Malaria Self-care, Province,

MALARIA SELF-CARE IN NIMBORAN SUBDISTRICT, JAYAPURA DISTRICT, PAPUA PROVINCE, INDONESIA

Betty Roosihermiatie1, Widjiartini1, Astridya Paramita1, Agung Nugroho2 and Agus Suprapto1

1Center of Research and Development for Humaniora and Health Management, National Institute of Health Research and Development, East ; 2East Java Province Health Office, Surabaya, East Java, Indonesia

Abstract. Papua is one of five provinces with high malaria incidence in Indone- sia. In 2009, the Indonesian Ministry of Health issued decree No 293 on malaria elimination. Socioeconomic, culture and psychological conditions, and perception of malaria are determining factors in seeking treatment. Health seeking behavior also are influenced by enabling factors, such as income and health insurance; and by health providers, such as availability of health care facilities, tariffs and living locationss. Self-care is one form of community participation in knowledge, prevention and early detection of malaria, and in seeking treatment and com- pliance to malaria treatment, especially among inhabitants in malaria endemic areas. This study was an observation in Nimboran Subdistrict, Jayapura District, Papua Province, Indonesia during 2013. Thirty individuals from ‘Pengurus Ru- kun Tetangga’ group were chosen randomly for the survey. Facts evaluated were knowledge of cause of malaria, disease transmission, symptoms and complication, diagnosis, treatment and side effects, medical seeking behavior and treatment, vector breeding sites, and attitude towards compliance of malaria treatment and use of mosquito nets. Self-care against malaria was considered important by 65% of the respondents. All participants had visited health centers and complied with prescribed drug regimen. All respondents with malaria-infected neighbors visited health centers. Regarding antimalarial malaria drugs, the majority of respondents knew of Darplex® and were aware that a common side effect of antimalarials was tinnitus. The majority of respondents identified ponds as malaria vector breeding places and recognized the importance of managing vectors in malaria prevention. The study concludes that malaria self-care was needed for awareness, prevention and treatment of this debilitating disease. Keywords: malaria awareness, malaria prevention, self-care, Indonesia

INTRODUCTION Correspondence: Betty Roosihermiatie, Cen- ter for Humaniora and Health Management, Indonesia still faces problems of ma- National Institute of Health Research and De- laria. It is one of three Asean Economic velopment, Jalan Indrapura No. 17, Surabaya, Community (AEC) countries, among 60176, East Java, Indonesia. Myanmar and , with high con- Tel: + 6231 3528748; Fax: + 6231 3528749 firmed malaria cases (Bhatia et al, 2013). E-mail: [email protected] Indonesia had 396 (80%) of 495 districts

Vol 48 No. 1 January 2017 1 Southeast Asian J Trop Med Public Health and cities with malaria outbreaks in 2007 seeking behavior is influenced by enabling (Department of Health Indonesia, 2009). factors, such as income and having health However, the incidence of malaria in insurance, in addition to health providers, Indonesia has decreased from 2.9% in such as availability of health care facilities, 2007 to 1.9% in 2013 (National Institute tariffs and residing in rural or urban areas of Health Research and Development, (Greenwood, 2008). 2008, 2013). Case fatality rate (CFR) of A recent study showed that health malaria was 0.26% in 2000 and increased technology alone can not decrease disease to 0.49% in 2003, but decreased to 0.056% morbidity and various aspects of commu- in 2007, still above the national target of nity empowerment are required (Kumar 0.04% (Department of Health Indonesia, and Preetha, 2012). The malaria control 2008). Five provinces with high malaria program conducted by Health Offices incidence are Papua, East Nusa Tenggara, should be supported by community activi- West Papua, Central and ties as the community is a resource for en- (National Institute of Health Research and suring success of the program (Directorate Development, 2010). The annual malaria of Community and Village Empowerment, incidence (AMI) and annual parasite in- 2009). Self care is one form of community cidence (API) in Papua Province is above participation in malaria control program the national API of 45.87 per 1,000 popula- by providing correct knowledge regarding tion at risk (Papua Province Health Office, malaria, its prevention and early detection, 2011). The Milleneum Development Goals seeking proper medical treatment and target 6 is to reduce malaria morbidity, an compliance to malaria treatment regimen, importamt cause of disease burden and especially among inhabitants in malaria reduction in human productivity. endemic areas (Innovations for Maternal, Malaria eradication efforts in Indo- Newborn and Child Health, 2010). nesia has been conducted for decades In order to increase malaria preven- (Dale et al, 2005). In 2009 the Ministry tion activities, health center functions of Health stated in Decree No 293 that should be accompanied with the parti- malaria elimination be composed of four cipation of community leaders of “self phases: eradication, pre-elimination, eli- care” to provide promotional, preventive, mination and maintanance of elimination curative and rehabilitative activities to status. Whereas the malaria elimination enhance health conditions among inhabi- was planned according to islands/prov- tants in malaria endemic areas. Hence this inces and targetted in 2010, 2015, 2020, study was to develop self care of malaria and 2030, respecticely. Papua Province in endemic areas by enhancing knowledge and other eastern provinces in Indonesia in the prevention, early detection and were targetted for malaria elimination by treatment of malaria. year 2030. It is known that characteristics as MATERIALS AND METHODS socioeconomic conditions, culture (Kloos, 1990) and psychological conditions of the This was an operational research for people, perception of illness or possibilty the development of a Modul Self Care of of coming down with malaria are deter- Malaria with a cross-sectional design. The mining factors for decision to seek treat- study was conducted in Nimboran Sub- ment (Heggenhougen et al, 2003). Health district, Jayapura District, Papua Province,

