Myanmar Artemisinin Resistance Containment Project Baseline … · 2018-04-09 · Myanmar Artemisinin Resistance Containment Baseline Survey 6 1.4 Malaria treatment Table 1.4.1 Household

Myanmar Artemisinin Resistance Containment Baseline Survey 1

Myanmar Artemisinin Resistance Containment Project

Baseline survey

Final report

December 2012


In collaboration with:

Department of Medical Research (Lower Myanmar)

With technical assistance from Malaria Consortium and World Health Organization

Funding provided by the Three Diseases Fund


TABLE OF CONTENTS

Table of contents ............................................................................................................................................................... 3

List of Tables ....................................................................................................................................................................... 5

List of Figures ...................................................................................................................................................................... 8

Acknowledgements .......................................................................................................................................................... 9

Abbreviations ................................................................................................................................................................... 10

Executive Summary ........................................................................................................................................................ 12

Background ....................................................................................................................................................................... 19

Objectives of the Survey ................................................................................................................................................ 21

Methods ............................................................................................................................................................................... 22

Survey Areas ....................................................................................................................................................................................... 23

Survey Design and Sampling ........................................................................................................................................................ 24

Fieldwork process ............................................................................................................................................................................. 26

Ethical considerations..................................................................................................................................................................... 27

Data processing and analysis ....................................................................................................................................................... 27

Results ................................................................................................................................................................................. 29

Issues to consider .............................................................................................................................................................................. 29

HOUSEHOLD AND PREVALENCE SURVEYS ........................................................................................................................... 30 Malaria prevalence and fever ............................................................................................................................................... 34 Malaria prevention ................................................................................................................................................................... 39 Malaria treatment ..................................................................................................................................................................... 47

DRUG OUTLET SURVEY .................................................................................................................................................................. 56 Characteristic of Drug outlets .............................................................................................................................................. 56 Antimalarial drugs stock and selling habits .................................................................................................................. 59

HEALTH FACILITY SURVEY .......................................................................................................................................................... 66 Health Facility Audit ................................................................................................................................................................. 67 Malaria Patient Follow-Up and Exit Interviews ........................................................................................................... 72

Discussion .......................................................................................................................................................................... 75

Key Recommendations .................................................................................................................................................. 80

References .......................................................................................................................................................................... 82

Annexes ............................................................................................................................................................................... 83

Annex 1. Household Questionnaire ........................................................................................................................................... 84

Annex 2. Drug Outlet Questionnaire ...................................................................................................................................... 112

Annex 3. Health Facility Questionnaire – Part 1 (Facility Audit) .............................................................................. 123


Annex 4. Health Facility Questionnaire – Part 2 (Malaria Follow-up) .................................................................... 138

Annex 5. Health Facility Questionnaire – Part 3 (Exit Interview) ............................................................................. 152


LIST OF TABLES

Table 1. Summary indicators

1. HOUSEHOLD AND PREVALENCE SURVEYS

1.1 Characteristics of the sample and summary results

Table 1.1.1 Denominators for households and sampled individuals

Table 1.1.2 Age and sex distribution of residents, visitors, people who travel away from home,

and people who go to the forest

Table 1.1.3 Details of temporary visitors in households

Table 1.1.4 Details of people in households who go to the forest and sleep overnight

Table 1.1.5 Details of usual residents away for more than 6 months

1.2 Malaria prevalence and fever

Table 1.2.1 Malaria prevalence by species and zone, and reported fever by Tier

Table 1.2.2 Malaria species by age/sex and socioeconomic group

Table 1.2.3 Malaria species by State

Table 1.2.4 Determinants of a positive blood slide

Table 1.2.5 Distribution of fever by socioeconomic group within Tiers

1.3 Malaria prevention

Table 1.3.1 Summary of household ownership of mosquito nets

Table 1.3.2 Summary of household ownership of sufficient mosquito nets

Table 1.3.3 Characteristics of household nets

Table 1.3.4 Places to obtain or retreat a net

Table 1.3.5 Household ownership of nets by State

Table 1.3.6 Summary of mosquito net usage (previous night) by target populations

Table 1.3.7 Determinants of the use of any mosquito nets and long lasting insecticide-treated

nets


1.4 Malaria treatment

Table 1.4.1 Household respondents’ knowledge of malaria and danger signs by Tier

Table 1.4.2 Respondent’s confirmation of signs and symptoms

Table 1.4.3 Respondents’ knowledge of malaria treatment

Table 1.4.4 Household respondents’ knowledge of providers for malaria diagnosis and

treatment

Table 1.4.5 Respondents’ reported prevalence and treatment of fever during the previous two

weeks

Table 1.4.6 Treatment seeking behavior of forest goers on last visit

Table 1.4.7 Specific drugs taken for fever

Table 1.4.8 Type, source, test and test result for individuals with fever in the past two weeks

who took any ACT

2. DRUG OUTLET SURVEY

2.1 Characteristic of sampled outlets

Table 2.1.1 Private providers (outlets) selling antimalarial drugs by Tier

Table 2.1.2 Knowledge among drug outlet respondents of drug resistance and ban on

monotherapies

2.2 Antimalarial drugs stock and selling habits

Table 2.2.1 Availability of antimalarial drugs sold in private drug outlets on survey day by Tier

Table 2.2.2 Details of rapid diagnostic tests sold in drug outlets

Table 2.2.3 Recommended antimalarial drugs in drug outlets by Tier

Table 2.2.4 Popularity of antimalarial by Tier

Table 2.2.5 Consumption habits by Tier

Table 2.2.6 Activity during the previous week by Tier

Table 2.2.7 Artesunate

Table 2.2.8 Coartem (A + L)

Table 2.2.9 Duocotexcin


Table 2.2.10 Cost of specific antimalarial drugs

3. HEALTH FACILITY SURVEY

Table 3.1 Description of the health facilities in the survey

Table 3.2 Health facility respondent characteristics

Table 3.3 Health facility staff characteristics

Table 3.4 Antimalarials, other drugs and RDTs usually stocked by Health Facilities

Table 3.5 Summary of artemisinin-based combination therapy (ACTs), antimalarials and rapid

diagnostic tests (RDTs) stocked at health facilities

Table 3.6 Laboratory services and equipment available at health facilities

Table 3.7 Details of malaria cases followed up and exit interview patients

Table 3.8 Assessment and antimalarials received by malaria cases and fever patients

Table 3.9 Treatment prescribed at public and private health facilities among malaria and fever

cases

Table 3.10 Reported diagnosis and treatment among exit interview fever patients


LIST OF FIGURES

Figure 1: Components of the MARC baseline survey

Figure 2: Rainfall intensity and pattern in the Study area

Figure 1.1.1: Selected clusters of the baseline survey

Figure 1.3.1 Knowledge of causes of malaria transmission mentioned by Tier

Figure 1.3.2 Knowledge of means of malaria prevention mentioned by tier

Figure 1.3.3 Attitude about ITN benefits mentioned by Tier

Figure 1.3.4 Malaria messages seen or heard in past 6 months by Tier

Figure 1.3.5 Source of malaria messages mentioned by Tier

Figure 1.4.1 Knowledge of signs or symptoms of malaria mentioned by Tier

Figure 1.4.2 Recognition of symptoms of serious illness by Tier

Figure 1.4.3 Antimalarial drug mentioned by respondents by Tier

Figure 1.4.4 Source of treatment by Tier

Figure 1.4.5 Reasons for not seeking treatment by Tier

Figure 2.1.1 Respondents knowledge of malaria signs and symptoms by Tier

Figure 2.1.2 Attitude of respondents if suspected malaria case

Figure 2.2.1 Factors determinant for stocking of antimalarial drugs

Figure 3.1 Location of public Health Facilities, MARC survey 2011


ACKNOWLEDGEMENTS

The authors would like to thank the Ministry of Health of Myanmar; in particular, Dr Saw Lwin, Deputy Director General, and Dr Thar Tun Kyaw, Director of the National Malaria Control Programme, for their guidance and support which has made the baseline survey for the Myanmar Artemisinin Resistance Containment (MARC) possible.

We would also like to thank the staff of the Vector borne Disease Control Division, Department of Health, Myanmar, and Dr Myat Phone Kyaw, Deputy Director, Head of Parasitology Research Division, Department of Medical Research, Lower Myanmar, and local partners for their dedication to the malaria control programme and their commitment to contain artemisinin resistance and controlling malaria in Myanmar. Special thanks to the Three Diseases Fund (3DF) for supporting this survey, with additional support from the World Health Organisation, Myanmar.

We also would like to express our sincere appreciation to all the members of the MARC 2011 baseline survey teams and technical partners, in particular WHO-Myanmar and Department of Medical Research, Lower Myanmar who provided invaluable technical support and assurance that field work and laboratory analyses were undertaken to the highest quality standards.

Special thanks to the many field interviewers and blood takers who worked arduously for data collection, as well as laboratory technicians who read and rechecked all the blood slides, without whose commitment and dedication we would not have been able to produce the following results.

And finally, we would like to express our gratitude to the thousands of households of Myanmar who participated in this large-scale baseline survey and contributed to the improving our understanding of the malaria situation and epidemiology of the country.


ABBREVIATIONS

3DF Three Diseases Fund

ACTs Artemisinin-based Combination Therapy

CQ Chloroquine

DBS Dried Blood Spot

DHA-PIP Dihydroartemisinin-Piperaquine

DHS Demographic and Health Survey

DMR Department of Medical Research

FDA Food and Drug Administration

GFATM Global Fund to fight AIDS, Tuberculosis, and Malaria

GPARC Global Plan for Artemisinin Resistance Containment

GPS Geographic Positioning System

HF Health Facility

IMCI Integrated Management of Childhood Illnesses

IOM International Organization for Migration

IPD In-patient Department

M&E Monitoring and Evaluation

MARC Myanmar Artemisinin Resistance Containment

MC Malaria Consortium

MICS Malaria Indicator Cluster Surveys

MQ Mefloquine

NMCP National Malaria Control Programme

OPD Out-patient Department

PCA Principle Components Analysis

PQ Primaquine

PSI Population Services International

SP Sulfadoxine-Pyrimethamine

TA Technical Assistance


TSG Technical Strategic Group

TORs Terms of Reference

VBDC Vector-Borne Disease Control

WHO World Health Organization


EXECUTIVE SUMMARY

The Myanmar Artemisinin Resistance Containment (MARC) baseline survey was conducted

from end of December 2011 through mid-March 2012, before the start of the rainy season by a

partnership of organisations supporting the Vector Borne Disease Control (VBDC) Division in

Myanmar. This large-scale household, drug outlet, and health facility survey was funded by the

Three Diseases Fund (3DF) and World Health Organization (WHO) and addressed indicators for

containment of artemisinin resistanceand provided key monitoring and evaluation data for the

MARC Task Force as well as the Technical Strategic Group (TSG) for refinement and

improvement of the containment strategy.

The main purpose of the MARC baseline survey was to assess the overall malaria prevalence in

the containment areas (Tier 1 and Tier 2), to assess and monitor the availability of oral

artemisinin monotherapies in the containment areas and to serve as baseline for the MARC

strategic and Monitoring and Evaluation Framework in 2011, as well as contribute to baselines

for other projects including the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM).

The household malariometric survey focused on the populations living within the containment

of artemisinin resistance areas in Myanmar, particularly Tier 1 (21 townships) and Tier 2 (31

townships). A total of 1992 households were visited and interviewed (40 clusters of 25

households in each Tier). Within the sampled households, individuals representing four age

categories were randomly selected for the malaria prevalence survey; a total of 5264 blood

samples were collected and analysed using standard microscopy and PCR.

A total of 120 drug outlets were visited (two drug outlets per cluster), purposely selected

based on the most popular source for antimalarial drugs in the vicinity of the community, using

local key informants in each cluster.

A total of 129 health facilities were included in the survey (50 public and 79 private facilities).

Health facilities were selected using stratified sampling within the catchment area of the

clusters for the household survey. In these health facilities, 362 malaria cases within the past

three months were followed up for case records (294 cases at public facilities and 68 at private

facilities). Furthermore, 232 exit interviews were conducted for fever cases presented at

health facilities during the time of the survey (183 at public facilities and 49 at private facilities).


Malaria and reported fever prevalence

Malaria prevalence using microscopy was overall 0.5% in the target area at the time of the

survey. There was a higher prevalence of Plasmodium vivax infection compared to Plasmodium

falciparum and there were no cases of mixed species infection. Malaria tended to be more

prevalent among children under five and among poorer households. People living in Tier 1 and

as expected in endemic malaria risk areas were more likely to have a malaria positive slide.

Comparison across tiers revealed that the proportion of infections of Plasmodium falciparum

was higher than Plasmodium vivax in Tier 1 but this trend was reversed in Tier 2. Although very

few malaria cases were detected on the survey day, there appears to be ongoing malaria

transmission in the studied villages and it would be useful to understand more about the levels

of transmission through the use of molecular (PCR) and serological techniques. It also may

suggest that malaria transmission was heterogeneous as the trends observed in Tier 1 tended to

reflect a lower transmission setting compared to Tier 2, considering the proportion of positive

slides and the species patterns.

Malaria awareness and prevention

In general, 20% of the respondents could not mention any transmission mode and several

misconceptions were cited but about 65% of respondents knew that mosquitoes could

transmit malaria. The most popular method for prevention appeared to be related to mosquito

net use and to insecticide treated nets (ITNs) to a lesser extent. In the same way, awareness

about ITN benefit was still relatively low. In the previous six months, only 12% mentioned

having received any information about malaria and the main message recalled was related to

mosquito net or ITN use, mainly cited from health facility or NGO staff as a source.

On the survey day, household ownership of any mosquito net was 97.4%, of any ITN was

35.1% and any long-lasting insecticidal net (LLIN) was 11.1%. The coverage of any mosquito

net was higher among richer households while ITN ownership appeared to be associated with

poorer households and concentrated in higher malaria risk area. Unsurprisingly, more mosquito

nets were found in the Tier 1 area and these nets tended to be more recent than those in Tier 2,

which is consistent with the above observation as malaria was more prevalent in Tier 1. In

general, the most popular source of these mosquito nets was a shop or the market in both tiers.

The proportion of all people who slept under a mosquito net the previous night was 76.5%

and as expected, these estimates for ITN and LLIN were much lower at 15.9% and 3.9%

respectively. Although more than a quarter of households had insufficient quantity of

mosquito nets (at least one mosquito net for every two people), 20% to 30% of households had

either an old or net that was not currently used by the household and the main reasons were to

save it for the future or for visitors. Furthermore, mosquito net use among mobile groups as

forest goers, travellers and temporary visitors tended to be significantly lower compared to all

individuals.


Malaria treatment

Nearly half (47.3%) of the respondents mentioned chills and fever as malaria signs and

symptoms, 30.4% could cite the main sign for fever severity (unconscious, fast breathing or

convulsion) and these proportions were higher in Tier 1. The most popular methods to confirm

the signs and symptoms mentioned were first “Doctor’s examination” followed by “Self-

assessment”. Less than 3% cited a rapid diagnostic test (RDT) or blood slide.

Less than 30% of household respondents could cite any antimalarial drug and less than 10%

mentioned any artemisinin-based combination therapy (ACT). However, artemisinin

monotherapies were mentioned by more than 10% in each tier.

The most popular source for diagnostic services and treatment appeared to be the rural health

centres, hospitals and private doctors while community malaria workers were mentioned by

only about 3%. The public sector appeared to be the most commonly cited source for diagnostic

services and treatment for malaria. Among all individuals in the households sampled, 2.6%

reported any fever in the previous two weeks. Among these 241 people, 70% sought treatment

mostly from a private doctor, a health centre or a midwife clinic and overall, public sector

channels appeared to be more common.

Interestingly, in Tier 2, fewer people sought treatment and an important source of advice or

treatment was a grocery shop. The first source for treatment in case of reported fever among

respondents in Tier 2 appeared to be from a private channel, as opposed to Tier 1. In both tiers,

time to treatment was fast, within 2 days for a vast majority of cases. Among all fever cases,

69% had either an RDT or a blood test for malaria. In most cases, the treatment consists of

non-antimalarial drugs (80.8%) and only 4 people had any ACT (Coartem).

Drug outlet surveys

The main finding from the drug outlet survey was that more than half of providers had no

previous health training and 80% of the drug outlets were in a general store where

consultations were offered. Awareness about artemisinin resistance was low in the sampled

outlets and in general, the most popular antimalarial drugs sold in the sampled outlets were: 1)

artesunate tablets, 2) chloroquine, 3) artemether injectables, and 4) artemether tablets. This

confirms that in the target area, artemisinin monotherapies (artesunate) was still the most

popular malaria treatment obtained in drug outlets.

The sale of partial packs of treatment regimens appeared to be common practice as 55.2% of

drug outlets reported selling incomplete doses in the previous month. Selling activity

during the past week was low, which is consistent with the low malaria prevalence and reported

fever found in the households surrounding these outlets and 60.4% reported selling less

antimalarial drugs than the previous year. On the other hand, availability of diagnostic services

was low with 20.8% outlets selling any test for malaria of which most tests were RDTs. Across

tiers, artemisinin-based antimalarils, either monotherapies or combined with another drug was

the most common treatment sold in Tier 1. However, in Tier 2, the most popular treatment was

chloroquine, suggesting that the clusters in Tier 2 were perhaps more underserved compared to

Tier 1. Likewise, drug providers in Tier 1 were more likely to refer customers to health facilities


and clients were more likely to bring in a prescription, suggesting better linkages between drug

outlets and the formal health system.

In Tier 2, consumption appeared more driven by customer demand. Considering the above

observations, it appeared that although availability of any antimalarial drugs was high among

the selected clusters, ACTs were found in less than 40% of outlets and artemisinin

monotherapies were still the most popular and widely available treatment for malaria.

Health facility survey

The aim of the health facility survey was to assess the delivery of services for fever and malaria

episodes within the public and private sectors. Due to the relatively low incidence of malaria

throughout the country, it was a challenge to identify and follow up prospective malaria cases.

Exit interviews and respective malaria case follow up interviews can provide a good way to

correlate patient’s perceived malaria services with those of providers. Public health facilities

were more likely to provide malaria diagnoses and health education compared to private

health facilities. However, private facilities were more likely to refer cases of severe malaria,

and had significantly more staff with malaria related training compared to public health

facilities. This was contradicted by the fact that knowledge of the recommended treatment for

P. falciparum and P. vivax was relatively higher among public health facilities.

Availability of ACTs (specifically Coartem) was higher among public health facilities;

however, stocks of ACTs and RDTs among private facilities may not be adequate to

currently address the need among those who seek treatment from private sources. An

high proportion of public and private facilites reported available stocks of chloroquine –

probably for the treatment of P. vivax. All public facilities seem to have good diagnostic

capabilities whereas 40% of private facilities lacked capacity for malaria diagnosis.

Although nearly all malaria cases who saw a health worker had a blood test, one of the key

findings from the malaria case follow up survey was that less than a quarter of cases in public

facilities received an ACT. This percentage was higher in the private sector but the number of

cases followed up in the private sector was low (68%). Among the patients receiving IV

infusion, 20% and 50% were diagnosed as malaria in the public and private health facility,

respectively. The over-reliance on the use of intravenous infusions for the treatment of fevers

and malaria should be assessed. Particularly as malaria declines in the country, more fevers

presented at public and private health facilities will likely be non-malaria related. Improved

and more sensitive algorithms and training for the treatment of these non-malaria fevers

should be developed and implemented.

In short, despite the low prevalence of malaria and fever cases at the time of the survey, the

trends highlighted in this report suggest heterogeneous malaria transmission in the areas

sampled. General awareness among the respondents about malaria, prevention measures,

diagnostic services and treatment was low. Although any mosquito net could be found in most

households, the coverage of ITN and LLIN was insufficient to have an impact on reducing or

preventing malaria transmission. On the other hand, general access to health care appeared

encouraging, considering the isolation of some of the selected villages. At this point in time, the


public sector seems to be the most popular source of malaria services and commodities

(mosquito net or retreatment). However, availability of diagnostic services and recommended

antimalarial drugs (ACTs) was low and insufficient for effective case management in order to

stop the spread of artemisinin resistance in the target area and in the country.


Table 1. SUMMARY OF KEY INDICATORS BY TIER

Indicator Indicator as measured in survey Tier 1 Tier 2

N % 95% CI N % 95% CI P-value

Household survey

Malaria prevalence in containment area

% malaria positive slides

% P. falciparum positive slides

% P. vivax slides

2557

0.8

0.2

0.5

0.4 to 1.6

0.0 to 0.5

0.2 to 1.1

2707 0.1

0.1

0.0

0.0 to 0.4

0.0 to 0.5

0.0 to 0.3

0.01*

Proportion of people with a history of fever in the last 2 weeks that have been tested for malaria (RDT or microscopy)

% with reported fever in the past 2 weeks and who had any test for malaria

128 21.9 14.9 to 31.0 113 24.8 16.3 to 35.7 0.88

% of confirmed malaria cases treated in accordance with any antimalarial drug within 24 hours of onset of symptoms

12 83.1 25.9 to 98.6 0 0.0 - 0.02*

% of confirmed malaria cases treated with any ACT within 24 hours of onset of symptoms

12 33.2 5.3 to 81.5 0 0.0 - 0.20

Proportion of people sleeping under an ITN/LLIN the previous night

% total population sleeping under any net the previous night

4612 78.0 72.2 to 82.8 4796 75.2 70.2 to 79.5 0.43

% total population sleeping under an ITN/LLIN the previous night

4612 18.8 13.7 to 25.2 4796 13.2 8.5 to 19.7 0.17

% of migrants/mobile populations sleeping under an ITN the previous night1: - Forest goers - Travelers away from home - Temporary visitors

14.4 9.9

23.7

8.2 to 24.1 5.6 to 16.7 9.7 to 47.5

10.8 12.4 3.7

5.0 to 21.8 6.8 to 21.5 0.8 to 15.4

1 This indicator may be better addressed through more specialized migrant studies and methodologies.


Proportion of households in target areas with at least 1 LLIN/ITN per 2 persons

% of households that owned any: - net - LLIN - LLIN/ITN for every 2 persons

997 997 997

96.6 10.9 3.0

92.2 to 98.5 6.3 to 18.2 1.4 to 6.3

995 995 995

98.3 11.3 2.9

95.2 to 99.4 6.1 to 19.9 1.4 to 6.0

0.30 0.93 0.94

% of respondents that mentioned: - using a net as prevention method

- using an ITN as prevention method

965 965

65.5 21.6

60.6 to 70.1 17.2 to 26.7

933 933

52.7 9.5

46.4 to 59.0 6.4 to 14.0

0.01* 0.01*

% of respondents that could name any ACT

997 2.4 1.4 to 4.0 995 1.1 0.6 to 2.1 0.05*

Drug outlet survey

% providers that know malaria signs2 61 77.0 66.2 to 88.0 59 49.2 36.0 to 62.3 0.01*

% providers that know the national recommended3 treatment for P.f.

61 26.2 14.9 to 37.6 59 8.5 1.2 to 15.8 0.01*

% providers that know the national recommended4 treatment for P.v.

61 1.6 0.0 to 4.9 59 3.4 0.0 to 8.1 0.54

Average number of anti-malarial treatment sold/distributed to consumers in the past seven days

61 mean=5.8 SD=1.8

59 mean=2.4 SD=0.49

Health facility survey Public Private

% of health facilities with no stockout of ACT5 50 92.0 79 57.0

% of health facilities with oral artemisinin monotherapy

50 16.0 79 36.7

% of health facilities with any RDT in stock 50 96.0 79 62.0

% of health facilities with appropriate diagnostic tools (slides and RDTs)

50 30.0 79 10.1

% of health staff interviewed who have had malaria related training in 2011

50 87.3 79 39.7

2 Know malaria if mentioned both fever and chills 3 ACT (A + L or Artesunate + Mefloquine) 4 Primaquine * Statistically significant, p<0.05 5 On day of the survey


BACKGROUND

The shift over the last few years away from failing drugs to the highly effective artemisinin-

based combination therapies (ACTs) has been a breakthrough, and it was hoped that their

design as combinations of two efficacious drugs with different modes of action would preserve

them for many years of use. However, recent evidence suggests that artemisinin resistant

Plasmodium falciparum parasites have emerged along the Thai-Cambodian border and it is

imperative to mount a vigorous response to stop spread from areas where artemisinin

resistance has been identified, whilst simultaneously undertaking further research to define

the nature and geographical extent of the problem.

