Injections, cocktails and diviners: therapeutic flexibility in the context of malaria elimination and drug resistance in Northeast Cambodia

• Published in: PloS one Vol. 8; no. 11; p. e80343
• Main Authors: Gryseels, Charlotte, Uk, Sambunny, Erhart, Annette, Gerrets, René, Sluydts, Vincent, Durnez, Lies, Muela Ribera, Joan, Hausmann Muela, Susanna, Menard, Didier, Heng, Somony, Sochantha, Tho, D'Alessandro, Umberto, Coosemans, Marc, Peeters Grietens, Koen
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 11.11.2013; Public Library of Science (PLoS)
• Subjects: Anopheles dirus; Antimalarials - therapeutic use; Artemether; Blister packs; Cambodia - epidemiology; Containment; Cross-Sectional Studies; Drug resistance; Drug therapy; Drugstores; Etiology; Health care facilities; Health facilities; Human behavior; Humans; Malaria; Malaria - drug therapy; Malaria - epidemiology; Medicine; Minority & ethnic groups; Native peoples; Parasitology; Patient compliance; Pharmacy; Plasmodium falciparum; Population; Private sector; Public health; Public sector; Regional planning; Research design; Side effects; Social sciences; Spirits; Surveys; Towns; Vector-borne diseases; Cambodia; San Francisco California; Vietnam; Belgium; United States > US
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0080343

Adherence to effective malaria medication is extremely important in the context of Cambodia's elimination targets and drug resistance containment. Although the public sector health facilities are accessible to the local ethnic minorities of Ratanakiri province (Northeast Cambodia), their illness itineraries often lead them to private pharmacies selling "cocktails" and artemether injections, or to local diviners prescribing animal sacrifices to appease the spirits. The research design consisted of a mixed methods study, combining qualitative (in-depth interviews and participant observation) and quantitative methods (household and cross-sectional survey). Three broad options for malaria treatment were identified: i) the public sector; ii) the private sector; iii) traditional treatment based on divination and ceremonial sacrifice. Treatment choice was influenced by the availability of treatment and provider, perceived side effects and efficacy of treatments, perceived etiology of symptoms, and patient-health provider encounters. Moreover, treatment paths proved to be highly flexible, changing mostly in relation to the perceived efficacy of a chosen treatment. Despite good availability of anti-malarial treatment in the public health sector, attendance remained low due to both structural and human behavioral factors. The common use and under-dosage of anti-malaria monotherapy in the private sector (single-dose injections, single-day drug cocktails) represents a threat not only for individual case management, but also for the regional plan of drug resistance containment and malaria elimination.