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Indonesia in 2013. Thirty participants were Table 1 randomly selected from ‘Pengurus Rukun Characteristics of ‘Pengurus Rukun Tetangga’ group with a proportion of 0.3, Tetangga’ respondents (n=30) at α = 0.1 and β = 0.2. Inclusion criterion was Genyem Health Center, Jayapura District, relatively newly selected Pengurus Rukun Papua Province, Indonesia in 2013. Tetangga, and exclusion criterion was Pen- Characteristic Number (%) gurus Rukun Tetangga not participating in health activities. Residence Variables were knowledge of malaria Rural 20 (67) regarding causation, transmission, symp- Urban 10 (33) toms and complications, diagnosis, treat- Age (years) ment and its side effects, health seeking Minimum 20 Maximum 57 behavior and treatment, vector breeding Average 39 places; attitude towards malaria treatment Gender compliance and practice of mosquito Male 17 (57) net use (Bruce-Chwatt, 1990; Directorate Female 13 (43) General of Communicable Diseases and Ethnicity Environment Health, 2011a, b). Papua 24 (80) Others 6 (20) RESULTS Education Elementary School 1 (3) Characteristics of respondents Junior School 1 (3) Sixty-seven percent of respondents High School 16 (54) lived in rural areas (Table 1). The average Diploma/University 12 (40) Occupation age was 39 years old and mainly of Papua Farmer 6 (20) ethnicity. Fifty-seven percent are males Self-employer 7 (23) with a high school education. Forty-three Housewife 2 (7) percent were farmers or self-employed, Kampong staff 2 (7) and 43% were civil servants. The average Civil servant 13 (43) monthly family income was Rp 1,356,667 Family income (Rp) (USD 111.5). Minimum 200,000 Knowledge on malaria Maximum 4,000,000 Average 1,356,667 Sixty-three percent of respondents knew that mosquito is a cause of malaria but 20% could correctly answer all the were reddish eyes, pale pallor, icterus on questions on the cause of malaria (Table eyes/face, dizziness or pain if stepping on 2). Ninety-four percents of respondents stones, and shouting. Regarding symp- were aware that infected mosquito is the toms of severe malaria, 27% indicated vector of malaria, but only 4 respondents high fever and seizure. The most frequent correctly identifiedAnopheles as a vector. answer to malaria complication was cere- Ninety-seven percent of respondents bral malaria. recognized a general symptom of malaria Ninety percent of respondents an- was fever and 63% as chill (Table 3). How- swered that malaria detection was by ever, 10% replied that malaria symptoms blood examination and rapid diagnostic

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Table 2 Knowledge on cause and transmission of malaria among ‘Pengurus Rukun Tetangga’ respondents at Genyem Health Center, Jayapura District, Papua Province, Indonesia in 2013.

Cause Number (%) Transmission Number (%)

Malaria parasite 6 (20) Mosquito 28 (94) Mosquito 19 (63) Blood 1 (3) Environment 3 (10) Low immunity 1 (3) Others 2 (7)

Table 3 therapy (ACT). Forty-three percent of Knowledge on malaria symptoms respondents recognized tinnitus as an among ‘Pengurus Rukun Tetangga’ antimalarial drug side effect. respondents at Genyem Health Center, All participants mentioned malaria Jayapura District, Papua Province, management was through visiting health Indonesia in 2013. centers or hospitals (data not shown). Ad- Parameter Number (%) ditional descriptions were by being active

