malaria control stations in border areas and specific measures to refer immigrants and people crossing the border toward malaria diagnosis stations is suggested.

Keywords: Malaria; Elimination; Challenge; Iran

Introduction

Overall, 212 million cases of malaria and reported in Iran and the incidence of this dis- 429 thousand deaths due to malaria have been ease was 0.2 per thousand people (3) and about reported around the world (1). Currently, about 95% of the cases had been reported from three 40% of the world's population who live in low- provinces, including Sistan and Baluchestan, income countries are at risk of malaria. Alt- Kerman and Hormozgan (4). hough the disease has existed in many parts of Environmental, climatologic, economic, so- the world, today it is mainly found in tropical cial and cultural conditions and also the prov- and subtropical countries and 90% of these ince's shared border with Afghanistan and Pa- cases are in poor African countries (2). kistan and illegal immigration seem to play Iran had 799 microscopic confirmed cases an important role in the high number of malar- that means the total number of cases were 799 ia cases in this province. This province has and 166 cases were local or autochthonous 1265km shared border with Afghanistan and cases (1). In 2006, 15896 cases of malaria were Pakistan (5). The south and southeast area of 94 *Corresponding author: Dr Narges Khanjani, E- http://jad.tums.ac.ir

mail: [email protected] Published Online: April 27, 2019

J Arthropod-Borne Dis, March 2019, 13(1): 94–103 K Soofi et al.: The Challenges of …

Iran is still a troubled region in terms of ma- uously and roles should be defined beforehand laria and it is not comparable with any other (8). In Peru, malaria was believed to be em- part of the country based on social, develop- bedded within their culture and people blamed mental, economic, cultural, and geographical this for lack of attention to prevention. People conditions. These areas are socially similar thought malaria prevention was their govern- to underdeveloped and deprived areas (3). ment's responsibility not their own. The other In recent years, there has been a lot of ef- barriers to malaria prevention were people not fort to control and eliminate malaria at glob- using bed nets at the right time, not knowing al level by interrupting the cycle of disease the purpose of space spraying and misconcep- transmission. The World Health Forum iden- tions about the cause and prevention of ma- tified a 15yr framework for all countries that laria (9). Some mothers in Gabon preferred to work on malaria control and elimination in consult a Nganga (traditional healer) and not a 2015 and called for the elimination of ma- physician for their children’s malicious fever laria in at least 10 countries by 2020, 20 coun- and thought it was supernatural (10). tries by 2025, and 35 countries by 2030. Less This qualitative study was carried out to than half of the 91 malaria-prone countries identify the challenges to control and eliminate are on track to achieve the 2020 goals of the malaria in the south-east of Iran. WHO (1). There is a risk of relapse or re- emergence of malaria in cleared areas and Materials and Methods even epidemics in malarious areas of Iran (6). Now, local distribution and transmission This research was a qualitative content anal- of the disease in Iran have been limited to ysis study conducted in 2015. Participants were the provinces of Sistan and Baluchistan, Hor- purposefully selected from co-operative ma- mozgan and Kerman. The ultimate goal of the laria patients and medical doctors willing to malaria elimination program in the horizon of share their experiences and beliefs with re- 2025 is to stop local transmission of the dis- searchers. Informed consent was taken from ease. Sarbaz City with Annual Parasite Inci- them before the study. Malaria patients were dence (API) equal to 4.5per ten thousand peo- selected from the list of diagnosed malaria cases ple in 2015 is a candidate for intensified ma- that were under treatment. Most of these pa- laria control operations (7). tients were from Sarbaz City. Sampling con- About 10% of local (autochthonous) ma- tinued until data saturation was achieved. laria cases in 2015 were from Sarbaz City, Sarbaz City is located in Sistan and Ba- which is one of the active foci of malaria in luchestan Province and because of its high ma- the south-east of Iran. Therefore, there are a laria incidence was a suitable place for doing series of cultural and social barriers that de- this research. The county has 121km common spite all efforts to control and eliminate ma- border with Pakistan and the farthest point is laria, this disease is still an important health about 250km away from the border. There is problem in the South East of Iran. no permanent river in this city but suitable lar- Although some qualitative studies have val habitats are present. The surrounding moun- been conducted about malaria control in world tains make access to health services difficult countries, no such study has been conducted in for rural people who are 92% of the residents. Iran, yet. A qualitative study about malaria pre- Interviews were conducted after partici- vention in Gambia suggested control programs pants' consent. The interviews were recorded should be conducted at the right time, the tar- and then transcribed. Interviews were done if get population should be properly educated, necessary in local language (Baluchi) and sensitization meetings should be held contin- then translated. The average duration of the 95 http://jad.tums.ac.ir