In a region where resistance to chloroquine (CQ), sulfadoxine-pyrimethamine (SP) and

mefloquine (MQ) has previously emerged, the declining efficacy of artemisinin would indeed

be a catastrophic setback for the progress achieved thus far in the global fight against malaria

if it were to spread to Africa. Recent evidence through routine antimalarial drug efficacy

monitoring suggests that artemisinin resistance may also be present in Myanmar and

therefore an urgent response was needed to determine the extent of resistance, contain it, and

prevent its spread across Myanmar and beyond. As malaria incidence rates in parts of

Myanmar are higher than those on the Thai-Cambodian border, the impact of resistance on

effective control in Myanmar and beyond could be serious.

After the experience of implementing programmes to contain artemisinin resistance in

Cambodia and Thailand and consultations with international experts, the World Health

Organization (WHO) launched the Global Plan for Artemisinin Resistance Containment

(GPARC) in January 2011. In line with the GPARC and with support from the Ministry of

Health, WHO and key nongovernmental implementing partners of malaria control in country,

the Myanmar Artemisinin Resistance Containment (MARC) strategy and framework was

released in April 2011. The stratification for artemisinin resistance containment operations in

Myanmar are based on the three-tier classification of the Global Plan for Artemisinin

Resistance Containment (GPARC) and available data from in vivo therapeutic efficacy

monitoring studies. Tier 1 includes all Tanintharyi Region (10 townships), Mon State (10

townships), and Bago East Region (1 township) where there is strong evidence of suspected

artemisinin resistance and a critical need to respond with intensive containment

interventions. Tier 2 includes Kayin State (7 townships), Kayah State (7 townships), Kachin

State (4 townships) and Bago East Region (13 townships) where there is currently unclear

evidence of suspected artemisinin resistance but borders areas in Myanmar, Thailand, and

China where resistance has been detected. Tier 3 covers the rest of the country where it is

expected that scale up and strengthening of malaria control activities will continue as planned

under Global Fund Round 9.


MARC Goal and Objectives:

The overarching goal of malaria control in Myanmar is to reduce malaria mortality and

morbidity (MDG6). The aim of the containment project is to build on and strengthen existing

control efforts to prevent, or at minimum, significantly delay the spread of artemisinin

resistant parasites within the country and beyond its borders. This implies intensification of

present activities and an expansion of specific interventions that target migrants and mobile

populations, set up extra sentinel sites to monitor efficacy of antimalarial medicines, increase

advocacy to engage local authorities and relevant stakeholders, engage the private sector and

bridgeinterventions with neighboring countries.

The objectives of the MARC are the following:

1. To improve access to and use of early diagnosis and quality treatment according to the

national treatment guidelines

2. To decrease drug pressure for selection of artemisinin resistant malaria parasites by

stopping the use of artemisinin mono‐therapies and substandard/fake drugs

3. To limit the transmission of malaria by vector control and personal protection

4. To increase migrant/mobile populations’ access to and use of malaria diagnosis,

treatment and vector control measures including personal protection

5. To support containment of artemisinin resistant parasites through advocacy and

BCC/IEC

6. To conduct studies, especially operational research to support the development of

evidence‐based containment policies and strategies


7. To provide effective management and coordination to enable rapid and high quality

implementation of the containment strategy

OBJECTIVES OF THE SURVEY

A key component of the monitoring and evaluation plan of MARC is to conduct surveys

(malariometric, coverage and behavior) at household, health facility, and drug outlet levels

undertaken in year 1 and follow-up in subsequent years of the project. These surveys were

expected to serve as the baseline for the containment framework and any future containment-

related projects; to monitor critical milestones and indicators for the project; and provide key

evaluation data for the MARC Task Force and/or Technical Strategy Group (TSG) for

refinement and improvement of the implementation of the containment strategy.

The objectives of the MARC Surveys were the following:

1. To determine the baseline malaria prevalence in the Containment areas (Tier 1 and

Tier 2)

2. To assess and monitor the availability of oral artemisinin monotherapies in the

Containment areas

3. To serve as baseline for the MARC Strategic and M&E Framework in 2011, as well as

contribute to baselines for other projects including Global Fund

Specific indicators that were estimated from MARC survey:

Household survey

proportion of confirmed malaria cases treated in accordance with national malaria

treatment guidelines within 24 hours of onset of symptoms

proportion of households in target areas with at least one LLINs/ITNs per 2 persons

proportion of population at risk sleeping under an ITN/LLIN the previous night

proportion of persons with a history of fever in the last two weeks who had been

tested for malaria (RDT or microscopy)

proportion of respondents aware of key messages

Drug outlet survey

proportion of private drug outlets selling artesunate monotherapies

Volumes of anti-malarial drugs sold/distributed to consumers in the past seven days

proportion of private drug sellers/providers that can correctly state that people

suspected of having malaria should be diagnosed (by RDT or microscopy);

proportion of private drug sellers/providers that can correctly state that people who

are malaria positive should be treated with ACT and Primaquine (if P.f. positive) and

take the full course of treatment


proportion of health facilities with no stockout of nationally recommended treatment

proportion of health facilities with appriopriate diagnositic tools (slides and/or RDT’s)

proportion of health facilities with nationally recommended treatment in stock

proportion of health facilities with staff who have malaria related training


METHODS

The MARC baseline survey was composed of three components, namely:

o Household survey (including prevalence survey)

o Outlet (drugs and nets) survey (in parallel with the household survey)

o Health facility survey

These surveys used a combination of survey techniques to obtain data that allowed key

indicators to be estimated and the provider/user situation to be assessed.

Figure 1: Components of the MARC baseline survey

Household Survey Household data Household characteristics

Residents

Household nets

People who travel to the forest

Mobile populations

People with fever

Prevalence data 0-4 years

5 to 14 years

Adult males

Adult females

Pregnant women

Temporary visitors

Drug Outlet Outlet data Drug availability and provider knowledge

Health Facility Survey Health Facility

Health facility services

Review of antimalarial & diagnostics stock

Outpatient records

Laboratory review

Health worker capacity & training

Exit interviews of fever cases

Malaria cases follow up

The household survey provides information about current knowledge, attitude, behaviour, and

practices (KABP) of people in villages at risk of malaria in prevention and treatment.

Additionally, the prevalence of Plasmodium infection and malaria illness was estimated by a

malariometric survey at household level. Blood samples were collected for preparation of

blood smears and dried blood spots for: 1) detection and species identification for malaria

measures, 2) seroprevalence analysis, and 3) remaining blood spots have been stored for

future screening of potential molecular markers and genotyping for drug resistance.

The drug outlet survey was conducted to assess whether malaria services were available and

adequate for the treatment and prevention of malaria within the community. Brands and types

of antimalarial medicines and diagnostics were recorded and enabled estimation of the key

provider indicators. In addition, samples of anti-malarial drugs were purchased for testing for

active ingredients, which could then be triangulated with the other methods used by the Food

and Drug Administration (FDA) of Myanmar and other partners.


The health facility survey was conducted in public and private health facilities in malaria

endemic areas. It was expected to provide an overview of malaria-related health care services

in target provinces and to assess the capacity of the health facilities to provide appropriate

diagnosis and treatment of malaria. The survey included an audit of malaria-related services,

including availability of antimalarial medicines, treatment guidelines, health worker training,

and laboratory diagnostic capacity. Exit interviews with current fever cases and follow-up

interviews with malaria cases recently listed in the case register (public health facilities only)

were also conducted to assess the quality of services and care provided at these health

facilities.

SURVEY AREAS

The surveys were undertaken in Tier 1 and Tier 2 of the containment area, these are

administrative townships that have evidence of delayed response to ACTs or are at risk of

spread of resistant parasites. Survey clusters were selected from malaria risk areas (risk strata

1a, 1b, 1c, 2, and 3)6, which includes all of Tier 1 and a subset of Tier 2. These townships are

the focus of the majority of the containment project interventions (e.g., LLIN distribution,

training of village health volunteers and BCC strategy). The survey areas are located in the

South East part of Myanmar and include Kayah, Kayin, Mon, Tanintharyi and Bago States. The

climate is tropical with three seasons: the southwest monsoon from mid-May to mid-October,

the cold season from mid-October till mid-February and the hot season from mid-February till

mid-May.

Figure 2: Rainfall intensity and pattern in the Study area

6 Based on the risk categories in “Malaria Risk Micro-stratification in UNICEF 80 Townships”. Stratum 1a = high

risk village, 1b = moderate risk village, 1c = low risk village, 2 = potentially malarious villages, and 3 = non-malarious villages

Data collected

from mid-December

till mid-

February


SURVEY DESIGN AND SAMPLING

Household survey

The household survey design is multi-stage, sampling of clusters at the first stage, households

within each cluster at the second stage, and then individuals within each household, for the

prevalence survey. Assuming an overall malaria prevalence of 9%7, a precision of +2.5%,

design effect of 1.75, non-response rate of 10%, power of 80% (beta error), and confidence

interval of 95% (alpha error), a sample size of 1000 households (e.g. 40 clusters with 25

households) was required in each Tier. As a result, the total number of households required

for the survey was 2000 households. Within each cluster, 25 households were randomly

selected from a list of all registered and unregistered families in the village obtained from local

authorities, with additional information provided by village based volunteers wherever

possible. A questionnaire was administered to a respondent in each selected household. The

person interviewed was the female head of household whenever possible. Questions

addressed household composition, characteristics and assets, mosquito net use, health and

treatment seeking behavior, knowledge of malaria transmission and prevention, frequent

travel, forest-related activities, and travel amongst permanent and temporary visitors.

Malaria prevalence survey

A finger prick blood sample was taken from a sub-sample of four individuals within the

household. One person was randomly sampled from each of the following groups: 1) aged 0 to

4 years, 2) aged 5-14 years, 3) adult female (15+ years), and 4) adult male (15+ years), to

compare malaria risk among these groups. The individuals for whom blood samples were

taken were recorded in the household schedule in the household questionnaire. A household

survey blood sample sheet was used to record details to identify and link the samples taken.

Blood smears were prepared for microscopy and two dried blood spots (DBS) for molecular

analysis using polymerase chain reaction (PCR) and serology were collected on filter paper. If

there were any pregnant women in the household, who were not included in the blood taking

sample for adult woman, their blood sample was also collected. In addition, blood samples

were obtained from temporary visitors residing in the household; up to four visitors per

household were randomly selected from this group. Additionally if there were any people in

the household who appeared to be symptomatic for malaria (fever), they were given a rapid

diagnostic test (RDT) and those with a positive result were treated with the appropriate first-

line antimalarial drug according to national treatment guidelines. Microscopic examinations of

Giemsa-stained blood smears were performed to determine the presence of malaria parasites.

An extensive training and quality assurance programme was implemented to best ensure

accuracy of prevalence data. Blood takers were trained in smear preparation and smear

staining procedures prior to the start of data collection.

7 Based on very limited information available and consultations


Drug outlet survey

For each selected household survey cluster (village), two drug outlets that serve the village

were conveniently sampled to triangulate the household survey data on treatment-seeking. It

is important to note that the drug outlets did not include any health facilities where drugs

could be purchased. These drug outlets were located within the village or in the nearest/most

easily accessible market or town. Information on all private, including informal drug outlets in

Tiers 1 and 2, were not readily available. The most common and accessible outlets were

selected, one in a central location and one in periphery of the village. A structured

questionnaire was used to document details of the outlet and the respondent. For drug outlets,

information on sale and stock management of ACTs, other antimalarial drugs and RDTs were

recorded, together with knowledge of national drug policy for malaria and common

dispensing practice. Awareness of ongoing activities to contain artemisinin resistance and

banned oral artemisinin monotherapies were also noted and referral practices for potential

severe malaria cases. Interviewers administered the questionnaire to the owner or any adult

(>15 years) respondents who was available to be interviewed.


The health facility survey was conducted among a sample of public health facilities that have

within their catchment area villages or towns designated as high risk in Tier 1 and Tier 2. This

survey aimed to provide an overview of malaria-related services in Tier 1 and Tier 2 and the

capacity of the health facilities to provide appropriate diagnosis and treatment of malaria.

The health facility survey included 3 components: 1) an audit of malaria services, 2) exit

interviews of individuals with recent fevers, and 3) follow up of malaria patients within the

last month.

The first component comprised of an audit of malaria-related services, including availability of

antimalarial medicines, existence of treatment guidelines and protocols, and availability of

laboratory diagnostic capacity.

Due to the low incidence of malaria, it was not possible to do structured observations of

patients presenting at the health facility. Since it was important to assess the delivery of

services for malaria within the public health facility system, a second component of the health

facility survey included exit interviews of patients (or caregivers) with recent fever to ascertain

the level of service received at the time of the survey. Teams remained at the health facility for

up to 3 days or until the sample size was reached.

A third component of the health facility survey included a follow-up of patients who were

recently treated for malaria within the past month. Up to 20 malaria cases from the register

books were followed up in their homes for a maximum of 3 days.

The health facility survey was conducted at the same time as the household and drug outlet

surveys, and required a different team of field staff. It was anticipated that 80 health facilities


each for public and private facility was sampled for a total of 160 health facilities (1 public and

1 private facility for each cluster). This sample size was based on an estimate that 70% of

public facilities were fully functioning, with 30% precision and a design effect (DE) of 1.75.

The public health facility was randomly selected from a list of all public facilities in the

catchment area of the selected clusters and sampling was done prior to the field work. For the

selection of private facilities, a list of all private care providers in the village was compiled by

the field team upon arrival and from this list, one facility was randomly selected, with the aim

to provide a sample including a range of private provider type in the study area.

FIELDWORK PROCESS

Household & Drug Outlet surveys

The sample design was 40 clusters in both Tier 1 and Tier 2, a total of 80 clusters.

2 x 40 clusters x 25 households / cluster = 2000 households

It was anticipated that each team would visit each cluster for one day and one night to avoid

bias from people absent during the day and to ensure that all of the blood samples would be

collected. Each team was assumed to be able to do three-four clusters per week (Monday to

Thursday days and nights) with Friday for planning, reporting and resupplying.

80 clusters @ 4 clusters per week = approximately 20 team-weeks

Proposed team composition for the household and outlet survey was 9 people consisting of:

1 x survey supervisor 4 x household interviewers 1 x supervisory technician 1 x outlet interviewer 2 x drivers

Blood takers were found locally in each cluster and integrated to the team on the survey day.

With 5 teams, 45 fieldworkers in total, each team would be in the field for 4 weeks. The 20

household interviewers were able to interview 6-7 households per day (approximately 45

minutes to 1 hour per household); the outlet interviewer visited one drug outlet in the

selected cluster, plus one drug outlet in the nearest market or town. Households with

individuals absent during the time of the visit were revisited by the survey team up to three

times. The team also took GPS coordinates for a central point in the village.

Health Facility Survey

The health facility survey required 5 teams of 5 field workers = 25 field workers. A total of 5

teams of 5 individuals (3 interviewers, 1 supervisor, and 1 driver) were trained. Each team

spent up to 3 days for data collection at each health facility. The interviewer roles were as

follows: Interviewer #1 was responsible for conducting exit interviews for all fever cases and


malaria cases at health facilities. Interviewer #2 conducted the checklist for the health facility,

staff details, and health facility, laboratory, and pharmacy inventories. Interviewer #3 did

follow-up malaria cases recorded in the register in the previous 3 months including

administering the questionnaire for private providers within the catchment area of the public

health facility.

ETHICAL CONSIDERATIONS

Individual informed consent was sought from all respondents before interviews were

conducted. Before each interviewee was asked to give consent, the interviewer gave a brief

description of the study objectives, the data collection procedure, the expected benefits, and

the voluntary nature of participation at all stages of the interview. Community consent was

obtained by holding a meeting with the village and commune leaders prior to the scheduled

visit to the study villages, informing them of the purpose and procedures involved and

obtaining their agreement. Assurances were given to all participants that data would be kept

private and confidential.

DATA PROCESSING AND ANALYSIS

Data entry for all survey data was done using Epidata 3.1, with the exception of slide readings which were recorded in Microsoft Excel. Double entry was done for all data and appropriate verification and validation carried out. All data was transferred to Stata 12.0 (StataCorp LP, College Station, TX USA) for data processing and analysis. After initial data cleaning and consistency checks, data were re-coded and key indicators generated using pre-defined definitions.

After this re-code stage, all household data analysis were adjusted for the survey design, i.e. clustering, and sample strata and sample weights at the household level and individual level were applied as appropriate. Analysis focused on key indicators providing overall estimates by background characteristics including tier, risk category and socioeconomic status (wealth quintiles).

A wealth index was obtained for each household in the survey based on household characteristics and assets using principle components analysis (PCA). All variables input to the PCA were itemized and the first component was used as the wealth index. Households were then classified into five wealth index quintiles and these were used as the relative socioeconomic groups. Wealth quintiles were calculated separately for each tier. The household quintile was applied to an individual for individual level analysis.

Sample weights

Within each tier, the sampling of clusters was non-proportional across risk categories;

therefore the sample data for the household survey was non-self-weighting. All household

survey analysis accounted for sample weights within each tier together with adjustment for

clusters and sampling strata, i.e. risk category strata. In addition, for the prevalence survey


where individuals were sampled for 4 different age and sex groups (under 5 years, 5 to 14

year olds, adult males (15+ years), and adult females (15+ years)), additional weighting was

required. Analysis of prevalence survey data accounts for these individual weights.


RESULTS

ISSUES TO CONSIDER

1. Representativeness. The intention of this data collection was to obtain information from

households on malaria prevalence and other malaria indicators that would be statistically

representative of the population in the Containment areas (Tier 1 vs. Tier 2 excluding

Kachin State). In order to achieve such representativeness, the sampling methodology

involved a two stage cluster sampling which is similar to those used in standard national

surveys as Malaria Indicator Cluster Surveys (MICS) and Demographic Health Surveys

(DHS).

2. Accessibility. A total of 16 out of 80 clusters (20%) were considered inaccessible due to

security concerns during the period of the survey. These clusters were then systematically

replaced, selecting randomly another cluster with the same tier and risk category.

However, one could expect the population living in inaccessible villages to be more prone

to get malaria due to poorer access to health care. As a result, it may be likely that the true

malaria prevalence presented in Tier 1 and Tier 2 may be under-estimated.

3. Sampling of individuals. The prevalence survey aimed at collecting blood from one

individual in each of the following age group in every household: children from 1-4,

children from 5 to 14, female over 15 and male over 15. Considering any household with

any individual in these categories, the theoretical sample size for the prevalence survey

was 5509. Overall, 5264 blood samples were collected and analysed, which means that

245 samples or 4.4% of the target were missed.

4. Risk stratification. Clusters were sampled using the malaria risk stratification performed

in 2007-2008 and based on ecological factors and long term malaria data. However, it is

likely that this stratification was not truly representative of the true malaria risk of the

population at the time of the survey (for example due to deforestation) given that this data

was already outdated. But it seems reasonable to suspect that any alteration of risk

stratification would rather occur in lower malaria risk area first as these were more

accessible. As clusters were purposely oversampled in higher risk area, this factor is

unlikely to have significantly impacted on the precision of the prevalence estimate.

5. Seasonality. Data collection occurred between mid-December 2011 through mid-

February 2012 towards the tail-end of the usual malaria transmission season. This will

inevitably affect the malaria prevalence based on traditional blood smears. However, this

survey included molecular analysis of samples to be able to detect low and sub-

microscopic parasitemia and even serological measures for transmission. Furthermore, it

is also important to balance the fact that collecting data during the dry season allowed

field teams to access villages that were likely to be in hard-to-reach area during the rainy

season.

6. Migrants and mobile populations. These populations are often most vulnerable and

most difficult to sample from. Although this survey attempted to include questionnaires

for mobile populations (including temporary visitors and those who go to the forest), the


design of the household survey was not intended to specifically address this population.

More specialized survey methodologies may be needed.

HOUSEHOLD AND PREVALENCE SURVEYS

1.1 Characteristics of the sample and summary results

Figure 1.1.1: Selected clusters of the baseline survey


Table 1.1.1 Denominators for households and sampled individuals

TOTAL Tier 1 Tier 2

N (100%) N (%) N (%)

Households 1992 997 (50.1) 995 (49.9)

People in households 9408 4612 (49.0) 4796 (51.0)

Under 5 years 886 405 (45.7) 481 (54.3) 5 to 14 year olds 2280 1065 (46.7) 1215 (53.3)

Male adults, 15+ years 2782 1383 (49.7) 1399 (50.3)

Female adults, 15+ years 3460 1759 (50.9) 1701 (49.1)

Currently pregnant (% of all eligible women)

74 33 (44.6) 41 (55.4)

Household nets: Any type of mosquito net ITN8 LLIN9

5986 1248 313

3011 (50.3) 690 (55.3) 147 (47.1)

2975 (49.7) 558 (44.7) 166 (52.9)

People who go to the forest and sleep overnight

453 167 (36.9) 286 (63.1)

People who travel and sleep away from home (past 6 months)

730 304 (41.6) 426 (58.4)

Temporary visitors in the household

124 42 (33.9) 82 (66.1)

People who reported fever in the previous two weeks

241 128 (53.1) 113 (46.9)

Blood samples taken for microscopy

5264 2557 (48.6) 2707 (51.4)

Number of drug outlets 120 61 (50.8) 59 (49.2)

A total of 1992 households were interviewed, which corresponds to 99.6% response rate of

the target sample size of 2000 households. The two tiers appeared quite different in terms of

basic demographic characteristics and distribution. The population living in the sampled

households appeared to be younger and more mobile in Tier 2 compared to Tier 1 and

included a larger proportion of pregnant women. More ITNs were found in the households of

Tier 1 while a larger proportion of LLIN were found in Tier 2. Finally, more people reported

fever in the previous two weeks in Tier 1.

8 ITN = insecticide-treated net, which includes recently treated and LLINs 9 LLIN = long lasting insecticide-treated net


Table 1.1.2 Age and sex distribution of residents, visitors, people who travel away from home, and people who go to the forest

TOTAL < 5 years 5-14 years 15+ years Males

15+ years Females

N % (N) % (N) % (N) % (N)

Total (N=9408)

Usual residents 9282 9.4 (877) 24.3 (2258) 29.4 (2729) 36.8 (3418)

Temporary visitors 124 7.3 (9) 17.0 (21) 41.9 (52) 33.9 (42) Travel away from home

730 3.8 (28) 8.2 (60) 53.7 (392) 34.2 (250)

Go to the forest 453 2.4 (11) 4.9 (22) 74.4 (337) 18.3 (83)

Tier 1 (N=4612)

Usual residents 4570 8.8 (403) 23.1 (1057) 29.9 (1367) 38.1 (1743)

Temporary visitors 42 4.8 (2) 19.1 (8) 38.1 (16) 38.0 (16)

Travel away from home

304 2.3 (7) 7.9 (24) 56.3 (171) 33.5 (102)

Go to the forest 167 4.8 (8) 3.0 (5) 72.5 (121) 19.8 (33)

Tier 2 (N=4796)

Usual residents 4712 10.1 (474) 25.5 (1201) 28.9 (1362) 35.5 (1675)

Temporary visitors 82 8.5 (7) 15.9 (13) 43.9 (36) 31.7 (26) Travel away from home

426 4.9 (21) 8.4 (36) 51.9 (221) 34.7 (148)

Go to the forest 286 1.0 (3) 5.9 (17) 75.5 (216) 17.5 (50)

Although not designed to specifically address indicators for mobile and migrant populations, this survey attempted to include as many migrant and mobile populations as possible. These included temporary visitors, those who traveled from their home within the past 3 months, and those who had spent the night in the forest. The distribution of those sampled was not significantly different among the different age and sex groups, and between tiers. Although it should be noted that there appeared to be slightly higher proportions of “mobile populations” (defined as temporary vistors, recent travelers, and those who spent the night in the forest) in Tier 2 (16.6%) compared to Tier 1 (11.1%).