a and healthy, consuming papaya leaves General symptom and flowers and “sambiloto” (Androg- Fever 29 (97) raphis paniculata), draining swamps and Chill 19 (63) maintaining a clean environment, using Dizziness 9 (30) Nausea 13 (43) mosquito nets, and taking paracetamol/ Vomiting 12 (40) antipyretic. Many said that if visiting Diarrhea 0 (0) the nearest health center was too far use Severe symptoma traditional treatment followed by trip High fever 8 (27) to hospital, or firstly undertake a blood Seizure 8 (27) examination and take antimalarial drug. Unconsciousness 7 (23) Regarding awareness of breeding Delirium 2 (7) places of malaria vectors, 53% of the Wrong uttering 1 (3) respondents mentioned ponds and 10% Tea-like urine 2 (7) Dyspnea 1 (3) mossy swamps (Table 5). Some said dirty Syncope 1 (3) environment, hanging clothes, bad smell- Complicationa ing and moist places, dirty ponds, open Cerebral malaria 2 (7) and closed water containers, dry leaves, Convulsion 0 (0) used cans, ditches, and clean and waste Renal dysfunction 1 (3) streams. Lung edema 1 (3) Sixty-seven percent were aware that aCould give more than one choice. using mosquito nets prevented malaria (Table 5). A number of respondents in- test (RDT) (Table 4). For malaria treat- cluded such measures as using mosquito ment, 43% and 40% replied quinine and coils, spraying insecticides and burning Darplex®, respectively. No respondent wood, and few mentioned eating regular/ mentioned artemisinin combination healthy meals, although some said tak-

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Table 4 Table 6 Knowledge on malaria detection and Mosquito net use among ‘Pengurus treatment among ‘Pengurus Rukun Rukun Tetangga’ respondents at Tetangga’ respondents at Genyem Genyem Health Center, Jayapura District, Health Center, Jayapura District, Papua Papua Province, Indonesia in 2013. Province, Indonesia in 2013. Parameter Number (%) Parameter Number (%) Never 6 (20) Detection Seldom 5 (17) Symptoms 3 (10) Frequently 1 (3) Blood examination 27 (90) Always 16 (53) Drugs Total 28 (93)a

Quinine 13 (43) a Chloroquine 4 (13) Two did not respond. Primaquine 2 (7) ACT 0 (0) ing spicy food and hot drink, and having ® Darplex 12 (40) a healthy life or keeping active. Others Paracetamol 1 (3) described keeping clean the environment, Side effecta houses/garden/cans, garbage sites, and Nausea 9 (30) Dizziness 9 (30) ditches. Tinnitus 13 (43) Attitude and behavior All had taken different antimalarial ACT, artemisinin combination therapy. aCould give more than one choice. drugs for various reasons to cure malaria completely so that there would not a re- current illness. Few said the drugs could be used for prevention and that there were Table 5 ways to prevent drug resistance. Fifty- Knowledge on malaria vector breeding three percent of respondents always used places and prevention among ‘Pengurus mosquito nets (Table 6). Rukun Tetangga’ respondents at Genyem Health Center, Jayapura District, History of malaria among respondents Papua Province, Indonesia in 2013. Thirty-seven percent had a neigh- bor with malaria during the previous 4 Parameter Number (%) months. All infected neighbors visited Breeding placea health centers. Four of the 11 respondents Swamp 3 (10) (36%) indicated that their neighbors Forest 0 (0) has vivax malaria and 3 (28.0%) having Beach 0 (0) neighbors with falciparum malaria. Four Pond 16 (53) respondents informed that infection was Rice field 1 (3) diagnosed by blood examination and that a Prevention 4 and 5 (45.0%) learnt that their neighbors Mosquito net 20 (67) were treated with Darplex® and prima- Mosquito repellant 2 (7) quine, respectively (data not shown). Prophylaxis 2 (7) All respondents had visit health cen- aCould give more than one choice. ters for malaria treatment, 5 also went to