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interviews was 45 to 60min. The questions turned white, I felt I was haunted, they took were semi-structured. The interviewer attempt- me to the Mullah …” ed to understand the experience, views, and beliefs of the interviewees. During the inter- B. Lack of information about the disease views, a better understanding of the situation Most patients did not have enough infor- was achieved and some more questions were mation about malaria, its contagiousness, and added to the interviews. Interviews were con- prevention to avoid being infected or seek ducted until data saturation was achieved. treatment on time. One patient said: “... First, when a headache and fever start- Results ed I felt I have a cold, but later when I took the test they said I got malaria! I don't know Seventeen malaria patients and two med- how I got malaria?! How should I know that ical doctors were enrolled. Six of the patients a mosquito bite can cause malaria?! ...” were drivers who worked across the Iran- Another patient said: “... I went to Pakistan Pakistan border (Table 1). and it was very hot there and I was heatstroke The data about the challenges of the ma- … I don’t know how I got malaria when my laria elimination program were classified into fever and headache began, I thought it was 4 main groups of concepts. icter [liver disease] …” Many patients felt that there is no serious Concept 1: Lack of on-time referral to health problem and the disease will get better on its services and delays in diagnosis and treatment own and ignored it, tried home remedies and can be due to several reasons: did not see a doctor which led to delayed di- agnosis and treatment. For example, a moth- A. Superstitious beliefs er whose child was sick said: Superstitious beliefs are one of the most “… First, we gave him a syrup and thought important factors that prevent patients from he will get better, after one week still he did visiting health care services and therefore by not feel better, … later we took him to a doc- causing delay in diagnosis and treatment lead tor …”. to persistence and transmission of the disease. Another patient said: “… When my fever One of the malaria patients confessed that when started I thought it is a usual fever and I took she was very ill and unconscious instead of tak- fever pills”. ing her to a doctor, her relatives burned Espand Some of the men said they thought they for her and thought she was stricken by the evil do not need to visit health centers and health eye. Burning Espand (a desert plant) is be- centers are for women, and unless they feel lieved to prevent the evil eye in superstitions. really bad or are under pressure from their “… I was fine, someone cast an evil eye families they would not visit the health cen- on me, my daughter in law burned Espand for ters. This ignorance makes the disease worse, me, but I didn't get better …” causes delayed diagnosis and treatment, leads Some patients especially Falciparum cas- to persistence of infection in the area and may es (the researcher knew the parasite type from even cause the patient's death. For example, the lab result), after showing severe malaria one of the people said: symptoms, believed that they were haunted by “Here, men do not visit the health centers elfs or nasty spirits and needed to see pray unless they really felt bad… when I had a fe- drafters, local witches, or religious figures to ver, I didn’t go to the doctor right away, alt- exorcize the evil spirits. One patient said: hough my family insisted… on the fourth “... I was shivering, I felt bad, my eyes day, I felt really bad and my family urged me 96 http://jad.tums.ac.ir