Table 1.1.3 Details of temporary visitors in households

Temporary Visitors TOTAL (N=124) Tier 1 (N=42) Tier 2 (N=82)

% (N) % (N) % (N)

Length of time in the village < 1 month 1–2 months 3–6 months > 6 months

37.5 (45) 19.2 (23) 15.0 (18) 28.3 (34)

33.3 (14) 23.9 (10) 21.4 (9) 21.4 (9)

39.7 (31) 16.6 (13) 11.5 (9)

32.1 (25)

Reason to travel in the village Work (arranged before arrival) Look for work Make new home Visit relatives Other

18.5 (23) 0.8 (1) 4.9 (6)

56.5 (70) 19.4 (24)

23.8 (10) 0.0 (0) 9.6 (4)

45.3 (19) 21.4 (9)

15.8 (13) 1.2 (1) 2.4 (2)

62.2 (51) 18.3 (15)

Intention of length of stay


< 2 weeks 2–4 weeks 1–3 months 3–6 months 6–12 months > 12 months Not sure

21.8 (27) 9.7 (12)

19.4 (24) 6.4 (8) 0.8 (1)

12.1 (15) 29.8 (37)

31.0 (13) 2.4 (1)

16.7 (7) 4.7 (2) 0.0 (0)

14.3 (6) 30.9 (13)

17.1 (14) 13.4 (11) 20.7 (17)

7.3 (6) 1.2 (1)

11.0 (9) 29.2 (24)

Intention to travel next

Return home Work in this province Work in another province Other Don't Know

88.7 (110) 1.6 (2) 2.4 (3) 4.8 (6) 2.4 (3)

90.5 (38) 0.0 (0) 7.1 (3) 0.0 (0) 2.4 (1)

87.8 (72) 2.4 (2) 0.0 (0) 7.3 (6) 2.4 (2)

Travelled abroad during 2011

Thailand 5.6 (7) 2.4 (1) 7.3 (6)

Most of the temporary visitors were in the selected villages for a month or more and the main

reason was to visit relatives. Tier 1 had a higher proportion of visitors coming for work reason

compared to Tier 2. About thirty percent were not sure how long they would stay but in Tier

1, visitors intended to stay for a shorter period than in Tier 2. The vast majority of visitors

intended to return home, although in Tier 1 some visitors planned to work in another

province. This may suggest that many of the temporary visitors were there more for economic

reasons and may reinforce the transient nature of this highly mobile population.

Of those who travelled abroad in 2011, only a few (5.6%) had visited Thailand but the

proportion was slightly higher for Tier 2.

Table 1.1.4 Details of people in households who go to the forest and sleep overnight

TOTAL (N=453) Tier 1 (N=167) Tier 2 (N=286)

% (N) % (N) % (N)

Last visit to the forest

Last night < 1 week 1 to < 4 weeks ≥ 4 weeks Not sure

23.0 (104) 28.0 (127) 18.6 (84)

28.5 (129) 2.0 (9)

29.3 (49) 26.9 (45) 10.8 (18) 31.1 (52)

1.8 (3)

19.2 (55) 28.7 (82) 23.1 (66) 26.9 (77)

2.1 (6)

Number of nights in the forest (last visit)

1–2 3–5 6–10 > 10 Not sure

22.7 (103) 22.1 (100) 22.3 (101) 22.5 (102) 10.4 (47)

17.9 (30) 19.1 (32) 16.2 (27) 32.9 (55) 13.8 (23)

25.5 (73) 23.8 (68) 25.9 (74) 16.4 (47) 8.4 (24)

The pattern of population mobility for forest goers seemed more frequent and for longer

periods in Tier 1 compared to Tier 2 (although there were more in Tier 2), suggesting that Tier

1 may have clusters that could be closer to the forest.


Table 1.1.5 Details of usual residents away for more than 6 months


% (N) % (N) % (N)

Age & sex

< 5 years 5 to 14 years 15+ male 15+ female

0.4 (5) 4.8 (55)

56.4 (642) 38.4 (437)

0.8 (4) 5.5 (27)

56.8 (281) 37.0 (183)

0.2 (1) 4.3 (28)

56.1 )361) 39.4 (254)

Education level

No education Some primary Completed primary Some secondary Completed secondary More than secondary

11.6 (132) 25.3 (288) 15.7 (179) 22.1 (252)

6.8 (78) 18.4 (210)

7.3 (36) 20.8 (103) 23.2 (115) 22.4 (111)

8.1 (40) 18.2 (90)

14.9 (96) 28.7 (185)

9.9 (64) 21.9 (141)

5.9 (38) 18.6 (120)

Reason for absence

Working on farm or forest Working in other township Working in Thailand Studying Holidays Other Not sure

2.7 (31) 16.7 (190) 66.5 (758)

7.6 (87) 1.1 (12) 3.6 (41) 1.8 (20)

3.6 (18) 19.8 (98)

61.2 (303) 8.5 (42) 0.8 (4)

2.4 (12) 3.6 (18)

2.0 (13) 14.3 (92)

70.6 (455) 7.0 (45) 1.2 (8)

4.5 (29) 0.3 (2)

The level of education of the usual resident that were absent for more than six months in Tier

1 was higher than in Tier 2 and the reason for absence was more likely to be to work or study

in the country; while in Tier 2, there were more people working in Thailand. This confirms

that the travelling habits in Tier 1 appeared shorter and more frequent compared to Tier 2. It

is also interesting to note that there were similar numbers of people moving out of the target

area than moving in (1317 considered as mobile population versus 1139 usual residents

absent for more than six months).

MALARIA PREVALENCE AND FEVER

Table 1.2.1 Malaria prevalence by species and zone, and reported fever by Tier

TOTAL (N=5264)

Tier 1 (N=2557)

Tier 2 (N=2707)

P-value*

% (N) 95% CI % (N) 95% CI % (N) 95% CI

Slides

Total Positive 0.5 (24) 0.3 to 0.8 0.8 (20) 0.4 to 1.6 0.1 (4) 0.0 to 0.4 0.01

P. f. prevalence 0.1 (7) 0.1 to 0.3 0.2 (4) 0.0 to 0.5 0.1 (3) 0.0 to 0.5 0.02

P. v prevalence 0.3 (14) 0.1 to 0.6 0.5 (13) 0.2 to 1.1 0.0 (1) 0.0 to 0.3

Species among positive slides (N=24)

P. falciparum 29.2 (7) 14.0 to 51.0 20.0 (4) 9.0 to 39.0 75.0 (3) 15.1 to 98.1 0.20

P. vivax 58.4 (14) 38.1 to 76.2 65.0 (13) 47.3 to 79.4 25.0 (1) 1.9 to 84.9


Not sure 12.4 (3) 3.0 to 39.4 14.9 (3) 3.4 to 46.6 0.0 (0) -

Fever in the household previous 2 weeks

Yes 2.6 (241) 2.1 to 3.1 2.8 (128) 2.1 to 3.7 2.4 (113) 1.9 to 2.9 0.37

* Comparison of Tier 1 and Tier 2

The overall proportion of positive slides was 0.5% and it is interesting to note that the

prevalence of Plasmodium vivax infections was higher than Plasmodium falciparum, although

this difference was not significant. The comparison by tier tells us that the malaria prevalence

was higher in Tier 1 and this was true for both malaria species. This trend was also observed

in reported prevalence of fever in the previous two weeks.

Looking at malaria species among the positive slides tells us that P. vivax accounted for the

highest proportion overall in Tier 1 while in Tier 2 this pattern was reversed. It is worth

noting that none of the cases had a mix infection of Pf and Pv.

Table 1.2.2 Malaria species by age/sex and socioeconomic group

Number of blood samples

Total positive % (N)

P-value P. falciparum % (N)

P. vivax % (N)

Not sure % (N)

Age group

< 5 years 562 1.3 (5) 0.05* 22.2 (1) 55.7 (3) 22.0 (1)

5 to 14 years 1152 0.6 (8) 0.0 (0) 100 (8) 0.0 (0)

Male 15+ years 1595 0.6 (7) 40.8 (4) 48.3 (2) 10.9 (1)

Female 15+ years 1955 0.3 (4) 28.8 (2) 17.1 (1) 54.1 (1)

SES

Q1 (poorest) 1076 1.3 (9) 0.28 23.6 (4) 45.5 (3) 30.9 (2)

Q2 1093 0.4 (4) 75.1 (2) 24.9 (2) 0.0 (0)

Q3 1037 0.9 (5) 0.0 (0) 100 (5) 0.0 (0)

Q4 1044 0.3 (4) 26.1 (1) 73.9 (3) 0.0 (0)

Q5 (least poor) 1014 0.3 (2) 0.0 (0) 44.7 (1) 55.3 (1)

* Significant at p<0.05

Malaria infection was higher among young children under 5 and this association was of

borderline significance. This is interesting compared to Thailand and Cambodia where adults

had higher prevalence rates. This suggests that local transmission may still be occuring in the

studied area.

As expected, people living in households in the poorest wealth quintile had a higher

probability to have a positive slide.

The interpretation of low numbers of positive slides should consider that data were collected

during the season of low malaria transmission. Often, in South East Asia, higher rates of P.


falciparum can be observed in higher transmission setting while as transmission decreases,

rates of P. vivax increases but this was not evident in these data.

Table 1.2.3 Malaria species by State/Division

State/Division Number of blood samples

Total positive % (N)

P. falciparum % (N)

P. vivax % (N)

Not sure % (N)

Bago 1167 0.3 (3) 100 (3) - -

Kayah 115 0.0 (0) - - -

Kayin 1496 0.1 (1) - 100 (1) -

Mon 1557 0.4 (6) 13.6 (1) 38.6 (3) 47.7 (2)

Tanintharyi 929 1.5 (14) 21.2 (3) 66.6 (10) 12.2 (1)

The most affected state in terms of malaria prevalence was Tanintharyi while in Kayah State,

there was no positive slide detected. It should be noted that these data presented by township

are interesting, but was not powered to be representative at township level.

Table 1.2.4 Determinants of a positive blood slide

Positive slides (N=5264)

% (N) 95% CI P value

Tier 1 (N=2557)

2 (N=2707)

1.1 (20) 0.1 (4)

0.4 to 2.5 0.0 to 0.2

<0.01*

Age and sex < 5 years (N=562)

5 to 14 years (N=1152) Male 15+ years (N=1595)

Female 15+ years (N=1955)

1.3 (5) 0.6 (8) 0.6 (7) 0.3 (4)

0.4 to 3.8 0.2 to 1.8 0.6 to 1.7 0.1 to 0.9

0.05

Wealth quintile Q1 (poorest) (N=1076)

Q2 (N=1093) Q3 (N=1037) Q4 (N=1044)

Q5 (least poor) (N=1014)

1.3 (9) 0.4 (4) 0.9 (5) 0.3 (4) 0.3 (2)

0.4 to 4.3 0.1 to 2.1 0.2 to 3.4 0.1 to 1.1 0.1 to 1.4

0.28

Go to the forest Yes (N=222)

No (N=5042)

0.8 (3)

0.6 (21)

0.2 to 3.0 0.3 to 1.6

0.80

Travel Yes (N=279) No (4985)

0.2 (1)

0.7 (23)

0.3 to 1.6 0.0 to 1.7

0.27


Reported fever in past 2 weeks

Yes (N=166) No (N=5098)

3.4 (7) 0.5 (17)

1.2 to 9.7 0.2 to 1.4

<0.01*

Used any net the previous night

Yes (N=4280) No (N=984)

0.5 (16) 1.4 (8)

0.2 to 1.2 0.5 to 3.7

<0.01*

Risk category 1a (N=1634) 1b (N=1324) 1c (N=1049)

2 (N=775) 3 (N=482)

2.9 (15) 0.4 (8) 0.0 (0) 0.0 (0) 0.0 (1)

1.3 to 6.4 0.2 to 0.8

- -

0.0 to 0.4

0.23


Living in Tier 1 and living in a household in a higher malaria risk category significantly

increased the risk of having a positive slide for malaria. Other patterns can be observed

although these are not statistically significant. Proportions of positive slides appeared to

increase across age category, with female adults having the lower chance of having a positive

chance. Unsurprisingly, the probably of a positive slide was also associated with poverty.

Interestingly, going to the forest increased slightly the chance of having a positive slide while

travelling away from home lowered the chance of being malaria positive. Finally, people who

reported fever in the previous two weeks had a higher proportion of positive slides as well as

those who did not use any net the previous night.

Table 1.2.5 Distribution of fever by socioeconomic group within Tiers

TOTAL (N=241)

Tier 1 (N=128)

Tier 2 (N=113)

P-value*

% (N) 95% CI % (N) 95% CI % (N) 95% CI

Prevalence of reported fever in the previous two weeks (N=9408)

Reported fever

2.6 (241) 2.1 to 3.1 2.8 (128) 2.1 to 3.7 2.4 (113) 1.9 to 2.9 0.37

Socioeconomic Group

Q1 (poorest) Q2 Q3 Q4 Q5 (least

poor)

24.9 (60) 25.3 (61) 18.3 (44) 17.0 (41) 14.5 (35)

17.1 to 34.9 17.9 to 34.5 13.6 to 24.1 11.9 to 23.8 9.4 to 21.7

21.1 (27) 34.4 (44) 14.8 (19) 16.4 (21) 13.3 (17)

12.7 to 33.0 23.2 to 47.6 9.4 to 22.7 9.9 to 26.0 7.3 to 22.8

29.2 (33) 15.0 (17) 22.1 (25) 17.7 (20) 15.9 (18)

16.9 to 45.6 8.1 to 26.1

14.5 to 32.2 10.5 to 28.2 8.4 to 28.2

0.13

* Comparison of Tier 1 and Tier 2

Fever within the past 2 weeks was positively associated with malaria slide positivity. The

prevalence of reported fever in the previous two weeks was similar across tiers. In general,

people living in poorer households tended to have higher risk of reporting fever in the

previous two weeks.


Table 1.2.6 Determinants of fever in the past two weeks

Tier 1 (N=4612) Tier 2 (N=4796)

N % 95% CI P-value N % 95% CI P-value

Age and sex < 5 years

5 to 14 years Male 15+ years

Female 15+ years

25 42 30 31

6.2 3.9 2.2 1.8

3.3 to 11.3 2.4 to 6.5 1.5 to 3.2 1.2 to 2.5

<0.01*

481 20 36 30

5.6 1.6 2.6 1.8

3.6 to 8.6 1.1 to 2.4 1.9 to 3.5 1.1 to 2.7

<0.01*

Wealth quintile Q1 (poorest)

Q2 Q3 Q4

Q5 (least poor)

28 43 19 21 17

3.2 4.5 2.0 2.3 1.8

2.2 to 4.8 3.1 to 6.6 1.1 to 3.6 1.4 to 3.8 1.0 to 3.2

<0.01*

33 17 25 20 18

3.5 1.8 2.6 2.0 1.8

2.3 to 5.2 1.1 to 3.1 1.7 to 4.0 1.3 to 3.0 1.0 to 3.2

0.12

Go to the forest Yes

No

5

123

3.0 2.8

1.3 to 6.7 2.0 to 3.7

0.86

17 96

5.9 2.1

3.0 to 11.3 1.7 to 2.7

<0.01*

Travel Yes

No

7

121

2.3 2.8

1.0 to 5.1 2.1 to 3.8

0.66

10

103

2.3 2.4

1.3 to 4.3 1.8 to 3.0

0.99

Used any net the previous night

Yes No

106 22

2.9 2.2

2.2 to 4.0 1.3 to 3.5

0.17

3605 1191

2.6 1.5

2.1 to 3.4 1.0 to 2.4

0.02*

Used any LLIN the previous night

Yes No

175 121

4.0 2.7

1.7 to 9.0 2.0 to 3.6

0.34

187 4609

1.6 2.4

0.4 to 6.8 1.9 to 3.0

0.57

Risk category 1a 1b 1c

2 3

53 35 17 17 6

3.7 3.1 1.9 2.3 1.5

2.8 to 4.8 1.4 to 6.7 0.8 to 4.5 1.2 to 4.3 0.5 to 3.9

0.39

42 26 26 9

10

3.0 2.1 2.8 1.2 2.2

2.0 to 4.3 1.1 to 4.0 2.1 to 3.8 0.7 to 2.0 1.4 to 3.4

0.16


This table presents the determinants of reported fever prevalence in the previous two weeks, by tier. Age and sex appeared to be associated in both tier with prevalence of reported fever, with children under five having a significantly higher risk of reporting fever in the previous two weeks. Another association was found in Tier 2, across forest-goers category, with an increased risk of reporting fever among the group that goes to the forest.


MALARIA PREVENTION

Figure 1.3.1 Knowledge of causes of malaria transmission mentioned by Tier (N=1898)

Household respondents were asked to mention any transmission mode for malaria. Although

the vast majority answered “mosquito bites”, it is worth noting the multitude of erroneous

ideas on transmission modes also mentioned. A non-negligible proportion of respondents

cited transmission modes related to drinking or bathing in dirty or river water. Also, nearly

20% of respondents in each tier did not know any transmission mode, which is relatively high

and suggests a need for more specifically targeted behaviour change communication.

Figure 1.3.2 Knowledge of means of malaria prevention mentioned by tier (N=1898)

0%10%20%30%40%50%60%70%80%90%

100%

Tier 1

Tier 2

0%10%20%30%40%50%60%70%80%90%

100%

Tier 1

Tier 2


The main prevention method mentioned by respondents was “Sleeping under a net” and this

proportion was higher among respondents in Tier 1. This suggests that the population living in

the target area may not be familiar to a large extent with insecticide treated net and this seems

particularly true for Tier 2. This is triangulated with the relatively low knowledge of the

benefits of using an ITN (Figure 1.3.3). In terms of personal protection methods, the most

popular answer was “mosquito coil”, with more than 15% in Tier 1 and over 10% in Tier 2.

Similarly to the awareness of transmission modes, a significant proportion of respondents

(nearly 20% in Tier 1 and nearly 30% in Tier 2) did not mention or did not know any

prevention method at all.

Figure 1.3.3 Perceptions about ITN benefits mentioned by Tier (N=1898)

The three most mentioned benefits of using an ITN were “prevent mosquito bites”, “repels

mosquitoes” and “kills mosquitoes”. Awareness of ITN benefits appeared higher in Tier 1

although very few respondent mentioned “protects against malaria”.

Figure 1.3.4 Malaria messages seen or heard in past 6 months by Tier (N=241)

0%10%20%30%40%50%60%70%80%90%

100%

Tier 1

Tier 2

0%10%20%30%40%50%60%70%80%90%

100%

Tier 1

Tier 2


Overall, only 12.1% (N=241) of household respondents had heard or seen any message

about malaria in the past six months and this proportion was similar across tiers (Tier 1,

11.9% versus Tier 2, 12.3%) . Among those who received any information, the messages most

mentioned were related to the use of any net and any ITN. It also appeared that behaviour

change communication coverage may be higher in Tier 1.

Figure 1.3.5 Source of malaria messages mentioned by Tier (N=241)

The most popular source of information was health facility staff in both tiers and the second

most common source of message in Tier 1 was “NGO”.

Table 1.3.1 Summary of household ownership of mosquito nets

Number of House-holds

At least one mosquito net

Any Type Any ITN Any LLIN

% (95% CI) P-value

% (95% CI) P-value

% (95% CI) P- value

Total 1992 97.4 (95.1 to 98.7) - 35.1 (28.4 to 42.4) - 11.1 (7.3 to 16.4) -

Tier

1 2

997 995

96.6 (92.2 to 98.5) 98.3 (95.2 to 99.4)

0.30 39.3 (29.8 to 49.6) 30.8 (21.9 to 41.5)

0.24 10.9 (6.3 to 18.2) 11.3 (6.1 to 19.9)

0.93

Risk Category

1a 1b 1c 2 3

599 495 400 299 199

95.3 (88.2 to 98.2) 96.6 (89.4 to 98.9) 99.5 (98.2 to 99.9) 99.3 (95.2 to 99.9) 99.0 (92.9 to 99.9)

0.10 55.1 (37.8 to 71.2) 41.6 (27.4 to 57.4) 19.0 (11.0 to 30.9) 23.1 (14.3 to 35.1)

9.0 (2.7 to 26.0)

0.01* 18.9 (10.1 to 32.7) 13.1 (5.6 to 27.7)

2.5 (1.4 to 4.5) 9.7 (4.3 to 20.3) 1.5 (0.5 to 4.1)

0.01*

Socioeconomic Group

Q1 (poorest) Q2 Q3 Q4 Q5 (least poor)

399 398 399 398 398

94.0 (86.0 to 97.5) 96.7 (93.0 to 98.5) 98.5 (96.2 to 99.4) 99.5 (97.9 to 99.9) 98.5 (96.4 to 99.4)

0.01* 41.0 (28.8 to 54.5) 38.2 (28.3 to 49.1) 34.3 (25.9 to 43.8) 33.2 (26.0 to 41.3) 28.6 (22.0 to 36.3)

0.18 14.8 (8.5 to 24.4) 13.6 (7.5 to 23.4) 11.0 (6.4 to 18.4) 10.3 (6.1 to 16.9)

5.5 (3.4 to 8.9)

0.05


Although a vast majority of households (97.4%) possessed at least one mosquito net on the

survey day, ownership of any ITN was much lower (35.1%) and this was even more marked

0%10%20%30%40%50%60%70%80%90%

100%

Tier 1

Tier 2


for any LLIN (11.1%). While coverage of any net appeared similar across tier and risk

category, there was a positive association with wealth. Coverage of any ITN and LLN showed a

significant association with risk category, suggesting that ITN and LLN distribution were more

intense in higher malaria risk areas. It is interesting to note that household ownership of any

ITN and LLIN was higher among poorer households and this trend was significant for any

LLIN. This probably reflects the free or subsidized distributions in the target areas by the

national malaria programme or non-governmental partners. Given the greater protection

provided by an insecticide-treated net, the strong culture of net ownership may provide a

great opportunity to shift from untreated to treated mosquito nets.

Table 1.3.2 Summary of household ownership of sufficient mosquito nets

Number of House-holds

Sufficient Nets (i.e., 2 people/net)

Any Type ITN LLIN

% (95% CI) P-value

% (95% CI) P-value

% (95% CI) P-value

Total 1992 73.2 (68.6 to 77.4) - 13.1 (9.9 to 17.3) - 3.0 (1.7 to 5.0) -

Tier

1 2

997 995

73.8 (65.3 to 80.8) 72.7 (68.2 to 76.7)

0.80 15.2 (10.2 to 22.2) 11.0 (7.3 to 16.4)

0.26 3.0 (1.4 to 6.3) 2.9 (1.4 to 6.0)

0.94

Risk Category

1a 1b 1c 2 3

599 495 400 299 199

65.9 (55.9 to 74.6) 72.4 (61.9 to 80.8) 80.3 (72.1 to 86.5) 71.9 (58.0 to 82.6) 85.4 (78.2 to 90.6)

0.05 20.3 (12.2 to 32.0) 13.5 (9.1 to 19.6) 11.0 (5.3 to 21.6) 7.4 (3.6 to 14.4) 3.5 (0.7 to 15.1)

0.03* 6.2 (2.8 to 13.0) 2.2 (1.0 to 4.9)

0.0 (-) 3.7 (1.7 to 7.7)

0.0 (-)

0.01*

Socioeconomic Group


399 398 399 398 398

60.6 (51.2 to 69.3) 66.1 (59.4 to 72.2) 76.9 (70.8 to 82.1) 78.1 (72.2 to 83.1) 84.4 (80.2 to 87.9)

0.01* 17.8 (11.1 to 27.2) 13.8 (9.3 to 20.1) 12.3 (8.2 to 18.0) 9.3 (6.3 to 13.6)

12.6 (8.2 to 18.8)

0.12 4.8 (2.5 to 9.0) 4.0 (1.9 to 8.5) 3.3 (1.5 to 6.9) 1.8 (0.9 to 3.6) 1.0 (0.2 to 4.7)

0.07


Although nearly three quarters (73.2%) of the sampled households owned at least one

mosquito net for every two people, very few reached universal coverage target with LLIN

(3.0%). A similar trend for household coverage of any type of mosquito net was observed.