Vol 48 No. 1 January 2017 5 Southeast Asian J Trop Med Public Health hospitals and 3 used traditional treatment all respondents acknowledged to have or took papaya leaves/flowers or “sambi- fully complied with the drug regimen loto”. Three persons (10%) visited other prescribed. This is important to prevent malaria endemic village for 1, 2 or 7 days. development of antimalarial drug resis- tance. DISCUSSION The common answers regarding ma- Almost all respondents were aware laria vector breeding places were ponds that mosquitoes are responsible for ma- because Nimboran Subdistrict has forest laria transmission and 63% that malaria areas suitable for malaria vector breeding. is caused by mosquitoes. The knowledge Knowledge of vector breeding places is of malaria transmission is important to important for managing sources of infec- prevent host (human) and vector (mos- tion agents to stop malaria transmission. quito) contact. However, just 53% of the But the natural ecology of Papua Province respondents who used mosquito nets with wide forest areas poses a challenge likely was influenced by the knowledge for controlling malaria vector breeding. of the cause of malaria. Thus regular use of mosquito nets should be promoted because of its effectiveness The majority of respondents knew in preventing malaria particularly as long that fever and chills are general symptoms lasting insecticide-treated nets can be used of malaria but fewer had knowledge of for 3-5 years. As mosquito repellants are symptoms of severe malaria, and fewer relatively expensive, wearing long sleeve still of those of cerebral malaria. In high shirts at night can also be useful. Anti- endemic areas, malaria is very common malarial prophylaxis should be recom- but have mild symptoms because inhabit- mended for travelers, not for residents in ants acquire natural immunity following malaria endemic areas. becoming infected. This possibly causes resident population not being aware The 37% of respondents had neigh- of symptoms of severe malaria form of bors with malaria during the previous 4 infection, complicated malaria or even months indicated malaria transmission in mortality from malaria. Although 90% of Nimboran Subdistrict was high. Among the participants knew of confirmation of these respondents, one-third knew the malaria by blood eaxmination, the low type of malaria and also confirmed the knowledge of severe malaria symptoms presumptive diagnosis and advised drug could cause delay in seeking treatment. treatment. This is in concordance with the use of Correct knowledge of malaria should malaria medication showing about 40% be enhanced in the effort to promote of the respondent indicated quinine and malaria prevention, especially in high en- Darplex® (artemisinin and piperaquine demic areas (Denver, 1984). It needs edu- combination). It is likely that quinine cation on malaria causation, transmission, is the first choice as antimalarial drug symptoms, ealy diagnosis and prompt although ACT is the present standard treatment, and compliance to treatment therapy. Regarding antimalarial drugs regimen if there is to be any decrease in side effects, tinnitus was frequently men- malaria that is responsible for economic tioned because of its unusual symptom loss. The role of self-care is to empower so that people remember. For attitude, community leaders to improve health

6 Vol 48 No. 1 January 2017 Malaria Self-care, Papua Province, Indonesia education among inhabitants to achieve its environmental relationships. Southeast malaria elimination (WHO SEARO, 2008, Asian J Trop Med Public Health 2005; 36: 2009; Directorate General of Communi- 1-13. cable Diseases and Environment Health, Denver GEA. Epidemiology in health service 2011c). management. Maryland: Aspen System Corporation,1984. In summary, results from this ques- tionnaire study conducted among 30 Department of Health, the Republic of Indone- ‘Pengurus Rukun Tetangga’ members sia. Ministry of Health No. 293/IV/2009 on malaria elimination in Indonesia. : of Jayapura District, Papua Province in Department of Health, the Republic of 2013 on malaria self-care revealed that Indonesia, 2009. (i) mosquito net use was about 65%, (ii) Department of Health, the Republic of Indo- knowledge of severe malaria symptoms nesia. Health profiles of Indonesia year and complications were lacking but such 2007. Jakarta: Department of Health the awareness is because in high endemic Republic of Indonesia, 2008. malaria areas the disease was assumed to Directorate General of Communicable Diseases be a common mild illness, (iii) less than a and Environment Health. Guidance book ® half of the respondents knew of Darplex , for village malaria post cadres. Jakarta: an ACT, although all visited health centers Directorate General of Communicable Dis- for malaria treatment, (iv) respondents eases and Environment Health, Ministry with neighbors sick with malaria said they of Health, 2011a. all visited health centers, (v) the major- Directorate General of Communicable Diseases ity of respondents knew tinnitus was a and Environment Health. Guidance book side effect of antimalarial drugs, (vi) all for cadres training on conducting village respondents complied with prescribed malaria post activities. Jakarta: Directorate drug regimen, and (vii) the majority of General of Communicable Diseases and respondents recognized ponds as malaria Environment Health, Ministry of Health, vector breeding places. The study con- 2011b. cludes that malaria self-care was needed Directorate General of Communicable Dis- for promotion of malaria prevention and eases and Environment Health. Book of treatment efforts in the region. malaria elimination in Indonesia. Jakarta: Directorate General of Communicable Dis- eases and Environment Health, Ministry CONFLICT OF INTERESTS of Health, 2011c. The authors declare no conflict of Directorate of Community and Village Em- powerment. Community empowerment, interests. guides for facilitators. Jakarta: Ministry REFERENCES of Internal, 2009. Greenwood MB. Control to elimination: im- Bhatia R, Mani Rastogi R, Ortega L. Malaria plications for malaria research. Trends successes and challenges in Asia. J Vector Parasitol 2008; 24: 44-54. Borne Dis 2013; 50: 239-47. Heggenhougen HK, Hackethal V, Vivek P. The Bruce-Chwatt LJ. Essential malariology. Lon- behavioural and social aspects of malaria don: William Heinemann Medical Book, and its control. Geneva: UNDP/World 1990. Bank/WHO, Special Programme for Re- Dale P, Sipe N, Anto S, et al. Malaria in Indo- search and Training in Tropical Diseases nesia: a summary of recent research into (TDR), 2003.

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