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to go to the clinic …” serious and therefore lead to more delayed di- Also by observing the patients living con- agnosis and more time for disease transmission ditions, the researchers realized that the peo- in the area. A patient said: ple living in this area and especially their “... I went to the clinic because of my weak- men are very tough and tolerating. They have ness and abdominal pain, but the doctor did not grown up in harsh conditions and won't take a even get suspicious that it was malaria and fever serious unless they are well informed he just gave me a shot and a serum …” about the dangers of malaria. Or another patient said: “I had fever for 4 days, the first day I went to the clinic and C. Fake doctors they took a blood sample and said you do not Another reason people do not visit the have malaria and on the fourth day because I health care centers is their trust in the fake got worse I went to the clinic again and they doctors known as Bengali doctors. Fake doc- took another blood sample and diagnosed that it tors are fraudulent people who have no aca- was … malaria and I was taken to the hospi- demic degree and attempt to cure patients for tal by an ambulance …” money. They are an important threat to public health in this region. A third of the patients Concept 2: Lack of trust in interventions that we spoke with had initially visited a fake done by the health system doctor and then after getting a series of med- Many patients said they did not believe the ications and not recovering and feeling worse, interventions done by the health care system eventually visited the health centers. work. For example, one of the health interven- “The second day because I felt so much tions done in the malaria-prone areas is indoor worse I went to the Bengali doctor, he gave me residual spraying. In order to prevent malaria, two injections, but I didn’t get better, on the people have to believe that this method works fourth day because I got worse my family in- and allow proper spraying to be done. But most sisted that I should go to the health center …” patients were not fully aware of its effects and The mother of a sick child said: "First thing, considered it useless and futile and were re- I took my baby to a Bengali doctor and he gave luctant to cooperate with the healthcare offic- him medicine. He took the medicine for two ers. They thought the pesticides are ineffective days but he did not get better …” and the workers who do the job do not have the Two of the doctors working in Sarbaz passion and commitment. Sometimes due to City also believed that the presence of Ben- the frustration of repeated pesticide spraying, gali doctors is a threat to public health and hot weather, the trouble of unloading home complained about the wrong treatments, fake appliances, ruining paint and … people are and illicit medications and other harmful reluctant to cooperate. Comments of some treatments. patients were as follows: “We spray to kill mosquitoes, but the in- D. False diagnoses secticides don't work.” Sometimes, despite the onset of symptoms, “... Sometimes we don't feel like spraying, due to general and non-specific symptoms of because it is hot and unloading the house is the disease, low number of parasites in blood hard …” samples, lab mistakes, and non-native doctors’ “... we did spray insecticides but we did that are not aware of the common diseases in not see any benefit, the insecticides don't kill the area, early diagnosis of malaria is delayed. anything since there is dust, spraying becomes A false diagnosis may also keep a patient con- ineffective ...” fident for a long time that his disease is not Another patient had a strange thought and 97 http://jad.tums.ac.ir

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said: “… spraying insecticides are useless, the them. It is not enough, for 6 people we only workers don't spray well … some workers take have one net, if the air conditioning is on, we [steal] the insecticides. They spray water, if don’t use it …” they did spray insecticides well, mosquitos But according to the participant's comments, would get killed”. even in households where there are enough bed nets, they might not be used properly: Concept 3: Improper use of the available “… We are 7 people and we have 4-bed facilities to prevent malaria nets, but only 2 or 3 of us use them …” One of the ways for preventing malaria in Participants also mentioned other reasons the area covered by Sarbaz City health sys- for not using mosquito nets at the beginning tem is the use of insecticide-treated bed nets. of night and one was the disturbance of live- However, they are not used and appreciated by stock. the residents for various reasons. People might “... If we use them at the beginning of the use this protective tool only when electricity is night, the goats will tear them apart …” gone, they have no appropriate cooling system, Moreover, sometimes the mosquito nets or when they rest in the yard. For example, they use are defective and there is a risk of one of the patients stated: mosquito bites. “... When electricity is available and air “… We have bed nets but they have been conditioning is on we do not use bed nets; we torn apart …” only use them when power is cut off or when These statements can confirm that people we are sleeping in the yard…” have not been well educated about how to The small number of people who use the properly use and take care of their nets. net, do this in order to get rid of annoying In addition, in order for spraying to be ef- insect bites rather than the prevention of ma- ficient, it should be done in accordance with laria. For example, one of the people said: correct principles to have a good performance. “... If we don't use bed nets mosquitos do But people do not allow their houses to be not let us sleep …” sprayed for different reasons and they rely on It was understood from the statements of spraying their non-residential premises. the participants that even this limited use was “… If they come for spraying we will let not done correctly either. The common time them spray the outdoors, there is no need to to use mosquito nets in this area is usually af- spray the indoors…” ter the evening prayers, after having dinner and bedtime, while the Anopheles mosquitoes Concept 4: Traveling to high-risk countries are active from sunset and there is a possibil- People in this area travel to Pakistan for ity to get bitten before the time that they ac- various reasons, such as treatment of illness- tually use their nets. Patients commented that: es, seeing their relatives, occupation (such as “... We have bed nets and we use them truck driver), and trade, and become infected when we are going to sleep. We cannot use by malaria there. Most of the interviewed pa- them from the beginning of night …” tients had a history of traveling to Pakistan. Moreover, in some households, there are "... I went to Pakistan for 20 days, I am a not enough bed nets and everyone cannot sleep truck driver and I always travel between Iran under the mosquito net. and Pakistan”. “… We have bed nets but it is not enough “… I am a cross-border driver and I usu- for 4 adults, only little kids sleep under a mos- ally travel to Pakistan, I think I was infected quito net ...” in Pakistan because there was no malaria in “… We have bed nets but we don’t use our village…” 98 http://jad.tums.ac.ir