Table 1.3.3 Characteristics of household nets

TOTAL Tier 1 Tier 2

N Mean ± SD (95% CI)



Number of nets in household

5986 3.08 ± 0.08 (2.93 to 3.23)

3011 3.13 ± 0.12 (2.87 to 3.38)

2975 3.04 ± 0.09 (2.87 to 3.21)

Age of net

< 6 months 6 mo to < 1 year 1 year to < 2 years 2 years to < 3 years 3 years to < 5 years ≥ 5 years Not sure

695 841

1456 1050 853

1036 55

11.6 14.1 24.3 17.5 14.2 17.3 0.9

406 541 775 502 383 381 23

13.5 18.0 25.7 16.7 12.7 12.7 0.8

289 300 681 548 470 655 32

9.7 10.1 22.9 18.4 15.8 22.0 1.1

Source of net


Gift (family/friend) Government NGO Shop/Market Itinerant seller Other Not sure

302 427 419

4236 525 68 9

5.0 7.1 7.0

70.8 8.8 1.1 0.2

133 221 248

2205 151 51 2

4.4 7.3 8.2

73.2 5.0 1.7 0.1

169 206 171

2031 374 17 7

5.7 6.9 5.7

68.3 12.6 0.6 0.2

Price of net

No cost < 4,000 4,000 to < 12,000 12,000 or more Not sure

663 1400 1388 1386 1149

11.1 23.4 23.2 23.2 19.2

410 667 690 647 597

13.6 22.2 22.9 21.5 19.8

253 733 698 739 552

8.5 24.6 23.5 24.8 18.6

Type of net

LLIN: Powernet Permanet JICA MoH Olyset CONVENTIONAL: Lace Military No logo Cotton CYC Other

8

166 1 4

222

3249 207 377

1021 731

0.1 2.8 0.0 0.1 3.7

54.3 3.5 6.3

17.1 12.2

2

104 0 2

77

1852 89

104 417 364

0.1 3.5 0.0 0.1 2.6

61.5 3.0 3.4

13.8 12.1

6

62 1 2

145

1397 118 273 604 367

0.2 2.1 0.0 0.1 4.9

47.0 4.0 9.2

20.3 12.3

Holes in net (based on asking respondent if net has any holes)

Yes No

1190 4796

19.9 80.1

478 2533

15.9 84.1

712 2263

23.9 76.1

Net repaired

Yes No

616 5370

10.3 89.7

235 2776

7.8 92.2

381 2594

12.8 87.2

Frequency washed

Never Weekly Every 2-3 weeks Monthly Every 2 - 3 months Twice per year Once a year < once a year Not sure

1008 500 998

1516 1013 490 254 66

141

16.8 8.4

16.7 25.3 16.9 8.2 4.2 1.1 2.4

576 284 509 814 459 180 79 39 71

19.1 9.4

16.9 27.0 15.2 6.0 2.6 1.3 2.4

432 216 489 702 554 310 175 27 70

14.5 7.3

16.4 23.6 18.6 10.4 5.9 0.9 2.4

Used last night

Yes No

3566 2416

59.6 40.4

1865 1145

61.9 38.0

1701 1271

57.2 42.7

Any old nets not being used for sleeping? (N=1941 households)

Yes No Not sure

321 1618

2

16.5 83.4 0.1

148 814

1

15.4 84.5 0.1

173 804

1

17.7 82.2 0.1

What are these old nets being used for? (N=321 households)

Saving for visitors Fishing Protect garden Protect animals Other

214 6 6 7

143

66.7 1.9 1.9 2.2

44.5

102 4 5 4

51

68.9 2.7 3.4 2.7

34.5

112 2 1 3

92

64.7 1.2 0.6 1.7

53.2

Any new nets not being used for sleeping? (N=1941 households)

Yes No

678 1262

34.9 65.0

379 583

39.4 60.5

299 679

30.6 69.4

Why aren't these new nets being used? (N=678 households)

Saving for visitors Saving for future No place to hang Have enough nets

374 184

5 115

55.2 27.1 0.7

17.0

214 101

4 60

56.5 26.6 1.1

15.8

160 83 1

55

53.5 27.8 0.3

18.4


The average number of mosquito nets of any sort found among households surveyed

was 3.1 and was similar across tier. Half of these nets were less than 2 years old and it seemed

that in Tier 1, nets tended to be younger than in Tier 2. Also, it was interesting to see quite a

high number of very old nets still in use by the household members – nearly one-quarter of

mosquito nets used in Tier 2 were more than 5 years old!

A majority of the household nets (70%) were purchased from the shop or the market and half

of these were conventional, untreated nets. In Tier 1, a higher proportion of the nets were

given out freely (13.6 versus 8.5%). As expected, the vast majority of the nets were

conventional or untreated and nets tended to be in better condition or intact in Tier 1 than

Tier 2.

Similarly, washing frequency seemed higher in Tier 1 as well as the proportion of net used the

previous night. These observations suggest that net distributions recently focused primarily in

Tier 1. On the other hand, less than 20% of households reported owning any old net used for

other purpose while more than 30% possessed any new nets not currently used for sleeping.

The main reason for not using these old or new nets was to save them for future use or for

visitors, a habit that could have some benefit to limit malaria transmission among mobile

populations.

Table 1.3.4 Places to obtain or retreat a net


N % N % N %

Place to obtain a new net

Shop/seller in village Nearest market Itinerant seller Wait for distribution Would not buy other Other Don’t know where to buy Not sure

87 1563 265 10 41 9

16 1

4.4 78.5 13.3 0.5 2.1 0.5 0.8 0.1

38 819 112

3 10 4

11 0

3.8 82.2 11.2 0.3 1.0 0.4 1.1 0.0

49 744 153

7 31 5 5 1

4.9 74.8 15.4 0.7 3.1 0.5 0.5 0.1

Place to treat or retreat a net

Wait for health staff Go to health centre/hospital Private health facility NGO Pharmacy Market/shop VHM/VHV Net all pre-treated Don’t want insecticide Have no net Other School Pagoda Don’t know

301 230 57 27 9 6

43 6

100 10

122 6 6

1069

15.1 11.5 2.9 1.4 0.5 0.3 2.2 0.3 5.0 0.5 6.1 0.3 0.3

53.7

155 135 44 24 4 2

16 3

26 9

33 6 2

538

15.6 13.5 4.4 2.4 0.4 0.2 1.6 0.3 2.6 0.9 3.3 0.6 0.2

54.0

146 95 13 3 5 4

27 3

74 1

89 0 4

531

14.7 9.5 1.3 0.3 0.5 0.4 2.7 0.3 7.4 0.1 9.0 0.0 0.4

53.4

Most households mentioned a private source to obtain a new mosquito net, mainly a

shop or the market or an itinerant seller. On the other hand, more than half of respondents did


not know where to go to retreat their net and the most popular places mentioned were “wait

for health staff” or “go to health centre or hospital”.

Table 1.3.5 Household ownership of nets by State

State Number House- holds

At least one mosquito net Sufficient nets

% (95% CI)

Sufficient ITN

% (95% CI) Any type

% (95% CI) LLIN

% (95% CI)

Bago Kayah Kayin Mon Tanintharyi

425 46

549 622 350

99.5 (96.7 to 99.9) 100 (-)

97.3 (91.8 to 99.1) 99.8 (98.8 to 100) 90.5 (80.3 to 95.7)

7.8 (2.5 to 21.3) 4.3 (1.2 to 14.9)

14.4 (6.5 to 28.9) 15.0 (8.3 to 25.6)

3.7 (1.8 to 7.5)

75.8 (70.8 to 80.1) 65.2 (50.2 to 77.8) 70.5 (63.3 to 76.8) 85.8 (81.5 to 89.3) 53.1 (36.6 to 69.0)

4.7 (1.9 to 11.3) 17.4 (15.4 to 19.6) 15.3 (9.4 to 23.8)

20.1 (13.4 to 29.0) 7.1 (2.9 to 16.6)

Household ownership of nets by State/Division tells us that Mon and Kayin States had the

highest coverage of any LLIN ownership, reaching respectively 15.0% and 14.4%, perhaps due

to the high numbers of NGOs operating in these areas.

Table 1.3.6 Summary of mosquito net usage (previous night) by target populations

N TOTAL % (95% CI)

Tier 1 % (95% CI)

Tier 2 % (95% CI)

P-value*

Any Net

All people 9408 76.5 (72.9 to 79.8) 78.0 (72.2 to 82.8) 75.2 (70.2 to 79.5) 0.43

Under 5 years 886 82.8 (78.2 to 86.7) 81.2 (74.3 to 86.6) 84.2 (77.6 to 89.1) 0.48

Pregnant women 74 77.0 (66.6 to 84.9) 81.8 (63.5 to 92.1) 73.1 (60.0 to 83.2) 0.37

People who go to the forest

453 53.0 (44.9 to 60.8) 47.3 (36.9 to 58.0) 56.3 (45.2 to 66.7) 0.25

People who travel away from home

730 44.8 (38.1 to 51.7) 34.5 (24.8 to 45.8) 52.1 (43.7 to 60.4) 0.01*

Temporary visitors 124 57.3 (43.1 to 70.3) 57.1 (36.0 to 75.9) 57.3 (39.0 to 73.8) 0.99

ITN





453 12.1 (7.4 to 19.2) 14.4 (8.2 to 24.1) 10.8 (5.0 to 21.8) 0.53


730 11.4 (7.4 to 17.1) 9.9 (5.6 to 16.7) 12.4 (6.8 to 21.5) 0.56

Temporary visitors 124 10.5 (4.9 to 21.0) 23.7 (9.7 to 47.5) 3.7 (0.8 to 15.4) 0.01*

LLIN





453 1.8 (0.7 to 4.2) 1.2 (0.3 to 4.9) 2.1 (0.7 to 6.0) 0.53


730 1.0 (0.3 to 2.8) 0.7 (0.1 to 4.5) 1.2 (0.3 to 4.4) 0.62

Temporary visitors 124 1.6 (0.4 to 6.8) 2.4 (0.3 to 17.1) 1.2 (0.2 to 9.0) 0.64

*Comparison between Tier 1 and 2, significant at p<0.05

In general, groups traditionally considered as most vulnerable for malaria (children under five

and pregnant women) had the highest proportion of net use in the survey. Also, estimates of

any net, ITN, and LLIN use among all people, under five and pregnant women appeared not to

differe significantly across tier.


Considering “mobile” groups in general, mosquito net use was the highest among temporary

visitors, then forest goers and finally travellers, for any mosquito net. However, ITN and LLIN

use was higher among forest goers. This could potentially reflect the rise in awareness about

malaria risk among households owning insecticide treated nets, assuming these nets were

more recent.

Table 1.3.7 Determinants of the use of any mosquito nets or insecticide-treated net

Slept under a mosquito net last night

Any Net P-value Any ITN P-value

N % (95% CI)

N % (95% CI)

Tier

1 2

4612 4796

78.0 (72.2 to 82.8) 75.2 (70.2 to 79.5)

0.43 4612 4796

18.8 (13.7 to 25.2) 13.2 (8.5 to 19.7)

0.17

Risk Category

1a 1b 1c 2 3

2859 2376 1810 1494 869

68.1 (59.6 to 75.5) 72.2 (64.0 to 79.2) 85.0 (79.9 to 89.0) 79.8 (70.3 to 86.8) 92.7 (89.0 to 95.3)

<0.01* 2859 2376 1810 1494 869

22.6 (14.8 to 32.8) 17.4 (11.2 to 26.1) 12.9 (6.7 to 23.5) 10.2 (4.9 to 20.1) 6.2 (1.3 to 25.0)

0.11

Socioeconomic Group


1804 1873 1900 1900 1931

70.7 (62.4 to 77.7) 75.9 (70.6 to 80.5) 75.3 (69.6 to 80.3) 77.2 (72.6 to 81.2) 83.2 (77.7 to 87.5)

0.01* 1804 1873 1900 1900 1931

20.6 (13.9 to 29.4) 17.3 (12.2 to 23.9) 14.1 (9.8 to 19.8) 13.5 (9.5 to 18.9) 14.4 (9.5 to 21.2)

0.21

Age / Sex

< 5 years 5 to < 15 years Male 15+ years Female 15+ years

886 2280 2782 3460

82.8 (78.2 to 86.7) 77.5 (73.0 to 81.5) 69.9 (66.0 to 73.6) 79.6 (75.8 to 82.8)

<0.01* 886 2280 2782 3460

19.4 (14.6 to 25.4) 16.6 (12.6 to 21.6) 14.5 (11.3 to 18.3) 15.7 (12.1 to 20.2)

<0.01*

Goes to forest and sleeps overnight

Yes No

453 8955

53.0 (45.0 to 60.8) 77.7 (74.0 to 81.1

<0.01* 453 8955

12.2 (7.5 to 19.1) 16.1 (12.5 to 20.6)

0.20

Travels away from home

Yes No

730 8678

44.8 (38.1 to 51.7) 79.2 (75.6 to 82.4)

<0.01* 730 8678

11.4 (7.4 to 17.1) 16.3 (12.7 to 20.7)

0.03*

Residence

Usual Resident Temporary Visitor

9282 126

76.8 (73.2 to 80.1) 56.3 (42.6 to 69.2)

<0.01* 9282 126

16.0 (12.4 to 20.4) 10.3 (4.9 to 20.5)

0.21

Had fever past two weeks

Yes No

241 9167

83.4 (77.5 to 88.0) 76.4 (72.7 to 79.7)

0.01* 241 9167

19.9 (13.9 to 27.7) 15.8 (12.3 to 20.2)

0.11

Sufficient nets/LLINs10

Yes No

6083 3325

84.6 (81.6 to 87.1) 61.9 (56.3 to 67.1)

<0.01* 934 8474

16.9 (13.1 to 21.6) 14.1 (10.2 to 19.2)

0.15

Heard message about sleeping under a net/ITN (N=1203)

Yes No

692 511

80.3 (72.8 to 86.2) 70.9 (61.5 to 78.7)

0.05 360 843

37.0 (26.8 to 48.4) 28.1 (21.1 to 36.4)

0.16

*Significant at p<0.05

Several factors appeared to be associated with use of any mosquito net. People living in lower

malaria risk categories had higher mosquito net use proportions, probably reflecting better

socio-economic conditions and access to nets in these more accessible areas. Also, net use was

10 Sufficient net = at least one mosquito net for every two persons


higher among wealthier groups. It is encouraging to note that these trends disappeared or

even were reversed for use any ITN, even if this was not statistically significant.

Mobile groups including travelers, visitors, and forest goers had lower net use

proportions and children under five had a higher proportion compared to other age and sex

categories. Finally, net use was significantly associated with the availability of sufficient

quantity of nets at household level, encouraging increasing net ownership to reach

universal coverage, here defined as one net for every two people.

MALARIA TREATMENT

Table 1.4.1 Household respondents’ knowledge of malaria and danger signs by Tier

TOTAL (N=1992) Tier 1 (N=997) Tier 2 (N=995) P-value*

% (N) 95% CI % (N) 95% CI % (N) 95% CI

Know malaria11 47.3 (943)

44.5 to 50.2 52.8 (527) 48.3 to 57.3 41.8 (416) 38.2 to 45.5 0.01

Know serious fever12

30.4 (605)

27.2 to 33.7 37.3 (372) 32.2 to 42.7 23.4 (233) 19.7 to 27.5 0.01


Household respondents were asked to mention any malaria sign or symptoms they could

recall. Overall, less than half (47.3%) cited both chills and fever as malaria signs. The

awareness of any sign of severity for fever cases was even lower with only 30.4% of

respondents that could mention any of the signs. Knowledge of malaria and danger signs was

significantly higher among Tier 1 respondents. These low rates suggest that BCC on the

malaria signs and symptoms and severe malaria could be further improved.

Figure 1.4.1 Knowledge of signs or symptoms of malaria mentioned by Tier (N=1898)

11 Know malaria if mention chills and fever among symptoms 12 Know at least one of three signs of fever severity: unconscious, fast breathing, convulsion

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Tier 1

Tier 2


Table 1.4.2 Respondent’s confirmation of signs and symptoms

TOTAL (N=1605) Tier 1 (N=845) Tier 2 (N=760) N % N % N %

Previous experience Symptoms Doctors examination HA/LVH/MW/PHS exam Blood test or RDT Other Don’t know

237 460 483 251 41 28

105

14.8 28.7 30.1 15.6 2.6 1.7 6.5

128 235 320 91 18 17 36

15.1 27.8 37.9 10.8 2.1 2.0 4.3

109 225 163 160 23 11 69

14.3 29.6 21.4 21.1 3.0 1.4 9.1

Overall, most respondents would confirm the signs and symptoms through a doctor’s

examination or they would judge based on their recognition of the symptoms. It is worth

noting that very few respondents mentioned confirmation via RDT or blood test (2.6%).

Figure 1.4.2 Recognition of symptoms of serious illness by Tier, among those who

know malaria signs (N=1605)

Nearly one-third of respondents did not know or could not recall at least one of the danger signs of severe malaria illness. Further BCC in this regard may be warranted.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Tier 1

Tier 2


Table 1.4.3 Respondents’ knowledge of malaria treatment

TOTAL Tier 1 Tier 2

N % N % N %

Know names of specific malaria drug (N=1898)

Yes No

549 1349

28.9 71.1

309 656

32.0 68.0

240 693

25.7 74.3

Know correct duration of most of treatment (N=1073)

Less than 3 days 3 days More than 3 days

84 516 473

7.8 48.1 44.1

47 249 238

8.8 46.6 44.6

37 267 235

6.9 49.5 43.6

Know consequence of not respecting duration of treatment (N=1992)

Nothing Get sick again Does not recover Other Don’t know

45 605 774 39

432

2.3 30.4 38.8 2.0

21.7

27 381 326 11

217

2.7 38.2 32.7 1.1

21.8

18 224 448 28

215

1.8 22.5 45.0 2.8

21.6

Know consequence of not respecting dosage of treatment (N=1992)

Nothing Get sick again Does not recover Other Don’t know

44 601 798 25

428

2.2 30.2 40.0 1.3

21.5

17 396 313 10

217

1.7 39.7 31.4 1.0

21.8

27 205 485 15

211

2.7 20.6 48.7 1.5

21.2

Know any malaria drug not recommended anymore (N=1898)

Yes No

21 1877

1.1 98.9

8 957

0.8 99.2

13 920

1.4 98.6

The proportion of respondents’ knowledge of any antimalarial drug was low, with only 28.9%

being able to name any specific drug. Very few people were aware that some antimalarial

drugs are no longer recommended and this proportion was lower in Tier 2. However, the

majority knew that the duration of most treatment against malaria was at least three days or

more. The main consequences of not respecting treatment duration or dosage were thought to

be “get sick again” or “does not recover”. So in general, awareness on the ban on

monotherapies was low in both tiers.

Figure 1.4.3 Antimalarial drug mentioned by respondents by Tier (N=528)

0%10%20%30%40%50%60%70%80%90%

100%

Tier 1

Tier 2


Very few or less than 10% of respondents mentioned any ACT as antimalarial drug. The main

drugs cited were cocktail drugs (40% in Tier 1), chloroquine, and quinine. It is surprising that

cocktails were mentioned almost as frequently as chloroquine and quinine. Even of more

concer, artemisinin monotherapies were mentioned by more than 10% in both Tier 1

and Tier 2.

Table 1.4.4 Household respondents’ knowledge of providers for malaria diagnosis and treatment

TYPE OF PROVIDER Place to go for a test (N=1898)

Place to go for advice or treatment (N=1898)

Tier 1 (N=965) Tier 2 (N=933) Tier 1 (N=965) Tier 2 (N=933)

% (N) % (N) % (N) % (N)

VHW/HW in village - - 1.5 (14) 2.8 (26)

Malaria staff 1.2 (12) 1.3 (12) - -

VMW 3.1 (30) 1.9 (18) 2.0 (19) 1.0 (9)

Rural health centre 27.1 (262) 32.9 (307) 29.5 (285) 32.9 (307)

Township hospital 22.8 (220) 35.9 (335) 19.2 (185) 31.6 (295)

Private doctor 22.3 (215) 8.8 (82) 27.1 (261) 11.7 (109)

Midwife 10.7 (103) 7.5 (70) 11.2 (108) 8.2 (77)

Auxiliary midwife 3.6 (35) 4.2 (39) 3.5 (34) 5.0 (47)

Unlicensed practitioner 1.5 (14) 0.6 (6) 1.9 (18) 1.7 (16)

Drug store (drugs only) - - 0.3 (3) 0.9 (8)

Grocery shop - - 0.5 (5) 0.6 (6)

Private laboratory 2.6 (25) 0.6 (6) - -

Home treatment - - 0.9 (9) 1.3 (12)

Other 0.8 (8) 0. (3) 0.9 (9) 0.6 (6)

Don’t know 4.3 (41) 5.9 (55) 1.6 (15) 1.6 (15)

Delivery channel

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bago Kayah Kayin Mon Tanintharyi

Any ACT

Artemisinin mono

Any other antimalarial


Public13 68.6 (662) 83.7 (781) 66.8 (645) 81.6 (761)

Private14 26.3 (254) 10.1 (94) 30.7 (296) 16.2 (151)

Other 0.8 (8) 0.3 (3) 0.9 (9) 0.6 (6)

Not sure 4.3 (41) 5.9 (55) 1.6 (15) 1.6 (15)

The most popular sources for diagnostic services and treatment were rural health centres,

township hospitals and private doctors. Village malaria workers did not seem to be a common

source for diagnosis or treatment. Private doctors or laboratories appeared to be more

popular in Tier 1 than in Tier 2 and this was true for both diagnostic services and advice or

treatment. In general, the public sector appeared to be the most popular source for test and

for treatment and this is even more marked in Tier 2 were the private sector seemed to be less

common source for diagnosis and treatment than in Tier 1. This could suggest that the private

sector may be less developed in Tier 2.

Table 1.4.5 Respondents’ reported prevalence and treatment of fever during the previous two weeks

FEVER PAST 2 WEEKS TOTAL Tier 1 Tier 2

% (N) 95% CI % (N) 95% CI % (N) 95% CI

Total (N=9408) 2.6 (241) 2.1 to 3.1 2.8 (128) 2.1 to 3.7 2.4 (113) 1.9 to 2.9)

Seek treatment for fever (N= 241)

Yes No

71.8 (173) 28.2 (68)

64.6 to 77.9 22.1 to 35.4

79.6 (102) 20.4 (26)

70.0 to 86.8 13.2 to 30.0

62.8 (71) 37.2 (42)

53.4 to 71.4 28.6 to 46.6

Where first seek treatment (N=173)

VHW VMW Rural health center Township hospital Private clinic Midwife clinic Aux midwife Unlicensed practitioner Drug store (drugs only) Grocery shop Traditional healer Don’t remember

5.8 (10) 5.8 (10)

18.5 (32) 2.9 (5)

19.1 (33) 12.1 (21) 12.7 (22)

3.5 (6) 4.6 (8)

8.7 (15) 1.2 (2) 5.2 (9)

2.5 to 12.7 1.8 to 16.9

11.9 to 27.5 1.0 to 8.2

11.3 to 30.4 7.4 to 19.3 5.9 to 25.2 1.1 to 10.6 2.3 to 9.0

4.8 to 15.1 0.3 to 4.8

2.1 to 12.5

5.9 (6) 9.8 (10)

22.5 (23) 2.0 (2)

20.6 (21) 7.8 (8)

16.6 (17) 3.9 (4) 2.0 (2) 2.0 (2) 2.0 (2) 4.9 (5)

2.3 to 14.2 3.3 to 25.6

13.3 to 35.5 0.5 to 8.0

9.7 to 38.6 3.3 to 17.4 6.4 to 36.7 0.8 to 17.3 0.5 to 7.8 0.5 to 7.6 0.4 to 8.3

1.6 to 14.5

5.6 (4) 0.0 (0)

12.7 (9) 4.2 (3)

16.9 (12) 18.3 (13)

7.0 (5) 2.8 (2) 8.4 (6)

18.3 (13) 0.0 (0) 5.6 (4)

1.2 to 22.7 -

5.9 to 25.2 0.9 to 16.9 8.9 to 29.8

10.3 to 30.6 2.8 to 16.7 0.7 to 11.1 4.1 to 16.5

10.6 to 29.6 -

1.2 to 22.2

Delivery channel for the first source of treatment for fever

Public Private Not sure

57.8 (100) 37.0 (64)

5.2 (9)

45.7 to 69.0 26.0 to 49.6 2.1 to 12.5

64.6 (66) 30.4 (31)

4.9 (5)

47.1 to 78.9 16.8 to 48.7 1.6 to 14.5

47.9 (34) 46.5 (33)

5.6 (4)

35.1 to 61.0 32.2 to 61.4 1.2 to 22.2

Time to treatment (N=173)

Same day Day after Two days after 3+ days after Not sure

66.5 (115) 28.3 (49)

2.3 (4) 2.3 (4) 0.6 (1)

58.2 to 73.9 20.9 to 37.2 0.5 to 10.1 0.5 to 10.2 0.1 to 3.7

70.6 (72) 21.5 (22)

3.9 (4) 2.9 (3) 1.0 (1)

61.3 to 78.5 14.0 to 31.6 0.9 to 16.1 0.4 to 18.0 0.2 to 5.7

60.6 (43) 38.0 (27)

0.0 (0) 1.4 (1) 0.0 (0)

45.5 to 73.9 25.0 to 53.0

- 0.2 to 9.5

-

Diagnostic test (N=241)

Yes No Not sure

23.2 (56) 75.1 (181)

1.7 (4)

17.6 to 30.0 68.3 to 80.9

0.6 to 4.5

21.9 (28) 76.6 (98)

1.6 (2)

14.9 to 30.9 67.7 to 83.6

0.4 to 6.5

24.8 (28) 73.4 (83)

1.8 (2)

16.3 to 35.9 62.1 to 82.3

0.4 to 7.0

Tested before treatment (N=56)

Yes No

69.6 (39) 26.8 (15)

53.6 to 82.0 15.1 to 43.1

85.7 (24) 14.3 (4)

64.3 to 95.2 4.8 to 35.7

53.5 (15) 39.3 (11)

31.0 to 74.7 19.4 to 63.5

13 VHM/HW, Malaria staff, VMW, rural health centre, Township hospital, Midwife and aux midwife 14

Private doctor, unlicensed practitioner, drug store, grocery shop, private laboratory, home treatment


Not sure 3.6 (2) 0.8 to 14.0 0.0 (0) - 7.1 (2) 1.7 to 25.4

Place of test

VMW Public health facility Private facility/lab Private nurse/dr Other

3.6 (2) 64.2 (36)

7.1 (4) 14.3 (8) 14.3 (6)

0.8 to 14.5 48.6 to 77.3 2.6 to 18.0 6.3 to 29.4 4.4 to 23.7

3.6 (1) 60.6 (17)

3.6 (1) 14.3 (4) 17.9 (5)

0.4 to 24.6 37.2 to 80.0 0.4 to 24.2 3.8 to 41.3 6.9 to 39.1

3.6 (1) 67.9 (19) 10.7 (3) 14.3 (4) 3.6 (1)

0.4 to 23.6 46.8 to 83.5 3.7 to 27.5 5.1 to 33.9 0.5 to 22.2

Type of test (N=56)

RDT Blood slide Not sure

73.2 (41) 10.7 (6) 16.0 (9)

55.2 to 85.9 4.4 to 24.0 5.9 to 36.9

71.5 (20) 10.7 (3) 17.8 (5)

41.7 to 89.8 3.6 to 27.9 3.4 to 57.2

75.0 (21) 10.7 (3) 14.3 (4)

53.7 to 88.6 2.5 to 35.9 5.1 to 33.9

Test result (N=56)

Positive Negative Not sure

21.5 (12) 67.8 (38) 10.7 (6)

11.9 to 35.6 50.6 to 81.3 2.6 to 34.9

21.5 (6) 64.2 (18) 14.2 (4)

8.0 to 46.6 34.6 to 85.9 1.9 to 58.8

21.4 (6) 71.4 (20)

7.1 (2)

10.9 to 37.9 55.5 to 83.4 1.7 to 25.4

Type of malaria (N=12)

Not told species P. falciparum P. vivax Mixed (Pf & Pv) Not sure

49.9 (6) 25.0 (3) 8.3 (1) 8.3 (1) 8.5 (1)

18.8 to 81.0 4.7 to 69.3 0.8 to 51.4 0.8 to 51.5 0.8 to 52.0

33.1 (2) 50 (3) 0.0 (0) 0.0 (0)

16.9 (1)

5.5 to 81.5 9.9 to 90.0

- -

1.4 to 74.1

66.7 (4) 0.0 (0)

16.6 (1) 16.7 (1) 0.0 (0)

20.9 to 93.8 -

1.5 to 72.1 1.5 to 72.1

-

Still having fever on survey day (N=241)

Yes No Not sure

37.3 (90) 60.2 (145)

2.5 (6)

28.8 to 46.8 50.5 to 69.1

1.0 to 6.1

38.3 (49) 61.0 (78)

0.8 (1)

26.1 to 52.1 47.2 to 73.2

0.1 to 5.7

36.3 (41) 59.3 (67)

4.4 (5)

25.3 to 49.0 45.5 to 71.8 1.7 to 11.1

The overall prevalence of reported fever in the previous two weeks was 2.6%. More than 70%

of the fever cases sought treatment and this proportion was higher in Tier 1 (79.6%) versus

Tier 2 (62.8%). The most popular sources of treatment were private doctors, rural health

centres and midwives; overall, more people tended to go to the public sector for treatment. In

Tier 2, there were substantially more people seeking treatment from a grocery shop

compared to rural health centre, suggesting that access to health care might be poorer in these

areas. Indeed, similar proportions were found across delivery channels.

Time to treatment was the same day in the majority of cases (66.5%) and this proportion was

higher in Tier 1 (70.6% vs 60.6%) but nearly all cases sought treatment within the next 2

days. However, diagnostic services were accessed by less than a quarter of the fever cases and

among these, 69% had a test for malaria. This proportion was higher in Tier 1 (85.7% versus

53.5%), probably due to fewer people seeking treatment in a health facility in Tier 2. Indeed,

the main source of diagnostic services was from public health facilities and the main type of

test was with an RDT. Among fever cases tested, 21.5% were positive but among these, nearly

half of them were not told the species. Interestingly, nearly 40% reported still having fever on

the survey day.

Sector most cited for test and treatment


When comparing where a respondent would go for testing and treatment, two-thirds mentioned that they would go to the public sector which included malaria staff, rural health centre, township hospital, midwife and auxiliary midwife. Interestingly, this also correlates with what respondents with a recent fever within the past two weeks did as a first source of treatment (55% in the public sector). Treatment seeking from the private sectors was about one-third. However, it is important to note that public and private sector providers can sometimes be blurred and difficult to differentiate. Treatment-seeking from VHWs was low in both Tiers but it is unclear which of these villages actually had VHWs available. Further analysis on this may be warranted.

Figure 1.4.4 Source of treatment by Tier (N=213)

15 Malaria staff, rural health centre, township hospital, midwife and auxiliary midwife 16 Private clinic, unlicensed practitioner, drug store, grocery shop, traditional healer

0%10%20%30%40%50%60%70%80%90%

100%

Tier 1

Tier 2

Place to go for a test Place to go for treatment Place to go for a test Place to go for treatment

Tier 1 Tier 2 Tier 1 Tier 2

VMW 3.1 (30) 1.9 (18) 2.0 (19) 1.0 (9)

Public15 65.5 (632) 81.8 (763) 64.8 (626) 80.6 (752) Private16 26.3 (254) 10.1 (94) 30.7 (296) 16.2 (151)

Other 0.8 (8) 0.3 (3) 0.9 (9) 0.6 (6)

Not sure 4.3 (41) 5.9 (55) 1.6 (15) 1.6 (15)

First source of treatment of recent fever cases (N=173)

VMW 9.8 (10) - (0) Public15 54.8 (56) 47.9 (34)

Private16 30.4 (31) 46.5 (33)

Not sure 4.9 (5) 5.6 (4)


The sources of treatment were from rural health centers and private doctors in Tier 1, whereas mainly from market or shops in Tier 2.

Table 1.4.6 Treatment seeking behavior of forest goers on last visit


N % N % N %

Got sick last time in the forest

Yes No Don’t remember

66 383

4

14.6 84.6 0.9

20 147

0

12.0 88.0 0.0

46 236

4

16.1 82.5 1.4

Source of treatment last time while away (N=66)

VHW/VMW Rural health centre Township hospital Private clinic Midwife clinic Aux midwife Unlicensed practitioner Drug store (drugs only) Grocery shop Private laboratory Not sure

5 8 1 4

15 7 1 6 3 2

14

7.6 12.1 1.5 6.0

22.8 10.6 1.5 9.1 4.5 3.0

21.2

3 0 0 0 3 2 0 2 3 1 6

15.0 0.0 0.0 0.0

15.0 10.0 0.0

10.0 15.0 5.0

30.1

2 8 1 4

12 5 1 4 0 1 8

4.4 17.4 2.2 8.7

26.1 10.9 2.2 8.7 0.0 2.2

17.4

Delivery channel (N=66)

Public Private Not sure

36 16 14

54.6 24.2 21.2

8 6 6

40.0 29.9 30.1

28 10 8

60.9 21.7 17.4

Less than 15% of people going to the forest reported having been sick during their previous

visit to the forest and the main source of treatment was the midwife, the auxiliary midwife or

the health center. Indeed, more people got treatment from the public sector and this was true

across tier.

Figure 1.4.5 Reasons for not seeking treatment by Tier (N=68)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Waitedfever go

away

No money Difficulttransport

Not illenough

Traditionalmedicine

Other

Tier 1

Tier 2


The most common reason for not seeking treatment promptly or at all included for both Tier 1 and Tier 2 was that the respondent was not ill enough. With more than half of respondents delaying treatment seeking if the illness was not serious enough, it will be important to ensure that proper BCC for symptoms of danger signs are properly promoted in communities.

Table 1.4.7 Specific drugs taken for fever

TOTAL (N=213)

% (N)

Tier 1 (N=117)

% (N)

Tier 2 (N=96) % (N)

Coartem (AL) 1.9 (4) 1.7 (2) 2.1 (2)

Cotecxin 0.5 (1) 0.9 (1) 0.0 (0)

Artesunate 0.5 (1) 0.9 (1) 0.0 (0)

Artemether 1.4 (3) 1.7 (2) 1.0 (1)

Chloroquine 1.9 (4) 0.9 (1) 3.1 (3)

Primaquine 0.5 (1) 0.9 (1) 0.0 (0)

Other antimalarial drugs 0.9 (2) 0.9 (1) 1.0 (1)

Antibiotics 3.8 (8) 3.4 (4) 4.2 (4)

Paracetamol/Aspirin 32.4 (69) 22.2 (26) 44.8 (43)

Vitamin 0.5 (1) 0.0 (0) 1.0 (1)

Traditional herbs 2.4 (5) 0.9 (1) 4.2 (4)

Other non-antimalarial drugs 41.8 (89) 49.6 (58) 32.3 (31)

Not sure 11.7 (25) 16.2 (19) 6.3 (6)

Drugs category

Any ACT17 1.9 (4) 1.7 (2) 2.1 (2)

Any Artemisinin based monotherapy18 2.4 (5) 3.4 (4) 1.0 (1)

Other antimalarial drugs 3.3 (7) 2.6 (3) 4.2 (4)

Other non-antimalarial drugs 80.8 (172) 76.1 (89) 86.5 (83)

Not sure 11.7 (25) 16.2 (19) 6.3 (6)

The majority of fever cases (80.8%) were treated with non-antimalarial drugs and this

proportion was higher in Tier 2. However, only 1.2% or 4 fever cases (Table 1.4.8) took any

ACT, which was lower than expected considering that 12 people tested positive, although

some may have been P. vivax infections.

Table 1.4.8 Type, source, test and test result for individuals with fever in the past two weeks who took any ACT (N=4)

Source Had test for malaria

Test result

Tier Sex and sex State ACT brand

Rural health centre Yes Positive 1 15+ male Mon Coartem

Auxiliary midwife Yes Positive 1 0-4 years Tanintharyi Coartem

Auxiliary midwife Yes Positive 2 15+ female Kayin Coartem

Private clinic Yes Positive 2 0-4 years Kayin Coartem

17 A+Lum, Art+Mefl, As+Mq, Duo-Cotexcin 18 Artesunate, Artemether, Cotexcin


DRUG OUTLET SURVEY

CHARACTERISTIC OF DRUG OUTLETS

Table 2.1.1 Private providers (outlets19) selling antimalarial drugs by Tier

DRUG OUTLETS TOTAL % (N)

Tier 1 % (N)

Tier 2 % (N)

Total 100 (120) 50.8 (61) 49.2 (59)

Respondents’ position

Owner Employee Family member

85.0 (102) 4.2 (5)

10.8 (13)

91.8 (56) 4.9 (3) 3.3 (2)

78.0 (46) 3.4 (2)

18.6 (11)

Respondents’ sex

Male Female

38.3 (46) 61.7 (74)

36.1 (22) 63.9 (39)

40.7 (24) 59.3 (35)

Respondents’ training

Doctor Pharmacist Health assistant Nurse Midwife Other health training No health training

1.7 (2) 9.2 (11) 0.8 (1) 4.2 (5) 5.0 (6)

27.5 (33) 51.7 (62)

1.6 (1) 9.8 (6 1.6 (1) 4.9 (3) 6.6 (4)

29.5 (18) 45.9 (28)

1.7 (1) 8.5 (5) 0.0 (0) 3.4 (2) 3.4 (2)

25.4 )15) 57.6 (34)

Location of outlet

Village Town

52.6 (63) 47.5 (57)

42.6 (26) 57.4 (35)

62.7 (37) 37.3 (22)

Type of outlet

Village drug outlet Private clinic Health centre/Worker Pharmacy General store/shop

9.2 (11) 5.8 (7) 5.0 (6)

35.0 (42) 45.0 (54)

4.9 (3) 4.9 (3) 8.2 (5)

45.9 (28) 36.1 (22)

13.6 (8) 6.8 (4) 1.7 (1)

23.7 (14) 54.2 (32)

Offer consultations

Yes 78.3 (94) 78.7 (48) 78.0 (46)

Number of consultations a day

< 1 per day 1 to 5 per day 6 to 10 per day More than 10 per day Don’t know

8.5 (8) 53.2 (50) 18.1 (17) 19.2 (18)

1.1 (1)

6.3 (3) 43.8 (21) 25.0 (12) 22.9 (11)

2.1 (1)

10.9 (5) 63.0 (29) 10.9 (5) 15.2 (7) 0.0 (0)

Offer consultations for malaria (N=94)

Yes No

58.5 (55) 41.5 (39)

50.0 (24) 50.0 (24)

67.4 (31) 32.6 (15)

Number of malaria consultations a day (N=55)

< 1 per day 1 to 5 per day

30.9 (17) 52.7 (29)

37.5 (9) 45.8 (11)

25.8 (8) 58.1 (18)

19 Including village drug shops, private clinic, health centre or health workers’ home, pharmacy, or general store or shop


6 to 10 per day More than 10 per day

10.9 (6) 5.5 (3)

16.7 (4) 0.0 (0)

6.5 (2) 9.7 (3)

Provide any information about malaria

Yes No

15.0 (18) 85.0 (102)

24.6 (15) 75.4 (46)

5.1 (3) 94.9 (56)

Keep records/register of malaria cases diagnosed or treated

Yes 5.0 (6) 9.8 (6) 0.0 (0)

Inspection in past 6 months

Yes No

9.2 (11) 90.8 (109)

11.5 (7) 88.5 (54)

6.8 (4) 93.2 (55)

Have a license to sell drugs

Yes No

58.3 (70) 41.7 (50)

73.8 (45) 26.2 (16)

42.4 (25) 57.6 (34)

License on display on survey day (N=70)

Yes No Not sure

28.6 (20) 70.0 (49)

1.4 (1)

33.3 (15) 20.0 (5) 2.2 (1)

64.4 (29) 80.0 (20)

0.0 (0)

Drug outlets in the survey included any place where antimalarial drugs are known to be sold

in the community, including village drug shops, private clinic, health centre or health workers’

home, pharmacy, or general store or shop.

The characteristics of the selected drug outlets appeared very different between tiers, pointing

out the heterogeneity of private providers in the target areas. In Tier 1, more respondents

tended to be female and were more likely to have had health related training. Drug outlets in

Tier 1 were more likely to be located in a town and situated in a pharmacy or the health

centre; whereas in Tier 2, a higher proportion were in a village and were found in a general

store or village drug outlet.

In both Tiers, about 78% of drug outlets did offer consultation and the daily activity appeared

higher in Tier 1. On the other hand, Tier 2 providers were more likely to provide malaria

consultation but only a few outlets provided malaria information. This proportion was higher

in Tier 1. Also, in Tier 1, drug outlets tended to be more likely to keep records of malaria cases

and to have had an inspection in the past six months although these proportions were only

9.8% and 11.5% respectively. Finally, nearly three quarters of outlets in Tier 1 had a

license to sell drugs compared to 42.4% in Tier 2 but the latter were more likely to have

displayed their license on the survey day compared to Tier 1 outlets.

This strongly suggests that the villages located in Tier 2 are more remote and probably implies

poorer access to health care compared to Tier 1.

Table 2.1.2 Knowledge among drug outlet respondents of drug resistance and ban on monotherapies

TOTAL N=120 % (N)

Tier 1 N=61 % (N)

Tier 2 N=59 % (N)

Heard of activities to stop spread of drug resistance

Yes 10 (12) 16.4 (10) 3.4 (2)

Aware that some antimalarial drugs are banned

Yes 11.7 (14) 16.4 (10) 6.8 (4)


Specified an oral monotherapies20 as a banned drug (N=14)

Artesunate 14.3 (2) 10.0 (1) 25.0 (1)

Heard about fake drugs

Yes No

70.0 (84) 30.0 (36)

73.8 (45) 26.2 (16)

66.1 (39) 33.9 (20)

Seen any fake drug (N=84)

Yes No

19.1 (16) 80.9 (68)

15.6 (7) 84.4 (38)

23.1 (9) 76.9 (30)

Respondent’s awareness about drug resistance was low in general but as expected was higher

in Tier 1, although some caution is required in interpreting these estimates as questions about

fake drugs seemed sensitive. On the other hand, it is interesting that about 11.7% of the

respondents specified an oral monotherapy as banned since the official ban had not yet been

implemented at the time of data collection.

Figure 2.1.1 Respondents knowledge of malaria signs and symptoms by Tier (N=120)

Figure 2.1.2 Attitude of respondents if suspected malaria case (N=113)

20 Artesunate or artemisinin monotherapies

0%10%20%30%40%50%60%70%80%90%

100%

Tier 1

Tier 2

0%10%20%30%40%50%60%70%80%90%

100%

Examinepatient

Sell/performtest

Refer to HF Sellantimalarial

drug

Other

Tier 1

Tier 2


The two figures above suggest that access to formal health care structures tended to be more

available in Tier 1 as more drug providers would refer suspected malaria cases to health

facilities; whereas in Tier 2, they would be more likely to sell directly an antimalarial drug. It is

important to note the small proportions of respondents that would sell or perform a malaria

test, reflecting the lack of availability of diagnostic services (RDT) among drug outlets.

ANTIMALARIAL DRUGS STOCK AND SELLING HABITS

Table 2.2.1 Availability of antimalarial drugs sold in private drug outlets on survey day

by Tier

TOTAL N=120 % (N)

Tier 1 N=61 % (N)

Tier 2 N=59 % (N)

Coartem (A + Lum) > 15 years 2.5 (3) 3.3 (2) 1.7 (1)

Artefan 0.0 (0) - -

Duocotexcin 0.8 (1) 0.0 (0) 1.7 (1)

Artecom 2.5 (3) 1.6 (1) 3.4 (2)

Arfloquin 0.0 (0) - -

Artemodi 0.0 (0) - -

Arco 4.2 (5) 3.3 (2) 5.1 (3)

Artesunate tablets 50.0 (60) 55.7 (34) 44.1 (26)

Artesunate injectables 12.5 (15) 14.8 (9) 10.2 (6)

Artemether tablets 34.2 (41) 45.9 (28) 22.0 (13)

Artemether injectables 35.0 (42) 44.3 (27) 25.4 (15)

Artemisinin tablets 0.8 (1) 0.0 (0) 1.7 (1)

Chloroquine 47.5 (57) 41.0 (25) 54.2 (32)

Quinine tablets 21.7 (26) 19.7 (12) 23.7 (14)

Quinine injectables 24.2 (29) 26.2 (16) 22.0 (13)

Mefloquine 17.5 (21) 18.0 (11) 16.9 (10)

Primaquine 5.0 (6) 8.2 (5) 1.7 (1)

Sulfadoxine + Pyrimethamine (SP) 5.0 (6) 4.9 (3) 5.1 (3)

Cocktail drugs 9.2 (11) 6.6 (4) 11.9 (7)

In general, the most popular antimalarial drugs sold in the sampled outlets were: 1)

artesunate tablets, 2) chloroquine, 3) artemether injectables, and 4) artemether tablets. This

suggests that most customers would still be sold monotherapy (e.g., artesunate) at the time of

the survey. Comparison between tiers the most common treatment sold in Tier 1 was

artesunate, whereas in Tier 2, the most popular treatment available was chloroquine,

reinforcing that the notion that clusters in Tier 2 tended to be more underserved compared to

Tier 1. Furthermore, Coartem was only reported to be available in 2.5% of drug outlets.


Table 2.2.2 Details of rapid diagnostic tests sold in drug outlets

TOTAL N=120 % (N)

Tier 1 N=61 % (N)

Tier 2 N=59 % (N)

RDT type

CareStart Paracheck

0.8 (1) 6.7 (8)

0.0 (0) 9.8 (6)

1.7 (1) 3.4 (2)

Overall, availability of rapid diagnostic test was low, with 0.8% for CareStart™ and 6.7% for

Paracheck™.

Table 2.2.3 Recommended antimalarial drugs in drug outlets by Tier

TOTAL N=120 % (N)

Tier 1 N=61 % (N)

Tier 2 N=59 % (N)

Most recommended drug for P. falciparum

Coartem (A+L) Mefloquine Artesunate Artemether Quinine Chloroquine Other antimalarial drugs Antibiotics Don’t Know

9.2 (11) 4.2 (5)

9.2 (11) 8.3 (10) 4.2 (5) 1.7 (2) 0.8 (1) 0.0 (0)

62.5 (75)

13.1 (8) 1.6 (1) 6.6 (4) 9.8 (6) 1.6 (1) 0.0 (0) 0.0 (0) 0.0 (0)

67.2 (41)

5.1 (3) 6.8 (4)

11.9 (7) 6.8 (4) 6.8 (4) 3.4 (2) 1.7 (1) 0.0 (0)

57.6 (34)

Know the national recommended treatment for P.f. (Coartem = Artemether + Lumefantrine)

Yes No

17.5 (21) 82.5 (99)

26.2 (16) 73.7 (45)

8.5 (5) 91.5 (54)

Most recommended drug for P. vivax

Coartem (A+L) Mefloquine Artesunate Artemether Quinine Chloroquine Other antimalarial drugs Antibiotics Don’t Know

0.8 (1) 0.8 (1)

10.0 (12) 6.7 (8) 2.5 (3)

25.8 (31) 0.8 (1) 0.8 (1)

51.7 (62)

0.0 (0) 1.6 (1) 8.2 (5) 4.9 (3) 0.0 (0)

24.6 (15) 0.0 (0) 0.0 (0)

60.7 (37)

1.7 (1) 0.0 (0)

11.9 (7) 8.5 (5) 5.1 (3)

27.1 (16) 1.7 (1) 1.7 (1)

42.4 (25)

Know the national recommended treatment for P.v. (=Primaquine)

Yes No

2.5 (3) 97.5 (117)

1.6 (1) 98.4 (60)

3.4 (2) 96.6 (57)

More than 80% of the respondents did not know the recommended treatment for P.

falciparum. Perhaps due to sensitivity issues, the majority of the respondents (62%) were

not able to recommend any drug for the treatment of P. falciparum. In Tier 1, the most

commonly recommended drugs were Coartem, artesunate, and artemether; whereas in Tier 2,

artesunate, mefloquine, artemether, or quinine were most commonly mentioned.

The most commonly recommended drugs for P. vivax were chloroquine, artesunate and

artemether and these patterns were similar across tier. Likewise, very few respondents


(2.5%) among drug outlets were aware of the nationally recommended treatment for P.

vivax.

Table 2.2.4 Popularity of antimalarial by Tier

TOTAL N=120 % (N)

Tier 1 N=61 % (N)

Tier 2 N=59 % (N)

Sell any antimalarial drugs

Yes No

80.0 (96) 20.0 (24)

75.4 (46) 24.6 (15)

84.8 (50) 15.3 (9)

Most popular drug for malaria (N=96)

Coartem (A+L) Artesunate + Mefloquine Artesunate Artemether Quinine Chloroquine Other antimalarial drugs

2.1 (2) 1.0 (1)

54.2 (52) 16.7 (16)

4.2 (4) 20.8 (20)

1.0 (1)

2.2 (1) 2.2 (1)

60.9 (28) 19.6 (9) 2.2 (1)

13.0 (6) 0.0 (0)

2.0 (1) 0.0 (0)

48.0 (24) 14.0 (7) 6.0 (3)

28.0 (14) 2.0 (1)

Source of antimalarial drugs (N=96)

Yangon whole seller Province whole seller Medical detailer Province pharmacy (Gvt)

8.3 (8) 71.9 (69) 18.8 (18)

1.0 (1)

4.4 (2) 63.0 (29) 32.6 (15)

0.0 (0)

12.0 (6) 80.0 (40)

6.0 (3) 2.0 (1)

According to drug outlet respondents, the most commonly sold anti-malarial drugs were

overwhelmingly artesunate (54%), artemether (17%) and chloroquine (21%). Among Tier 2

respondents, chloroquine was reported to be the second most commonly sold anti-malarial

drug. The main source of drugs was purchased from a state or division whole seller.