Published Online: April 27, 2019 J Arthropod-Borne Dis, March 2019, 13(1): 94–103 K Soofi et al.: The Challenges of …

"... I traveled to Pakistan and stayed for a came back to Iran and after 5 nights my fe- month and a mild fever began there, then I ver and chills worsened…”

Table 1. Some characteristics of the malaria patients participating in this study

Gender Education Job Male Female Illiterate Elementary High Truck Housewife Farmer Unemployed Labor School School Driver Worker 12 5 7 5 5 6 4 2 3 2

Discussion

One way to prevent malaria and reduce the also mentioned in the case-control study in risk of death in patients with this disease is ear- City in which the education level ly detection and proper treatment (11-13). One of the control group was higher than the pa- of the expected outcomes of the malaria elim- tients with malaria (18). In southern Iran, a ination program for 2025 is diagnosis in less direct relationship was found between the than 24h after the onset of symptoms and start- level of education and people's preparedness ing the treatment within 24h after diagnosis (7). to participate in the malaria control programs Our study showed that social and cultural on a voluntary basis (19). factors are among the factors that have led to High literacy levels through increased peo- malaria elimination failure in the South-East ple's participation in malaria control programs, of Iran. Lack of adequate information about the use of protective equipment, child care, disease disease, superstitious beliefs and prejudices, not knowledge and appropriate job and housing taking the disease and its treatment serious, vis- safety can be effective in controlling malaria iting fake doctors and incorrect diagnoses are (18). Implementation of educational interven- among the factors that have led to late diagno- tion programs can increase knowledge, attitude sis and treatment and eventually longer oppor- and the practice of preventing malaria in the tunities for disease transmission and its persis- society (20). The reduced incidence of malaria tence in the region. had taken place for reasons such as an increase The role of social factors such as employ- in knowledge, attitude and proper performance ment status and location of residence in the of people (21). Therefore it seems necessary to persistence of malaria in the South East of plan to increase awareness in the health per- Iran, has been discussed in previous studies sonnel, public and authorities by local facili- (14). In Ghana, the economic and social situ- ties and also take the necessary measures to ation was significantly related to malaria identify arrest and punish fake doctors who are (15). In Gambia, social factors such as low- a threat to public health and take advantage of quality housing were related to malaria (16). In people nescience to earn money. Minab, Jask and Roudan in Hormozgan Prov- The low number of parasite in peripheral ince, Iran; a significant relationship between blood is one of the most important problems social factors such as illiteracy and distance and challenges in the malaria elimination pro- from health facilities and the incidence of ma- gram. A negative blood smear does not mean laria was observed (17). the patient does not have malaria. Therefore, Cultural problems such as the low rate of whenever a person is suspected of having ma- literacy and health education have had a role in laria but the blood test is negative, his test the incidence of malaria in Iran (12). This was should be repeated in the next few days (13) 99 http://jad.tums.ac.ir