Figure 2.2.1 Factors determinant for stocking of antimalarial drugs (N=96)

0%10%20%30%40%50%60%70%80%90%

100%

Tier 1

Tier 2


Not surprisingly, the main factors that determine which antimalarials to stock were mainly

profit and demand driven.

Table 2.2.5 Consumption habits by Tier

TOTAL % (N)

Tier 1 % (N)

Tier 2 % (N)

Customer ask for drug by name (N=96)

Yes No, ask for recommendation No, bring in prescription

74.0 (71) 10.4 (10) 15.6 (15)

69.6 (32) 8.7 (4)

21.7 (10)

78.0 (39) 12.0 (6) 10.0 (5)

Provider decide which drug customer receives (N=96)

Yes No, give what is requested No, bring in a prescription Don’t know

39.6 (38) 37.5 (36) 21.9 (21)

1.0 (1)

34.8 (16) 32.6 (15) 32.6 (15)

0.0 (0)

44.0 (22) 42.0 (21) 12.0 (6) 2.0 (1)

Antimalarial sold compared to last year (N=96)

Selling more Selling same Selling less Don’t know Did not sell last year

4.2 (4) 25.0 (24) 60.4 (58)

6.3 (6) 4.2 (4)

2.2 (1) 19.6 (9)

71.7 (33) 6.5 (3) 0.0 (0)

6.0 (3) 30.0 (15) 50.0 (25)

6.0 (3) 8.0 (4)

Sold partial pack in past month (N=96)

Yes No Don’t know

55.2 (53) 43.8 (42)

1.0 (1)

41.3 (19) 58.7 (27)

0.0 (0)

68.0 (34) 30.0 (15)

2.0 (1)

Sell malaria cocktails (N=96)

Yes No

25.0 (24) 75.0 (72)

15.2 (7) 84.8 (39)

34.0 (17) 66.0 (33)

Sell any malaria test (N=120)

Yes No

20.8 (25) 79.2 (95)

26.2 (16) 73.8 (45)

15.3 (9) 84.8 (50)

Type of test (N=25)

RDT / Dipstick Both RDT and Blood slide

96.0 (24) 4.0 (1)

100 (16) 0.0 (0)

88.9 (8) 11.1 (1)

Tests sold compared to last year (N=25)

Selling more Selling same Selling less Did not sell last year

12.0 (3) 24.0 (6)

52.0 (13) 12.0 (3)

6.3 (1) 25.0 (4)

68.8 (11) 0.0 (0)

22.2 (2) 22.2 (2) 22.2 (2) 33.3 (3)

Customer ask for malaria test (N=120)

Yes No

25.0 (30) 75.0 (90)

24.6 (15) 75.4 (46)

25.4 (15) 74.6 (44)

Response to test request (N=30)

Sell and test them with RDT Refer to public HF Refer to private clinic/lab Other

20.0 (6) 50.0 (15) 10.0 (3) 20.0 (6)

20.0 (3) 40.0 (6) 6.7 (1)

33.3 (5)

20.0 (3) 60.0 (9) 13.3 (2) 6.7 (1)

Nearly three quarters of drug providers reported that customers requested a drug by name

and 39.6% said they usually decide which drug the customer receives. In Tier 2, it appeared

that the selling habits are more driven by customer demand compared to Tier 1, potentially

suggesting that the providers in Tier 2 tended to be less considered as a good source for advice

than in Tier 1. In the same way, customers in Tier 1 were more likely to bring in a

prescription compared to Tier 2, reinforcing the fact that the population in Tier 2 had a

poorer access to health care and were more likely to opt for self-treatment.


More than 60% of providers reported selling less antimalarial drugs compared to last

year, 55% admitted to selling partial pack in the previous month, and 25% had sold

antimalarial cocktails. In Tier 2, there were higher proportion of providers selling the same

quantity of antimalarial drugs as the previous year; more of them reported having sold partial

packs and antimalarial cocktails, supporting the fact that these sellers are less aware of

current good practices.

Nearly 80% reported not selling any malaria test and if any did sell a test, it was mostly

RDT or dipstick tests. Similarly to what was observed for antimalarial drugs, the providers

mostly reported selling less than the previous year and three quarters said customers do not

ask for malaria test and in most cases. They would refer the patient to a health facility if the

customer would ask for the test. Diagnostic services appeared to be less available in Tier

2.

Table 2.2.6 Activity during the previous week by Tier

TOTAL N=120

Mean (SD)

Tier 1 N=61

Mean (SD)

Tier 2 N=59

Mean (SD)

Number of clients bought antimalarial drug

4.07 (0.90) 5.84 (1.75) 2.42 (0.49)

Number of clients bought cocktail drugs

3.64 (1.01) 2.17 (0.75) 4.19 (1.35)

Number of clients that were tested or bought a test

1.09 (0.38) 1.28 (0.55) 0.75 (0.41)

The mean number of patients seen by drug outlet respondents during the past 7 days was

reported to be significantly higher in Tier 1 (mean=5.8, SD 1.8) compared to Tier 2 (mean=2.4,

SD 0.5). On the converse, more antimalarial cocktails were sold and purchased from Tier

2 drug outlets during the past week.

Table 2.2.7 Artesunate

TOTAL % (N)

Tier 1 % (N)

Tier 2 % (N)

Heard of artesunate (N=120)

Yes No

90.8 (109) 9.2 (11)

91.8 (56) 8.2 (5)

89.8 (53) 10.2 (6)

Sell artesunate (N=109)

Yes No

71.6 (78) 28.4 (31)

71.4 (40) 28.6 (16)

71.7 (38) 28.3 (15)

Last bought artesunate (N=78)

Within last week Within last month More than a month ago Not sure

28.2 (22) 32.1 (25) 37.2 (29)

2.6 (2)

27.5 (11) 35.0 (14) 37.5 (15)

0.0 (0)

28.9 (11) 28.9 (11) 36.8 (14)

5.3 (2)

Number of tablets per pack (N=78)

12 tablets 24 tablets

97.4 (76) 2.6 (2)

97.5 (39) 2.5 (1)

97.4 (37) 2.6 (1)

Next buy artesunate (N=78)

Within next week Within next month

16.7 (13) 9.0 (7)

15.0 (6) 2.5 (1)

18.4 (7) 15.8 (6)


In more than a month No plan to buy Not sure

5.1 (4) 19.2 (15) 50.0 (39)

5.0 (2) 15.0 (6)

62.5 (25)

5.3 (2) 23.7 (9)

36.8 (14)

Table 2.2.8 Coartem (A + L)

TOTAL % (N)

Tier 1 % (N)

Tier 2 % (N)

Heard of Coartem (N=120)

Yes No

53.3 (64) 46.7 (56)

62.3 (38) 37.7 (23)

44.1 (26) 55.9 (33)

Sell Coartem (N=64)

Yes No

9.4 (6) 90.6 (58)

7.9 (3) 92.1 (35)

11.5 (3) 88.5 (23)

Last bought Coartem (N=6)


- - 0.0 (0) 16.7 (1) 66.7 (4) 16.7 (1)

Next buy Coartem (N=6)

Within next week Within next month In more than a month No plan to buy Not sure

- - 16.7 (1) 16.7 (1)

0.0 () 16.7 (1) 50.0 (3)

Table 2.2.9 Duocotexcin

TOTAL % (N)

Tier 1 % (N)

Tier 2 % (N)

Heard of Duocotexcin (N=120)

Yes No

8.3 (10) 91.7 (110)

6.6 (4) 93.4 (57)

10.2 (6) 89.8 (53)

Sell Duocotexcin (N=10)

Yes No

30.0 (3) 70.0 (7)

0.0 (0)

100 (4)

50.0 (3) 50.0 (3)

Last bought Duocotexcin (N=3)


- - 0.0 (0) 0.0 (0) 66.7 (2) 33.3 (1)

Next buy Duocotexcin (N=3)

Within next week Within next month In more than a month No plan to buy Not sure

- - 0.0 (0) 0.0 (0) 0.0 (0) 100 (3) 0.0 (0)

Overall, most providers had heard about artesunate (90.8%), more than half heard about

Coartem (53.3%) and less than 10% heard about Duo-Cotexcin (8.3%). In Tier 1, more drug

providers heard of these drugs compared to Tier 2, except for Duo-Cotexcin where this trend

was reversed (6.6% versus 10.2%).


Table 2.2.10 Cost of specific antimalarial drugs (in Kyats)

TOTAL N=120

Mean (SD)

Tier 1 N=61

Mean (SD)

Tier 2 N=59

Mean (SD)

Artesunate 1509.3 (45.8) 1435.0 (66.1) 1587.5 (61.6)

Coartem 1766.7 (459.4) 1700 (435.9) 1833.3 (928.0)

Duocotexcin 2633.3 (233.3) - 2633.3 (233.3)

The mean price of a full treatment course of artesunate was 1500 Kyats (approximately $1.75 USD) which did not different significantly between Tier 1 and Tier 2. The mean price of Coartem was 1766 Kyats ($2.00 USD) and Duo-Cotexcin was 2633 Kyats ($3.00 USD). Prices remained fairly consistent between Tier 1 and Tier 2.


HEALTH FACILITY SURVEY

There were a total of 129 health facilities included in the survey, 50 public facilities (63% of

the target sample) and 79 private facilities (99% of target sample). Figure 3.1 shows the

location of public health facilities included in the survey; GPS data was not available for the

private health facilities.

In the absence of sufficient daily malaria cases in order to assess malaria services, a total of

362 malaria cases within the last 3 months were followed up from case records, 294 cases

at public facilities and 68 cases at private facilities. To address the quality of services received,

a total of 232 exit interviews were carried out among fever patients (or their caregivers) at

both public (n=183) and private (n=49) facilities.

Figure 3.1 Location of public health facilities (N=50), MARC survey 2011


HEALTH FACILITY AUDIT

Table 3.1 Description of the health facilities in the survey

Public facilities N=50 N (%)

Private facilities N=79 N (%)

Total N=129 N (%)

Type of facility

Referral hospital Township hospital Station hospital Rural Health center Rural health sub center Private specialist hospital Private polyclinic General practitioner clinic (with beds) General practitioner clinic (without beds) Other

6 (12.0) 8 (16.0) 4 (8.0)

10 (20.0) 15 (30.0)

0 (-) 0 (-) 0 (-) 0 (-)

7 (14)

0 (-) 0 (-) 0 (-) 0 (-) 0 (-)

3 (3.8) 5 (6.3)

0 (-) 45 (57.0) 26 (32.9)

6 (4.7) 8 (6.2) 4 (3.1) 10 (7.8)

15 (11.6) 3 (2.3) 5 (3.9)

0 (-) 45 (34.9) 33 (25.6)

Services provided

Malaria case management Inpatient Department (IPD) Outpatient Department (OPD) Malaria diagnosis ITN distribution/Tablet distribution Malaria education Antenatal screening for malaria IMCI21 Blood bank Referral of severe malaria

48 (98.0) 18 (36.0)

50 (100.0) 48 (96.0) 20 (40.0) 47 (94.0) 39 (78.0) 49 (98.0) 9 (18.0)

38 (76.0)

78 (98.7) 5 (6.3)

79 (100.0) 53 (67.1) 20 (25.3) 41 (51.9) 34 (43.0) 28 (35.4)

0 (-) 64 (81.0)

127 (98.5) 23 (17.8)

129 (100.0) 101 (78.3) 40 (31.0) 88 (68.2) 73 (56.6) 77 (59.7)

9 (7.0) 102 (79.1)

Table 3.1 details the services provided by the health facilities selected in the survey. The

majority of public health facilities were rural health centres/sub centres, while the majority of

private facilities were general practitoner clinics. Both public and private facilities were

similar for the provision of services for malaria case management, outpatient department and

referral of severe malaria. Compared to private facilities a significantly higher percentage of

public facilities had an inpatient department, offered malaria diagnosis, gave malaria

education, provided antenatal screening for malaria, implemented Integrated Management of

Childhood Illnesses (IMCI) and had a blood bank.

Private facilities were reported to be opened for more days and more hours per day compared

to public facilities. Supervisory visits were only carried out in public facilities only with 78%

of public facilities having had a supervisory visit during the previous 6 months. Almost

all public facilities had a copy of the National Malaria Treatment Guidelines compared to less

than half of the private facilities. Treatment of severe cases was higher in public facilities,

while referral of severe cases was significantly higher in private facilities.

21 Integrated Management of Childhood Illnesses


Table 3.1 cont. Description of the health facilities in the survey



Total N=129 N (%)

Days per week (median (min,max)) 5 (1,5) 5 (3,7) 5 (1,7)

Hours per day (median (min,max)) 4 (2,6) 9 (1,24) 6 (1,24)

Facility had a supervisory visit in last 6 months

39 (78.0) -

Visit by TMO22/PHD 18 (36.0)

Visit by project manager 3 (6.0)

Visit by person responsible for supervising

17 (34.0)

Other supervisor 20 (40.0)

Has copy of the National Treatment Guidelines for Malaria

45 (90.0) 34 (43.6) 79 (61.7)

Treat severe cases of malaria 20 (40.0) 13 (16.5) 33 (25.6)

Refer severe cases of malaria 31 (62.0) 75 (94.9) 106 (82.2)

Has outpatient register 43 (86.0) 22 (27.9) 65 (50.4)

Outpatient register up to date 42 (97.7) 17 (77.3) 59 (90.8)

Monthly list of cases 26 (59.1) 12 (54.6) 38(57.6)

The characteristics and knowledge of the key respondent in each health facility are shown in

Table 3.2. In both public and private facilities, the main respondent was the head of the

health facility. In public facilities, females were the majority of respondents whereas for

private facility the majority were male. Respondents were younger in public facilities and

older in private facilities. In private facilities, doctors were the main respondents, while in

public both doctors and midwives combined formed the majority of respondents

Knowledge regarding the recommended drug for P.falciparum and P.vivax was higher among

respondents in public facilities compared to those in private facilities. Over two thirds of

facilities had heard of activities to contain resistance; however, less than a quarter were

aware that some antimalarials were banned and this was similar in both public and private

facilities. A relatively high percentage of respondents in both public and private facilities had

heard about fake drugs however those who reported having seen fake drugs were more

prevalent among private facilities. Malaria related training during 2011 was high in public

facilities and low in private facilities.

Table 3.2 Health facility respondent characteristics



Total N=129 N (%)

Total 100 (50) 100 (79) 100 (129)

Respondent’s position

Health Facility Chief 84.0 (42) 81.0 (64) 82.2 (106)

22 Township Medical Officer


Deputy chief 4.0 (2) 1.3 (1) 2.3 (3)

Acting officer 6.0 (3) 2.5 (2) 3.9 (5)

Other 6.0 (3) 15.2 (12) 11.6 (15)

Respondent’s sex

Male 40.0 (20) 64.6 (51) 55.0 (71)

Female 60.0 (30) 35.4 (28) 45.0 (58)

Respondent’s age

20 to <40 years 64.0 (32) 35.4 (28) 46.5 (60)

40 to 49 years 24.0 (12) 25.3 (20) 24.8 (32)

>=50 years 12.0 (6) 39.2 (31) 28.7 (37)

Formal training

Doctor 36.0 (18) 58.2 (46) 49.6 (64)

Health Assistant 16.0 (8) 3.8 (3) 8.5 (11)

Public Health Supervisor (1) 2.0 (1) 3.8 (3) 3.1 (4)

Lady Health Visitor 4.0 (2) 5.1 (4) 4.7 (6)

Trained Nurse 6.0 (3) 3.8 (3) 4.7 (6)

Midwife 30.0 (15) 2.5 (2) 13.2 (17)

Public Health Supervisor (2) - (0) 3.8 (3) 2.3 (3)

Other Health Training 6.0 (3) 19.0 (15) 14.0 (18)

Knowledge of antimalarials

Knows recommended drug for uncomplicated P.falciparum

90.0 (45) 54.4 (43) 68.2 (88)

Knows recommended drug for uncomplicated P.vivax

76.0 (38) 45.6 (36) 57.4 (74)

Heard about activities to stop resistance

76.0 (38) 67.1 (53) 70.5 (91)

Aware that some antimalarials are banned

28.0 (14) 19.0 (15) 22.5 (29)

Knows which drugs are banned (any oral artemisinin based monotherapy)

42.9 (6) 26.7 (4) 34.5 (10)

Heard about fake drugs 66.0 (33) 77.2 (61) 72.9 (94)

Seen fake drugs 15.2 (5) 30.5 (18) 25.0 (23)

Had malaria related training in 2011 83.7 (41) 39.7 (31) 56.7 (72)

The results of facility staff review are shown in Table 3.3. Public facilities had significantly

more staff compared to private facilities. The majority of staff in public facilities was nurses /

midwives, while in private facilities the majority of staff was doctors, a reflection that private

facilities with only one member of staff will most likely be a trained doctor. Staff were most

likely to be present at the facility rather than in the field on the day of the survey. Private

facility staff had relatively fewer years in service than public health facility staff.

Table 3.3 Health facility staff characteristics

Public facility staff (N=312)

Private facility staff (N=138)

Number of staff per facility

Mean 11.6 4.0

Median 4 1

Minimum 1 1

Maximum 23 12


Highest qualification

Doctor 17.0 (53) 51.8 (71)

Health Assistant 3.2 (10) 3.7 (5)

Public Health Supervisor (1)

7.7 (24) 5.8 (8)

Trained Nurse 36.5 (114) 9.5 (13)

Midwife 24.7 (77) 3.7 (5)

Other Health Training 10.9 (34) 25.6 (35)

Other

Present on day of survey

In facility 78.5 (245) 85.4 (117)

In field 21.5 (67) 14.6 (20)

Years in service

=<5 years 22.4 (70) 35.0 (48)

>5 to <10 years 26.9 (84) 8.0 (11)

>10 to 20 years 29.2 (91) 22.6 (31)

>20 years 9.3 (29) 11.7 (16)

The inventory of antimalarial drugs, antibiotics and RDTs available in public and private

facilities is shown in Table 3.4 and summarised in Table 3.5. It is encouraging that stocks of

the nationally recommended antimalarials, Coartem and primaquine were high in public

facilities; however this was the case in less than half of the private facilities. Availability of

specified antibiotics was low in both sectors. Drug cocktails were only available in a small

number of private facilities. Carestart was the most commonly available RDT in both

public and private facilities.

Overall antimalarials were available in all but one public health facility and the majority

usually stocked appropriate ACTs. Almost a fifth of private facilities did not have any

antimalarials and just over half stocked ACTs. There were a small number of public facilities

(16%) with tablet formulations of artemisinin based monotherapy compared to relatively

higher number of private facilities (37%). Almost 70% of public facilities stocked

injections/suppositories of artemisinin based monotherapy compared to 38% of private

facilities. Nearly all public facilities and 62% private facilities stocked RDT’s.

Table 3.4 Antimalarials, other drugs and RDTs usually stocked by Health Facilities

Public facilities (N=50) % (N)

Private facilities (N=79) % (N)

AL (COARTEM 24) 90.0 (45) 45.6 (36)

AL (COARTEM 18) 68.0 (34) 26.6 (21)

AL (COARTEM 12) 72.0 (36) 20.3 (16)

AL (COARTEM 6) 72.0 (36) 19.0 (15)

DHA-piperaquine (DUO-COTECXIN)

- (0) 15.2 (12)

Artesunate tablet 12.0 (6) 34.2 (27)

Artesunate suppository - (0) - (0)

Artemether injection (80mg) 64.0 (32) 36.7 (29)

Artemether injection (40mg) 8.0 (4) 1.3 (1)


Artemether tablet 8.0 (4) 5.1 (4)

Artesunate + Amodiaquine - (0) 5.1 (4)

Artesunate + Mefloquine - (0) 3.8 (3)

Mefloquine tablet 14.0 (7) 15.2 (12)

Quinine Injection 16.0 (8) 13.9 (11)

Quinine tablet 22.0 (11) 21.5 (17)

Primaquine tablet (15 mg) 80.0 (40) 36.7 (29)

Primaquine tablet (7.5 mg) 16.0 (8) 12.7 (10)

Chloroquine tablet 88.0 (44) 53.2 (42)

Doxycycline 26.0 (13) 32.9 (26)

Tetracycline 12.0 (6) 22.8 (18)

Clindamycin 8.0 (4) 19.0(15)

Mixture of drugs for fever/malaria - (0) 5.1 (4)

Carestart (combo) 34.0 (17) 24.1 (19)

Carestart (SD) 84.0 (42) 49.4 (39)

Paracheck 22.0 (110 7.6 (6)

Other tests for malaria 2.0 (1) 3.8 (3)

Table 3.5 Summary of artemisinin-based combination therapy (ACTs), antimalarials and rapid diagnostic tests (RDTs) stocked at health facilities



Any antimalarial 98.0 (49) 82.3 (65)

ACTs 92.0 (46) 57.0 (45)

AMT (artemisinin based monotherapy) tablets 16.0 (8) 36.7 (29)

AMT (artemisinin based monotherapy) injections/suppositories

68.0 (34) 38.0 (30)

Non artemisinin antimalarials 96.0 (48) 70.9 (56)

Drug cocktail 0 (-) 5.1 (4)

Any RDTs 96.0 (48) 62.0 (49)

Table 3.6 summarises the laboratory services available in the health facilities. All public

facilities offer microscopy and/or RDTs compared to only 60% of private facilities and for the

latter testing was mostly performed with RDTs. Where facilities had microscopy, most had a

full time technician. Stockout of microscopy supplies and RDTs were low. Even though the

majority of public facilities said they usually stocked RDTs, availability as recorded in the

laboratory review was low. Use of an up-to-date laboratory register was good for facilities

with microscopy diagnostics. Only a third of the public facilities and very few private facilities

had a manual for malaria in the laboratory.

Table 3.6 Laboratory services and equipment available at health facilities



Malaria service

Microscopy & RDT 30 (15) 10.1 (8)

Microscopy only 8.0 (4) - (0)


RDT only 62.0 (31) 50.6 (40)

None - (0) 39.2 (31)

Has laboratory technician (for facilities which use microscopy)

Full time technician 89.5 (17) 87.5 (7)

Part time technician 5.3 (1) 12.5 (1)

None 5.3 (1) - (0)

Has working microscope (for facilities which use microscopy)

100.0 (19) 100.0 (8)

>1 week with no microscope in the last 3 months 10.5 (2) - (0)

>1 week with no slides in the last 3 months 10.5 (2) - (0)

>1 week with no giemsa stain in the last 3 months 5.3 (1) - (0)

Availability of RDTs (for facilities who use RDTs)

Carestart Combo 26.0 (13) 17.0 (8)

Carestart SD 46.0 (23) 42.6 (20)

Paracheck 12.0 (6) 10.6 (5)

Other 32.0 (16) 42.6 (20)

>1 week with no stock of RDTs 4.0 (2) 8.5 (4)

Has laboratory register/book 44.0 (22) 17.0 (8)

Laboratory register/book up to date (for those who had a register)

100.0 (22) 87.5 (7)

Has laboratory manual for malaria 34.0 (17) 8.3 (4)

In order to assess service delivery for malaria cases and episodes of fever, follow up interviews at home were done with malaria cases and exit interviews at the health facility for fever cases.

MALARIA PATIENT FOLLOW-UP AND EXIT INTERVIEWS

Table 3.7 Details of malaria cases followed up and exit interview patients

Case follow up- Malaria Cases

Exit interviews - Fever patients

Public facilities (N=294)

% (N)



% (N)


Age / sex

Under 5 years 3.4 (10) - (0) 13.1 (24) 10.2 (5)

5 to 14 years 15.6 (46) 13.2 (9) 18.6 (34) 18.4 (9)

15+years male 57.5 (169) 61.8 (42) 39.3 (72) 30.6 (15)

15+ years female 23.5 (69) 25.0 (17) 29.0 (53) 40.8 (20)

Education

Child <5years 3.4 (10) -(0) 14.2 (26) 16.3 (8)

No school 6.1 (18) 7.4 (50 4.4 (8) 6.1 (3)

Primary 45.2 (133) 25.0 (17) 45.9 (84) 36.7 (18)

Secondary 26.2 (77) 42.6 (29) 20.8 (38) 18.4 (9)

High school 11.2 (33) 11.8 (8) 10.4 (19) 16.3 (8)

University 7.5 (22) 5.9 (4) 3.3 (6) 4.1 (2)

Other 0.3 (1) 7.4 (5) 1.1 (2) 2.0 (1)

Occupation

Child 5.4 (16) 1.5 (1) 14.8 (27) 18.4 (9)

Student 14.6 (43) 11.8 (8) 19.1 (35) 12.2 (6)

Farmer 19.7 (58) 7.4 (5) 9.8 (18) 4.1 (2)


Labourer 6.1 (18) - (0) 6.0 (11) 2.0 (1)

Fisherman 1.4 (4) -(0) 1.1 (2) 4.2 (2)

Merchant 7.1 (21) 5.9 (4) 4.9 (9) 14.3 (7)

Housewife 4.8 (14) 7.4 (5) 11.5 (21) 10.2 (5)

Soldier 1.4 (4) - (0) - (0) - (0)

Other 39.5 (116) 66.2 (45) 32.8 (60) 34.7 (17)

Time at current address

<6 months 3.0 (9) 7.3 (5) 6.0 (11) 8.1 (4)

6 months to <1 year 2.4 (7) 2.9 (2) 3.3 (6) - (0)

More than 1 year 94.6 (278) 89.7 (61) 90.7 (166) 91.8 (45)

Slept in forest in the last 6 months 41.2 (121) 44.1 (30) 29.0 (53) 38.8 (19)

Travelled in the 2 weeks prior to illness

67.8 (82) 66.7 (20) na na

Sleep under net previous night 74.8 (220) 77.9 (53) 83.1 (152) 89.8 (440

A total of 362 patients with a malaria diagnosis in the previous 3 months were followed up

and interviewed (294 in public facilities, 68 in privates facilities) and a further 231 patients

presenting with fever (183 public facilities, 49 private facilities) were administered an exit

interview upon leaving the facility.

Table 3.8 shows demographics of malaria cases and fever patients found at the public and

private health facilities. Overall both groups were similar. A majority of malaria cases were

male adults. Nearly all cases and fever patients had resided at their current address for over

one year, suggesting they were residents of the communities.

Table 3.8 Assessment and antimalarials received by malaria cases and fever patients

Case follow up- Malaria Cases

Exit interviews - Fever patients

Public

facilities (N=294)

% (N)



% (N)


Saw health worker and had blood test 98.3 (289) 100.0 (68) 38.8 (71) 44.9 (22)

Saw health worker and received ACTs 22.4 (66) 44.1 (30) 5.5 (10) 8.2 (4)

Saw health worker and received antimalarials

25.2 (74) 50.0 (34) 7.7 (14) 12.2 (6)

Reported all 3 key assessments performed by health worker23

52.7 (155) 44.1 (30) 16.4 (30) 18.4 (9)

Reported all 3 key assessments performed by health worker (excluding travel)24

87.8 (258) 73.5 (50) 33.9 (62) 32.7 (16)

If given antimalarials health worker advised how to take them

100.0 (74) 97.1 (33) 100.0 (14) 83.3 (5)

23 Health care provider asked about travel & fever, auxiliary temperature taken, and tested 24 Health care provider asked about fever, auxiliary temperature taken, and tested


Table 3.9 provides a summary of health worker assessments and antimalarials received for

malaria cases and fever patients. It was encouraging to see that nearly all the malaria cases

who visited the health facility saw a health worker and had been administered a blood test,

however these are patients who have been recorded in outpatient records as having a malaria

diagnosis so it is unlikely they would not have had a blood test. The low percentage of fever

cases seeing a health worker reflects that many of these would be unlikely to be malaria and

the clinical assessment most likely resulted in a different diagnosis.

For both malaria cases and fever patients it seemed that where an antimalarial was given it

was most likely an ACT. In public facilities less than a quarter of the malaria patients received

an ACT but this was double among private facilities. Less than 10% of fever patients in both

public and private facilities received an ACT.

It was interesting that the percentage of fever patients reporting being asked about all three

key assessments (travel and fever, auxillary temperature taken, and tested) was low and the

same across both public and private sector, suggesting attention may be needed to improve

quality of care through further training and supervision.

In contrast, the percentage of malaria cases reporting all three key assessments, especially

when travel was excluded from the assessment was high, and again similar for both public and

private facilities. Health worker advice on taking antimalarials was high for malaria cases and

fever patients in both public and private facilities.

Table 3.9 below shows the reported treatment received among malaria cases and fever

patients. Focusing first on malaria cases, the percentage who reported receiving an ACT

(specifically Coartem) was very low and more so among private facilities. A considerable

percentage received paracetamol and vitamins (15% in public facilities, 20% in private

facilities). Reporting of any treatment was surprisingly low for fever patients with

approximately 6% receiving Coartem in both public and private facilities. There seemed to be

some confusion about infusion in treatment prescribed. Some malaria cases (28.2% and

14.7% in public and private facilities, respectively) reported to have had an infusion but did

not specify this when asked about drugs prescribed at health facilities. Similarly in exit

interviews with fever cases (20.2% and 2.0% in public and private facilities, respectively)

reported having had an infusion when asked directly but did not specify this when asked

about specific treatments. This suggested under-reporting of infusion use.

Table 3.9 Treatment prescribed at public and private health facilities among malaria

and fever cases

Case follow up- Malaria Cases Exit interviews - Fever patients


% (N)



% (N)


Coartem (AL) 14.4 (52) 5.2 (19) 5.5 (10) 6.1 (3)

Artesunate + Mefloquine 1.7 (5) 1.5 (1) - (0) - (0)

Other artesunate + mefloquine 1.7 (5) 1.5 (1) - (0) - (0)


Duo-Cotecxin 1.4 (4) - (0) - (0) - (0)

Other DHA-piperaquine - (0) 13.2 (9) - (0) 2.0 (1)

Cotecxin 0.7 (2) 4.4 (3) 0.5 (1) 2.0 (1)

Mefloquine - (0) - (0) - (0) - (0)

Artesunate only 2.0 (6) - (0) 0.5 (1) - (0)

Artemether only - (0) - (0) 0.5 (1) - (0)

Artemisinin only 0.3 (1) - (0) - (0) - (0)

Quinine - (0) - (0) - (0) - (0)

Chloroquine - (0) 1.5 (1) - (0) - (0)

Primaquine 1.4 (4) - (0) 1.1 (2) - (0)

Mixture of drugs for fever/malaria - (0) - (0) 0.5 (1) 2.0 (1)

Antibiotics 6.8 (20) 10.3 (7) 0.5 (1) 2.0 (1)

Paracetamol 7.1 (21) 5.9 (4) - (0) 2.0 (1)

Vitamins 8.2 (24) 14.7 (10) 1.6 (3) 2.0 (1)

Infusion 0.3 (1) - (0) - (0) - (0)

Traditional herbs - (0) - (0) - (0) 2.0 (1)

Other non anti malarial 0.7 (2) 2.9 (2) 0.5 (1) - (0)

Table 3.10 shows the reported diagnoses for prescribed treatment categories among exit

patients only. Patients can have multiple diagnoses and multiple treatments. Malaria was the

most common diagnosis among respondents of the exit interviews followed by respiratory

infection, gastric intestinal (GI) infections and other. Although the numbers were small, it is

encouraging to see that all patients receiving an ACT/antimalarial had been diagnosed

with malaria. Infusion appears to be the most common treatment for all diagnosis groups

demonstrating a huge over-reliance on infusions.

Table 3.10 Reported diagnosis and treatment among exit interview fever patients

Diagnosis Treatment received

N ACT Any antimalarial

Any antibiotic Infusion

% of patients receiving

treatment (N)


treatment (N)


treatment (N)


treatment (N)

Public health facility

Malaria 29 100.0 (9) 100.0 (11) 100.0 (1) 19.6 (19)

Acute/upper respiratory infection

5 - (0) - (0) - (0) 4.1 (4)

Cold / flu 73 - (0) - (0) - (0) 73.2 (71)

GI infection 6 - (0) - (0) - (0) 3.1 (3)

Private health facility

Malaria 15 100.0 (4) 100.0 (6) 100.0 (1) 50.0 (14)

Acute/upper respiratory infection

11 - (0) - (0) - (0) 3.6 (1)

Cold / flu 12 - (0) - (0) - (0) 42.9 (12)

GI infection 1 - (0) - (0) - (0) 3.6 (1)

DISCUSSION


HOUSEHOLD AND PREVALENCE SURVEYS

Malaria prevalence

Overall, malaria prevalence was only 0.5% in both Tier 1 and Tier 2 at the time of the survey.

There was a higher prevalence of Plasmodium vivax infection compared to Plasmodium

falciparum and there were no cases of mixed species infection. Malaria tended to be more

prevalent among children under five and poorer households and people living in Tier 1 and in

higher malaria risk area had higher chance of having a positive slide.

In absolute numbers, there were more malaria cases found in Tier 1 (4 Pf and 13 Pv) than in

Tier 2 (3 Pf and 1 Pv). However, comparison across tier suggested that the proportion of

infections of P. falciparum was higher than P. vivax in Tier 2 but this trend was reversed in Tier

1. With respect to the containment of artemisinin resistance, the fact that there were more P.

falciparum cases proportionally in Tier 2 suggests that more intensive efforts should be

placed in Tier 2.

The higher prevalence of malaria among children under five years of age suggests that there

may be ongoing malaria transmission in the studied villages. Further routine monitoring of

confirmed malaria cases throughout the year may help to shed some light on the malaria

epidemiology and trends in Tier 1 and Tier 2 areas. Malaria transmission appeared to be

heterogeneous as the trends observed in Tier 1 tended to reflect a lower transmission setting

compared to Tier 2. However, the association of malaria slide positivity with children under 5

years of age, presence of fever, net use the previous night, and high malaria risk strata all

suggest much more stable transmission. Thus, it will be even more critical to include more

sensitive end-points for measuring parasitemia and transmission with molecular tools such as

PCR and serology, respectively, into this analysis.

Malaria awareness and prevention

In general, 20% of the respondents could not mention any transmission mode and several

misconceptions were cited but about 65% of respondents knew that mosquitoes transmit

malaria. Awareness about ITN benefit was low. In the previous six months, only 12%

mentioned having received any information about malaria and the main message remembered

was related to net or ITN use, from health facility or NGO staff.

On the survey day, household ownership of any net was 97.4%, of any ITN was 35.1% and any

LLIN was 11.1%. The coverage of any net was higher among richer households while the

availability and use of insecticide treated nets appeared to be associated with less wealthy

households and those living in higher malaria risk area. Considering already very high

coverage of any net among households, it may be worthwhile to look at intermediate

strategies for converting these conventional nets into LLINs as soon as possible – while

being careful not to adversely affect household behaviors and perceptions of these important

prevention tools. The longer term strategy, however, should be to replace conventional nets

with LLINs that households want to have and to use.


Unsurprisingly, more nets were found in the Tier 1 and the nets tended to be ‘newer’ than

those in Tier 2, perhaps due to the intensified activities in this priority area for containment of

artemisinin resistance. However, with many mosquito nets found in Tier 2 more than 5 years

old, it will be important to expand these intensive efforts to the more remote, harder to

reach areas of Tier 2 as well.

The proportion of all people who slept under a net the previous night was a respectable 76.5%

but these estimates for ITN and LLIN were much lower at 16% and 4%, respectively. Although

more than a quarter of households had insufficient nets (at least one net per every two

people), at least 20% of households also possessed nets that were not currently used by the

household and were saved for the future or for visitors. Lastly, net use among mobile

groups as forest goers, travellers and temporary visitors tend to be significantly lower

compared to all individuals. More efforts are needed to target BCC messages around the

importance of having and sleeping under an insecticide-treated net, particularly among

populations that are highly mobile.

Malaria treatment

Nearly half of the respondents knew the signs and symptoms of malaria (chills and fever) but

only one-third could cite the main sign for fever severity (unconscious, fast breathing or

convulsion). These figures suggest that more BCC is needed to improve malaria knowledge

and treatment-seeking behaviors.

Less than 30% of household respondents knew any antimalarial drug and less than 10% could

mention an ACT. However, artesunate monotherapy was mentioned by more than 10% by

respondents living in either tier. Considering that the ban on artesunate monotherapies had

not been fully implementated during the time of the survey, there are still opportunities for

improving peoples’ knowledge and awareness about the use of ACTs for the treatment of

malaria.

Among all individuals in the sampled households, 3% reported fever during the previous two

weeks. Among these 241 people, 70% sought treatment mostly to a private doctor, a health

centre or a midwife clinic and overall, public sector channels were more common. However, in

Tier 2, fewer people sought treatment and an important source of advice or treatment was a

grocery shop. There is particular need to address this potentially dangerous practice of

treatment seeking from unqualified shopkeepers.

For the most part, the first source of treatment-seeking for reported fevers appeared to be a

private channel. In both tiers, time to treatment was fast, within 2 days for a vast majority of

cases. Among all fever cases, 69% had either an RDT or a blood test for malaria. In most cases,

the treatment consisted of non-antimalarial drugs (80.8%) for presumably non-malaria fevers

and only 4 out of 12 (33%) confirmed cases received an ACT (Coartem).

DRUG OUTLET SURVEY

The main finding from the drug outlet survey was that more than half of providers did not

have appropriate health training and 80% of the drug outlets were part of a general store


where consultations were offered. Awareness about artemisinin resistance was low in the

sampled outlets and in general, the most popular antimalarial drugs sold in the sampled

outlets were: 1) artesunate tablets, 2) chloroquine, 3) artemether injectables, and 4)

artemether tablets. This confirms that in the target area, artemisinin monotherapies (i.e.,

artesunate) were still the most popular malaria treatment obtained from drug outlets.

Also, more than half of the drug outles sold partial packs of antimalarial treatments in

previous month. Selling activity during the past week was low, which is consistent with the

low malaria prevalence and reported fever found in the households surrounding these outlets

and 60% reported selling less antimalarial drugs than the previous year.

Although availability of any antimalarial drugs was high among the sampled drug outlets, ACTs

were found in less than 40% of outlets and artemisinin monotherapies were still the most

popular and widely available treatment for malaria. Since the ban on oral artemisinin

monotherapies had not been fully implemented at the time of the survey, it was not surprising

that most drug providers were unaware of the issue of artemisinin resistance. Further work

on providing appropriate BCC training for drug outlet providers and ensuring the drug

outlets are stocking quality-asured antimalarials will be essential.

HEALTH FACILITY SURVEY

The aim of the health facility survey was to assess the delivery of services for management of

fever and malaria in both the public and private sectors. Due to the relatively low incidence of

malaria throughout the country, it was increasingly more difficult to conduct proper

assessment based on prospective malaria cases. As a result, exit interviews and malaria case

follow up interviews provided a good way to correlate patient’s perceived malaria services

with those of providers.

Public health facilities were more likely to provide malaria diagnosis and malaria

education compared to private facilities, in part due to the support from the National Malaria

Programme and Ministry of Health. On the other hand, private health facilities were more

likely to refer cases of severe malaria, and had significanlty less respondents with malaria

related training compared to public facilities. This is reflected in the low level of knowledge

about the recommended treatments for P. falciparum and P. vivax. These findings warrant

more intensive training for malaria case management, particularly among private

providers.

All public facilities seem to have good diagnostic capabilities whereas 40% of private facilites

had no facility for malaria diagnosis. If the private facilites are able to refer cases this is not

problematic, referal of potential malaria cases for testing and/or testing in private facilites

should be addressed.

Although nearly all malaria cases who saw a health worker had a blood test, one of the key

findings from the malaria case follow up survey was that less than a quarter of cases in public

facilites received an ACT. This percentage was higher in the private sector but the number of

cases followed up in the private sector was low (68). Among the patients receiving IV infusion,

20% and 50% were diagnosed as malaria in the public and private health facility, respectively.

The over-reliance on the use of intravenous infusions for the treatment of fevers and malaria

should be assessed. Particularly as malaria declines in the country, more fevers presented at


public and private health facilities will be non-malaria related. Improved and more sensitive

algorithms and training for the treatment of these non-malaria fevers should be developed and

implemented


KEY RECOMMENDATIONS

1. Promote better understanding of the malaria epidemiology in Myanmar

The low malaria prevalence (based on microscopy) and reported fevers found in this survey is

an encouraging testament of the progress achieved in Myanmar to date. However, further

analysis using molecular (PCR) and serological methods, if possible, should be completed as

soon as possible to complement these findings. In the longer term, the malaria surveillance

system in Myanmar should be strengthened to provide quality and reliable data on the malaria

trends over time across seasons and localities.

The epidemiology of malaria will likely change as the incidence of malaria continues to decline in the region and already in parts of Myanmar. Therefore, more research may be needed to evaluate the impact of changing species distributions (i.e., increasing P. vivax burden) on disease transmission dynamics. There is also a need for more information on the effect of the rapidly changing environment on malaria vector behavior and possible secondary malaria species.

2. Promote further awareness of malaria prevention and case management

General awareness of malaria and fever case management was found to be modest and further

work should be reinforced by behavior change communication focusing on prevention and

treatment of malaria and availablility of diagnostic services and treatment. In particular,

awareness about the benefits of using ITNs/LLINs was relatively low. Further efforts should

be placed on improving community perceptions and behaviors for malaria prevention,

building on the fact that nearly all households currently own at least one mosquito net and

nearly three-quarters of individuals slept under a mosquito net the previous night.

Areas for further intensification of BCC activities include ensuring that health staff (both public

and private) are properly trained, able to prescribe correct treatments, and able to give the

appropriate messages, as health facility staff are cited as one of the most common sources of

information about malaria messages. The opportunities to expand these interpersonal

communication channels through village malaria workers or volunteers should be explored.

3. Expand the availability and promote the use of ITNs/LLINs

The coverage of any mosquito net (i.e., at least one mosquito net per household) in both Tier 1

and Tier 2 was more than 96%. However, household coverage of any ITN or LLIN was

insufficient to impact on malaria prevention and transmission. Considering the high

household coverage of at least one mosquito net, the national malaria prevention strategy

could explore the role of short to medium-term approaches for net retreatment kits or

campaigns. For the longer term, strategies should be in place to promote the replacement of

current conventional mosquito nets, building on the existing opportunity of the “net culture”

in Myanmar.


4. Promote innovative strategies targeting vulnerable groups including mobile or

migrant population

The national malaria programme should specifically address this vulnerable risk group as they

are highly at risk for malaria. They should have access to prevention methods such as

insecticide treated nets or other personal prevention methods, be aware and have access to

diagnostic services and malaria treatment and be sensitized on the importance to seek health

care in case of fever. Innovative strategies and approaches should be piloted to specifically

address improving case management, prevention, as well as M&E and surveillance among

mobile populations. Furthermore, linkages with the private sector (i.e., development projects

and businesses employing migrants) should be strengthened.

5. Enforce the national ban on oral artemisinin monotherapies

Artemisinin monotherapies were found widely available and knowledge about the ban among drug sellers was limited. Despite efforts to enforce the ban on the importation of oral artemisinin monotherapies in the country, the availability of such monotherapies (e.g., artesunate) in 56% and 44% of private drug outlets in Tier 1 and Tier 2, respectively, highlights the need to intensify efforts on drug regulation and enforcement.

At the same time, there is also a need to improve the availability and knowledge of

artemisinin-based combination therapies in both public and private sectors, particularly

among community members and private providers. There is a need to strengthen

collaboration with private providers for training, M&E, and surveillance.

6. Promote awareness and increase knowledge of health care providers

Knowledge on management of severe malaria and recommended treatment for P. falciparum and P. vivax should be increased and strengthened among both public and private health facility staff through in-service and refresher trainings, particularly addressing the current reliance on intravenous infusion to treat uncomplicated malaria cases. As malaria transmission will most likely decrease in the coming years, it becomes more important and relevant to develop improved and more sensitive algorithms and approaches for the management of non-malaria fevers. 7. Strengthen routine malaria information systems at all levels

Malaria transmission will become more heterogeneous and localized as malaria continues to

decline in the region. Large scale malariometric surveys are useful for a ‘snap-shot’ and can

complement analysis of the malaria situation, but can inevitably be costly and not sensitive

enough for local decision-making. As a result, it will be critical to begin moving towards

improving the routine malaria information systems in Myanmar as a longer term strategy.


REFERENCES

UNICEF (2008) Malaria Risk Micro-stratification in UNICEF 80 Townships

Ministry of Health, Myanmar. National Treatment Guidelines for Malaria

WHO (2011) Strategic Framework for Artemisinin Resistance Containment in Myanmar

(MARC) 2011‐2015


ANNEXES

Annex 1. Household Questionnaire

Annex 2. Drug Outlet Questionnaire

Annex 3. Health Facility Questionnaire – Part 1




ANNEX 1. HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

Cluster code (01-80): Household number (01-25): ........................................

Head of Household: __________________________ Name of respondent: _____________

(enter code from section 1 - the household list line code)

State/Region: _______________________________ Township: ....................................................................

Village Tract: ________________________ Village: ________________________

HOUSEHOLD VISITS Visit 1 Visit 2 Visit 3 Final Visit

Date:

Interviewer's Name:

Result code:

_ _ / _ _ / _ _ (dd/mm/yy)

__________

_____

_ _ / _ _ / _ _ (dd/mm/yy)

__________

_____

_ _ / _ _ / _ _ (dd/mm/yy)

__________

_____

Date: __ __ / __ __ / __ __ (dd/mm/yy) Interviewer ID: Result code:

Next planned visit: Date:

Time:

_ _ / _ _ / _ _

_________

_ _ / _ _ / _ _

_________

Total number of visits:

* Result Codes:

1 = Completed 2 = No one (or no potential respondent) at home 3 = Refused 4 = Dwelling not found 5 = Other

COMPLETE AFTER HOUSEHOLD LISTING

Total members in household: Total visitors in the household: Line code of respondent:

(anyone who can answer, mostly females)

SUPERVISOR FIELD EDITOR OFFICE EDITOR DATA ENTRY

Name: _______________

Code:

Date: _ _ / _ _ / _ _

Name: _______________

Code:

Date: _ _ / _ _ / _ _

Name: _______________

Code:

Date: _ _ / _ _ / _ _

Name: _______________

Code:

Date: _ _ / _ _ / _ _


Section 1: Household Listing

"We would first like to ask you some information about the members of your household and any

temporary visitors to your household."

(Usual residents do not include those who are away from home for more than six months)

LINE NO. USUAL RESIDENTS AND TEMPORARY

VISITORS

RELATIONSHIP TO HEAD OF HOUSEHOLD

SEX AGE EDUCATION

Circle the line number if blood samples taken

Give the names of people who usually live in the house and visitors last night (If a baby does not have a name, write babymother's name)

What is the relationship of (NAME) to the head of household?

Is (NAME) male or female?

How old is (NAME)? [If <1 year, write "00" for years and record number of months]

Has (NAME) ever attended school?

What is the highest level of education attained?

Q1 Q2 Q3 Q4 Q5 Q6 Q7

Line code Name Code* Male Female Years Months Yes No Code**

01 1 2 1 2

02 1 2 1 2

03 1 2 1 2

04 1 2 1 2

05 1 2 1 2

06 1 2 1 2

07 1 2 1 2

08 1 2 1 2

09 1 2 1 2

10 1 2 1 2

11 1 2 1 2

12 1 2 1 2

13 1 2 1 2

14 1 2 1 2

15 1 2 1 2

"Just to make sure that I have a complete listing, are there any other persons living in your household that we have not listed, such as small children or infants?"

If yes, add these individuals to the two tables above

"Are there any other people living or staying here who may not be members of your family, such as visitors or friends or temporary workers?"


If yes, add these individuals to the two tables above Tick here if more than 14 people in the house and continuation sheet used:

LINE NO.

USUAL RESIDENTS

AND TEMPORARY

VISITORS

PERSON WHO TRAVELS AWAY

FROM HOME

SLEPT HERE LAST NIGHT

REASON FOR ABSENCE LAST

NIGHT

CURRENTLY FEBRILE

CURRENTLY PREGNANT

Circle the line number

if blood samples

taken

Is (NAME) a usual resident of the household or a

temporary visitor?