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rather than assuring the patient that he does laria vectors including Anopheles Stephensi and not have malaria. An. Culicifacies that have endophilic (rest in- Lack of people's trust in the interventions doors) and endophagous (feed indoors) tenden- done by the health system is another challenge cies (27). facing malaria elimination programs. Indoor Improper use of the existing facilities, de- residual spraying and bed net distribution are spite the high cost and financial burden that it among the preventive interventions performed has for the health system, is among the barri- by the Health Network. Although many people ers of prevention and eliminating malaria. Sev- are acquainted with spraying and bed nets, in eral studies have considered using bed nets and practice, the results of our study and other re- spraying, effective to control and prevent ma- search show that we are still far away from laria (12, 18) and the use of treated bed nets as the appropriate use of these preventive inter- one of the most promising tools for malaria con- ventions (12, 22, 23). trol in most parts of the world (14). However, In this study, some patients commented that misuse of for example window fly screens in- the insecticides were not effective. Studies have creases the risk of malaria even up to 5 times reported mosquito resistance to insecticides as (17). The proper use of mosquito nets especial- well (24-26). In order to prevent mosquitoes ly the treated ones requires continuous train- from developing tolerance, the type of insec- ing to ensure the correct use by the majority of ticide is changed periodically (23). On the other people (18). side, health authorities try to use insecticides Diverting mosquitoes from humans to an- that have the least danger for humans. These imals reduces the mosquito-human contact and insecticides might not kill the mosquito imme- has a protective role (12) but in case of incom- diately, but decrease the mosquito's lifetime and plete and inaccurate spraying, or only spraying therefore prevent the transmission of disease. outside places and leaving the indoors intact, However local people expect not to see any in- it will divert the mosquitoes to indoor spaces sects at all after spraying and therefore might (13). In order to just satisfy the health authori- think the insecticides are not effective. ties, some people allow pesticide spraying in The results of this study indicate the lack areas such as baths, toilets, animal barns and of willingness and cooperation of people for other places. Spraying these places alone can indoor spraying which is the main obstacle divert mosquitoes into the residential build- against the success of malaria elimination pro- ings and people's sleeping places and there- grams (12). In Iranshahr, only 30% of high- fore trouble malaria control programs. risk places were sprayed by insecticides and the If the spraying is done properly in place, reason was residents’ noncooperation despite the abundance of vectors is reduced (28, 29). the fact that most people knew residual spray- One of the main features of successful spray- ing was an effective method in reducing ma- ing is its comprehensiveness (spraying at-least laria transmission. Although more than 95% 70% of all places in the foci), completeness of Iranians and 90% of Afghan participants (covering all eligible surfaces) and sufficien- knew that spraying, drying swamps and us- cy (using the necessary amount of insecticide ing bed nets prevent malaria but only 24% of on surfaces) and repetition at regular intervals participants used mosquito nets and about 90 (13). % of Afghans and 62% of Iranians did not use Another challenge for southeastern Iran's nets, 77.7% of the participants slept inside and malaria elimination program is its shared bor- 64.9% of Iranians did not use flyscreens' for ders with high-risk countries. This province has windows (22). This is despite the fact that in 1265km of shared border with Pakistan and Af- Sistan and Baluchestan there are two major ma- ghanistan in which legal and illegal movement 100 http://jad.tums.ac.ir

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of people takes place. Among illegal commut- as insecticide spraying, mosquito nets, etc., and ers, no supervision or control in regard to their establishing portable sites for rapid diagnosis health status is imposed. Many studies have of malaria in border areas, is necessary. Em- been performed on traveling and migrating be- phasis on cross-sectoral and inter-sectoral co- tween malaria-infected centers and its role in operation, to attract more local health officers malaria transmission. For example, traveling who are familiar with the customs and common during the last one month before illness was diseases in the region, and planning long-term among the factors that increase one's risk of educational programs, is also suggested. getting malaria and people with a history of Moreover, in order to raise awareness travel during the last month had a 21 times among health professionals, local people and higher chance of being infected in comparison officials; local media, health networking, and to others. Chabahar a city near the Pakistan bor- the influence of religious leaders should also der has been introduced as one of the important be incorporated. Holding training sessions in foci of malaria transmission (18). Moreover, accordance with the culture, to increase public in the United Arabic Emirates, most malaria awareness and participation; and penalizing cases were Pakistani immigrants (30). fake doctors who sometimes have the sup- Newly arrived immigrants with less than port of local people and local authorities is three months of residence in Iran had a signif- also necessary. icantly higher incidence of malaria than the ones with more than 3 months of residence Acknowledgements (31). The presence of foreigners in this city in

2008, in addition to increasing the number of The authors appreciate the cooperation of malaria cases, has led to changes in malaria the Sarbaz County Health staff, as well as the foci (32) and people traveling from endemic patients who participated in this study. to non- endemic areas had a great role in the The authors declare that there is no con- outbreak of malaria (33). The important role flict of interests. of migrants in the transmission and outbreak of malaria has been studied by other researchers (34, 35). In Sarbaz County in the former cross- References ing point, a Malaria Passive Post or RDT (Rapid Diagnosis Test) Passive Post was es- 1. World Health Organization (2016) World tablished to discover malaria cases. However, Malaria Report. World Health Organiza- real success is achieved when all local people tion, Geneva, Switzerland. Available at: and officials understand the importance of ma- http://www.who.int/gho/malaria/epide laria and cooperate. In addition, since most mic/cases/en/ (accessed on 10 February commuting occurs in other parts of this county 2018). (such as Hong, Mortan, Kastag, Kozour, 2. World Health Organization (2012) World Eshkastag, and Ashar) which is illegal and un- Malaria Report. World Health Organi- controlled, planning to put these areas under zation, Geneva, Switzerland. Available at: surveillance seems necessary. http://www.who.int/gho/malaria/epide mic/cases/en/ (accessed on 27 Septem- Conclusion ber 2014). 3. Holakouie Naieni K, Nadim A, Moradi G,

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