During the past 6 months, did

(NAME) travel away from home

and stay overnight?

Did (NAME) sleep here last night?

If (NAME) did not sleep here last

night, what was the reason?

Is (NAME) febrile? FOR ELIGIBLE WOMEN: Is (NAME) currently

pregnant?

Q1 Q8 Q9 Q10 Q11 Q12 Q13

Line code Resident Visitor Yes No Yes No Code*** Yes No Yes No DK

01 1 2 1 2 1 2 1 2 1 2 8

02 1 2 1 2 1 2 1 2 1 2 8

03 1 2 1 2 1 2 1 2 1 2 8

04 1 2 1 2 1 2 1 2 1 2 8

05 1 2 1 2 1 2 1 2 1 2 8

06 1 2 1 2 1 2 1 2 1 2 8

07 1 2 1 2 1 2 1 2 1 2 8

08 1 2 1 2 1 2 1 2 1 2 8

09 1 2 1 2 1 2 1 2 1 2 8

10 1 2 1 2 1 2 1 2 1 2 8

11 1 2 1 2 1 2 1 2 1 2 8

12 1 2 1 2 1 2 1 2 1 2 8

13 1 2 1 2 1 2 1 2 1 2 8

14 1 2 1 2 1 2 1 2 1 2 8

15 1 2 1 2 1 2 1 2 1 2 8


AFTER LISTING HOUSEHOLD MEMBERS, SELECT MEMBERS FOR TAKING BLOOD. MAKE

RANDOM SELECTION FOR DIFFERENT AGE GROUPS AND CIRCLE LINE NO. FOR

SELECTED ONES. Check for completeness.

One to -4 years one person 5 – 14 one person

Above 15 (female) one person Above 15 (male) one person

Then, Pregnant women all

Temporary visitors all

Those with malaria symptoms all


"Now, we would continue to ask you some information about usual residents of your household who are away from house for more than 6 months."

LINE NO.

USUAL RESIDENTS AWAY FROM HOME FOR MORE THAN 6

MONTHS

RELATIONSHIP TO HEAD OF HOUSEHOLD

SEX AGE EDUCATION

REASON FOR

ABSENCE

CURRENT RESIDENCE

Give the names of people who are away from home for more than 6 months

What is the relationship of (NAME) to the head of household?

Is (NAME) male or female?

How old is (NAME)? [If <1 year, write "00" for years and record number of months]

Has (NAME) ever attended school?

What is the highest level of education attained?

What was the reason for being away?

Where does (NAME) stay?

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q11 Q11b

Line code Name Code* Male

Female Years

Months

Yes No Code** Code*** Country Township Others (specify)

01 1 2 1 2

02 1 2 1 2

03 1 2 1 2

04 1 2 1 2

05 1 2 1 2

06 1 2 1 2

07 1 2 1 2


* Codes for relationship to head of household (Q3):

01 = Head of household

02 = Spouse (wife/husband/partner)

03 = Son or daughter

04 = Son or daughter-in-law

05 = Grandchild

06 = Parent

07 = Parent in-law

08 = Brother or sister

09 = Niece or nephew

10 = Other relative

11 = Adopted/foster/stepchild

12 = Not related

** Codes for level of education (Q7):

0 = Never attended school

1 = Some primary

2 = Completed primary (Grade 6)

3 = Some secondary

4 = Completed secondary (Grade 12)

5 = More than secondary

8 = Don't know

*** Codes for reason for absence last night (Q11):

1 = Working on chamkar or plantation in this province

2 = Working on chamkar/plantation in another province

3 = Working in forest in this province

4 = Working in forest in another province

5 = Working in another province

6 = Working in Thailand

7 = Away at school / studying

8 = Holidays / visiting relatives or friends

9 = Hospitalized or caretaker of a patient

10 = Other (specify)

98 = Don't know


Section 2: Household Details

"Now I would like to ask you some general questions about this household."

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

Q14 What is the main source of drinking water in your household? (SINGLE RESPONSE)

Piped water into house or yard ................... 1 Rain water/gutter pipe ................................. 2 Tube well or borehole ................................. 3 Public tap/standpipe ................................... 4 Protected well/Spring .................................. 5 Cart or truck with tank ................................. 6 River/Stream/Pond/Lake ............................. 7 Other ........................................................... 8 Specify:_______________________________

Q15 What kind of toilet facility does your household use? (SINGLE RESPONSE)

Flush or pour toilet ...................................... 1 Pit latrine- ventilated or with slab ................ 2 Open pit (no slab) ....................................... 3 No facility/field/forest ................................... 4 Other ........................................................... 5 Specify:_______________________________

Q16 Does your dwelling have electricity? IF GENERATOR IS USED FOR THE WHOLE VILLAGE, ELECTRICITY WILL BE CONSIDERED AVAILABLE.

Yes .............................................................. 1 No ............................................................... 2

Q17 Does your household have any of the following assets? ASK ABOUT EACH OF THE ASSESTS AND CIRCLE "YES" IF THEY OWN IT OR "NO" IF THEY DO NOT

Yes No Radio ........................................... 1 2 Television .................................... 1 2 DVD player.................................. 1 2 Mobile phone/landline ................. 1 2 Freezer/refrigerator ..................... 1 2 Water storage jar ........................ 1 2 Bed .............................................. 1 2 Electric Kettle .............................. 1 2 Plastic bucket .............................. 1 2 Generator .................................... 1 2 Battery (12v) .............................. 1 2 Floor mat (smooth) ..................... 1 2 Pigs ............................................. 1 2 Cows/Buffalo/Goats .................... 1 2 Chickens/Ducks .......................... 1 2

Q18 What type of fuel does your household mainly use for cooking? (SINGLE RESPONSE)

Electricity..................................................... 1 Gas/kerosene ............................................. 2 Charcoal...................................................... 3 Firewood/straw ........................................... 4 Other ........................................................... 5 Specify:_______________________________

Q19 What is the main material of the roof? (SINGLE RESPONSE)

Plastic sheet/tent ........................................ 1 Thatch/palm/bamboo .................................. 2 Fibre glass/iron/aluminum ........................... 3 Tiles/cement................................................ 4 Other ........................................................... 5 Specify:_______________________________



Q20 What is the main material of the floor? (SINGLE RESPONSE)

Bamboo ....................................................... 1 Wood ........................................................... 2 Tiles/cement................................................ 3 Earth ........................................................... 4 Other ........................................................... 5 Specify:_______________________________

Q21 Does any household member own the following types of transport? ASK ABOUT EACH AND CIRCLE "YES" IF THEY OWN IT OR "NO" IF THEY DO NOT

Yes No Ox or horse cart .......................... 1 2 Bicycle ......................................... 1 2 Motorcycle or scooter ................. 1 2 Car or truck or Trollergy .............. 1 2 Motor boat .................................. 1 2

Q22 Does your household use metal or plastic screens on your windows to keep mosquitoes out?

Yes .............................................................. 1 No ............................................................... 2

Q23 Does your household use any chemicals to keep mosquitoes away (e.g., spray, coil or repellent)?

Yes .............................................................. 1 No ............................................................... 2

Q25

Q24 In the past month, how much did your household spend on chemicals to keep mosquitoes away?

Riel: ...............................................................

Not Sure .................................................... 98

Q25 During the past 12 months, has anyone sprayed the interior walls of your home against mosquitoes?

Yes .............................................................. 1 No ............................................................... 2 Don't know .................................................. 8

Q28 Q28

Q26 Who sprayed the house? Government worker/program ...................... 1 NGO worker/program ................................. 2 Private company ......................................... 3 Household member .................................... 4 Other ........................................................... 5 Specify:_______________________________

Not sure ...................................................... 8

Q27 Did you pay for the spraying? Yes .............................................................. 1 No ............................................................... 2 Don't know .................................................. 8

Q28 How many separate sleeping spaces are there in your household? INCLUDE ALL SLEEPING SPACES, INCLUDING IF THERE IS MORE THAN ONE SLEEPING SPACE IN EACH ROOM USED FOR SLEEPING

Number of sleeping spaces ..........................

Section 3: Household Nets


Q29 Does your household have any mosquito nets (bed nets or hammock nets) that can be used while sleeping?

Yes ............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8

Q52 Q52



Q30 How many mosquito nets does your household have? ALSO INCLUDE ANY THAT ARE NOT CURRENTLY IN USE

Number of bed nets: ..................................... Number of hammock nets: ........................... Total number of mosquito nets: ....................

NO. QUESTIONS Net 1 Net 2 Net 3

Q31 Ask to see the nets in the household.

Observed ................ 1 Not observed .......... 2

Observed ................ 1 Not observed .......... 2

Observed ............... 1 Not observed .......... 2

NOTE: IF THERE ARE MORE THAN THREE NETS IN THE HOUSEHOLD, USE ADDITIONAL SHEETS. FIRST ASK Q31-Q48 FOR NET 1, THEN Q31-Q48 FOR NET 2, THEN Q31-Q48 FOR NET 3, …

Q32 How long ago did your household obtain this net?

< 6 months ............. 1 6 mo to <1 year ...... 2 1 yr to < 2 yr ........... 3 2 yr to < 3 yr ........... 4 3 yr to < 5 yr ........... 5 ≥ 5 years ................. 6 Don't know .............. 8

< 6 months ............. 1 6 mo to <1 year ...... 2 1 yr to < 2 yr ........... 3 2 yr to < 3 yr ........... 4 3 yr to < 5 yr ........... 5 ≥ 5 years ................ 6 Don't know.............. 8

< 6 months ............. 1 6 mo to <1 year ...... 2 1 yr to < 2 yr ........... 3 2 yr to < 3 yr ........... 4 3 yr to < 5 yr ........... 5 ≥ 5 years ................ 6 Don't know ............. 8

Q33 Where did your household obtain this net?

Gift (family/friend) ... 1 Government ............ 2 NGO ....................... 3 Shop/Market ........... 4 Itinerant seller ......... 5 Other ...................... 6 Spec_____________ Don't know .............. 8

IF GIFT, SKIP TO Q35

Gift (family/friend) ... 1 Government ........... 2 NGO ....................... 3 Shop/Market ........... 4 Itinerant seller ......... 5 Other ...................... 6 Spec_____________ Don't know.............. 8


Gift (family/friend) ... 1 Government ........... 2 NGO ....................... 3 Shop/Market ........... 4 Itinerant seller ........ 5 Other ...................... 6 Spec_____________ Don't know ............. 8


Q34 How much did you pay for this net?

Kyat: ____________

Don't know .............. 8

Kyat: ____________

Don't know.............. 8

Kyat: ____________

Don't know ............. 8

Q35 Observe or ask the brand of the mosquito net. If brand is unknown, and you cannot observe the net, show pictures of typical net types/brands to respondent.

ITNs Powernet ................ 1 Permanet ................ 2 JICA ........................ 3 MoH ........................ 4 Olyset…………….. 5 Conventional nets: Lace ....................... 6 Military ................... 7 No logo ................. 8 Cotton CYC .......... 9 Other .................... 10 Spec_____________ Don't know ............ 98

ITNs Powernet ................ 1 Permanet ................ 2 JICA ....................... 3 MoH ........................ 4 Olyset…………….. 5 Conventional nets: Lace ...................... 6 Military ................... 7 No logo ................. 8 Cotton CYC .......... 9 Other .................... 10 Spec_____________ Don't know............ 98

ITNs Powernet ................ 1 Permanet ............... 2 JICA ....................... 3 MoH........................ 4 Olyset…………….. 5 Conventional nets: Lace ...................... 6 Military ................... 7 No logo ................. 8 Cotton CYC .......... 9 Other.................... 10 Spec_____________ Don't know ........... 98

Q36 Observe or ask the size of the mosquito net.

Single size .............. 1 Family size ............. 2 Hammock ............... 3





Q37 Observe or ask the colour of the mosquito net.

White ...................... 1 Blue ........................ 2 Green ..................... 3 Pink ........................ 4 Other ...................... 5 Spec_____________ Don't know .............. 8

White ...................... 1 Blue ........................ 2 Green ..................... 3 Pink ........................ 4 Other ...................... 5 Spec_____________ Don't know.............. 8

White ...................... 1 Blue ........................ 2 Green ..................... 3 Pink ........................ 4 Other ...................... 5 Spec_____________ Don't know ............. 8

Q38 Does the net have any holes? Yes ......................... 1 No ........................... 2

Yes ......................... 1 No ........................... 2

Yes ......................... 1 No........................... 2

Q39 Has the net been repaired? Yes ......................... 1 No ........................... 2

Yes ......................... 1 No ........................... 2

Yes ......................... 1 No........................... 2

Q40 When you got the mosquito net was it already treated with an insecticide to kill or repel mosquitoes?

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF YES, SKIP TO Q42

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF YES, SKIP TO Q42

Yes ......................... 1 No........................... 2 Not sure ................. 8

IF YES, SKIP TO Q42

Q41 Since you have had the net, has it ever been soaked or dipped in a liquid to kill/repel mosquitoes?

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF NO, SKIP TO Q44

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF NO, SKIP TO Q44

Yes ......................... 1 No........................... 2 Not sure ................. 8

IF NO, SKIP TO Q44

Q42 Where did you get your net treated the last time? IF NEVER RETREATED, SKIP TO Q44

At home .................. 1 In village ................. 2 In another village .... 3 Other ...................... 4 Spec_____________

Never retreated for original treated net .8





Q43 The last time you treated your net, how much did your household pay for dipping the net, if it paid anything?

Kyat: ____________

Don't know .............. 8

Kyat: ____________

Don't know.............. 8

Kyat: ____________

Don't know ............. 8

Q44 How long since the net was last soaked or dipped in a liquid to kill/repel mosquitoes?

IF LESS THAN ONE MONTH, WRITE "00"

Months: .....................

More than 3 years (36 months) ago ..... 95

Not sure ................ 98

Months: ....................


Not sure ................ 98

Months: ....................


Not sure ............... 98

Q45 How frequently has this net been washed since you received it?

Weekly ................... 1 Every 2-3 weeks…..2 Monthly ................... 3 Every 2-3 months ... 4 Twice per year ........ 5 Once per year ......... 6 < Once a year ......... 7 Never ...................... 0 Not sure .................. 8

Weekly ................... 1 Monthly ................... 2 Every 2-3 months ... 3 Twice per year ........ 4 Once per year ........ 5 < Once a year ........ 6 Never ...................... 7 Not sure .................. 8

Weekly ................... 1 Monthly .................. 2 Every 2-3 months ... 3 Twice per year ....... 4 Once per year ........ 5 < Once a year ........ 6 Never...................... 7 Not sure ................. 8

Q46 Did anyone sleep under this mosquito net last night?

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF NO, SKIP TO Q48

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF NO, SKIP TO Q48

Yes ......................... 1 No........................... 2 Not sure ................. 8

IF NO, SKIP TO Q48



Q47 Who slept under this mosquito net last night? ASK FOR THE NAME AND AGE OF EACH PERSON WHO SLEPT UNDER THE NET, THEN CHECK SECTION 1 FOR THE LIST OF HOUSEHOLD MEMBERS AND VISITORS AND WRITE THEIR LINE CODE (Q1)

1) Name__________

Line code: .................

2) Name__________

Line code: .................

3) Name__________

Line code: .................

4) Name__________

Line code: .................

5) Name__________

Line code: .................

1) Name__________

Line code: .................

2) Name__________

Line code: .................

3) Name__________

Line code: .................

4) Name__________

Line code: .................

5) Name__________

Line code: .................

1) Name__________

Line code: ................

2) Name__________

Line code: ................

3) Name__________

Line code: ................

4) Name__________

Line code: ................

5) Name__________

Line code: ................



Q48 Do you have any old nets that you are not using to sleep under?

Yes .............................................................. 1 No ............................................................... 2

Q50

Q49 What are you using these old nets for?

MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED

PROBE ONCE: ANYTHING ELSE?

Saving for visitors ....................................... 1 Fishing ........................................................ 2 Protect garden ............................................ 3 Protect animals ........................................... 4 Other ........................................................... 5 Specify:_______________________________

Q50 Do you have any new nets that you are not using to sleep under?

Yes .............................................................. 1 No ............................................................... 2

Q52

Q51 Why aren't you using these new nets? Saving for visitors ....................................... 1 Saving for future use ................................... 2 No place to hang up .................................... 3 Currently have enough nets in use ............. 4 Other ........................................................... 5 Specify:_______________________________

Q52 If you need to buy a net where would you go to buy one?

Shop or seller in village ............................... 1 Nearest market ........................................... 2 Itinerant seller ............................................. 3 Would not buy- wait for distribution ............ 4 Would not buy- other .................................. 5 Other ........................................................... 6 Specify:_______________________________

Don't know .................................................. 8

Q53 If you decided you needed to treat or re-treat a net (i.e., soaking or dipping in a liquid), where would you go?

Wait for project/health staff ......................... 1 Health center/hospital ................................. 2 Private health facility ................................... 3 NGO office .................................................. 4 Pharmacy .................................................... 5 Market/shop ................................................ 6 VMW/VHV ................................................... 7 Nets are all pre-treated ............................... 8 Don't want insecticide ................................. 9 Have no nets ............................................. 10 Other ......................................................... 11 Specify:_______________________________

Don't know ................................................ 98

Q54 What are the benefits of a mosquito net treated with insecticide compared to an untreated net?



Prevents mosquito bites ............................. 1 Repels mosquitoes ..................................... 2 Kills mosquitoes .......................................... 3 Kills other insects ........................................ 4 Sleep better................................................. 5 Protects against malaria ............................. 6 Other ........................................................... 7 Specify:_______________________________

Don't know .................................................. 8

Section 4: People who go to the forest




Q55 Does anyone in your household sometimes go to the forest and sleep there overnight?

Yes .............................................................. 1 No ............................................................... 2 Don't know .................................................. 2

Q69 Q69

Q56 How many people in your household sometimes go to the forest and sleep there overnight?

Number of people: ........................................

NO. QUESTIONS Person 1 Person 2 Person 3

Q57 Who in your household sometimes go to the forest and sleeps there overnight?

ASK FOR NAME AND AGE, CHECK SECTION 1 FOR THEIR LINE CODE (Q1) (Use additional sheets if more than 3 persons)

Name ____________

Line code: .................

Name ____________

Line code: .................

Name ____________

Line code: ................

Q58 When was (NAME) last in the forest?

Last night ................ 1 < 1 week ................. 2 1 to < 4 weeks ........ 3 ≥ 4 weeks ............... 4 Not sure .................. 8


Last night ............... 1 < 1 week ................. 2 1 to < 4 weeks ........ 3 ≥ 4 weeks ............... 4 Not sure ................. 8

Q59 How many nights did (NAME) stay in the forest on their last visit?

Nights: ......................

Not sure ................ 98

Nights: ......................

Not sure ................ 98

Nights: ......................

Not sure ............... 98

Q60 Did (NAME) take a hammock net or mosquito net with them the last time they went to the forest?

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF NO, SKIP TO Q65

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF NO, SKIP TO Q65

Yes ......................... 1 No........................... 2 Not sure ................. 8

IF NO, SKIP TO Q65

Q61 From where did (NAME) obtain the net?

Home ...................... 1 Shop near home ..... 2 Shop near forest ..... 3 Co-workers ............. 4 Other ...................... 5 Spec_____________ Don't know .............. 8

Home ...................... 1 Shop near home ..... 2 Shop near forest ..... 3 Co-workers ............. 4 Other ...................... 5 Spec_____________ Don't know.............. 8

Home...................... 1 Shop near home .... 2 Shop near forest .... 3 Co-workers ............. 4 Other ...................... 5 Spec_____________ Don't know ............. 8

Q62 Did (NAME) use a hammock net or mosquito net in the forest last time?

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF NO, SKIP TO Q65

Yes ......................... 1 No ........................... 2 Not sure .................. 8

IF NO, SKIP TO Q65

Yes ......................... 1 No........................... 2 Not sure ................. 8

IF NO, SKIP TO Q65

Q63 What type of net did (NAME) use in the forest last time?

Mosquito net ........... 1 Hammock net ......... 2 Not sure .................. 8

Mosquito net ........... 1 Hammock net ......... 2 Not sure .................. 8

Mosquito net .......... 1 Hammock net ......... 2 Not sure ................. 8

Q64 Was the net that (NAME) used last time treated to kill/repel mosquitoes?

Yes ......................... 1 No ........................... 2 Not sure .................. 8

SKIP TO Q66

Yes ......................... 1 No ........................... 2 Not sure .................. 8

SKIP TO Q66

Yes ......................... 1 No........................... 2 Not sure ................. 8

SKIP TO Q66



Q65 If (NAME) did not take a net with them to the forest last time or did not use it, what was the reason why?

Didn't want to use ... 1 Forgot to take ......... 2 Not enough nets in house .................... 3 Don't have hammock net ........................ 4 Nowhere to hang in forest .................... 5 No money to buy .... 6 Other ...................... 7 Don't know .............. 8

Didn't want to use ... 1 Forgot to take ......... 2 Not enough nets in house ................... 3 Don't have hammock net ........................ 4 Nowhere to hang in forest .................... 5 No money to buy .... 6 Other ...................... 7 Don't know.............. 8

Didn't want to use .. 1 Forgot to take ......... 2 Not enough nets in house ................... 3 Don't have hammock net ........................ 4 Nowhere to hang in forest .................... 5 No money to buy .... 6 Other ...................... 7 Don't know ............. 8

Q66 Did (NAME) take any other action to avoid getting malaria?

MULTIPLE RESPONSES, CIRCLE ALL MENTIONED

PROBE: ANYTHING ELSE?

Mosquito coil .......... 1 Repellent ................ 2 Boiled water ............ 3 Burned leaves ........ 4 Took medication ..... 5 Wore long clothes... 6 No action taken ...... 7 Other ...................... 8 Spec_____________ Don't know ............ 98

Mosquito coil .......... 1 Repellent ................ 2 Boiled water ........... 3 Burned leaves ........ 4 Took medication ..... 5 Wore long clothes .. 6 No action taken ...... 7 Other ...................... 8 Spec_____________ Don't know............ 98

Mosquito coil .......... 1 Repellent ................ 2 Boiled water ........... 3 Burned leaves ........ 4 Took medication ..... 5 Wore long clothes .. 6 No action taken ...... 7 Other ...................... 8 Spec_____________ Don't know ........... 98

Q67 Did (NAME) get sick while away from home?

Yes ......................... 1 No ........................... 2 Don't know .............. 8

IF NO, SKIP TO Q69

Yes ......................... 1 No ........................... 2 Don't know.............. 8

IF NO, SKIP TO Q69

Yes ......................... 1 No........................... 2 Don't know ............. 8

IF NO, SKIP TO Q69

Q68 Where did (NAME) get treatment while away?

Facility/Provider code: .......................

Other .................... 97 Spec_____________

Not sure ................ 98

Facility/Provider code: ......................

Other .................... 97 Spec_____________

Not sure ................ 98

Facility/Provider code: .......................

Other .................... 97 Spec_____________

Not sure ............... 98

Section 5: People who are temporary visitors

"I would now like to ask you about the temporary visitors in your household."


Q69 Are any people in your household temporary visitors?

CHECK Q8 (SECTION 1) TO VERIFY THEIR ANSWER WITH WHAT THEY SAID BEFORE, AND CORRECT ANY INCONSISTENCIES

Yes .............................................................. 1 No ............................................................... 2

Q80

Q70 How many people in your household are temporary visitors?

COUNT THE NUMBER OF LINE CODES WITH "VISITOR" CIRCLED FOR Q8

Number of people: ........................................




Q71 WRITE THE NAME AND LINE CODE OF THE TEMPORARY VISITORS FROM Q8

[Use additional sheets if more than 3 persons]

Name ____________

Line code: .................

Name ____________

Line code: .................

Name ____________

Line code: ................

Q72 How long has (NAME) stayed here in this village? (completed

months)

IF < ONE MONTH, WRITE "00"

Months: .....................

Not sure ................ 98

Months: ....................

Not sure ................ 98

Months: ....................

Not sure 98

Q73 Where does (NAME) come from (i.e., permanent address)? WRITE THE NAMES OF THE TOWNSHIP, AND VILLAGE OR TOWN. (FILL IN CODES LATER TO SAVE TIME)

State/Division ..............

_________________

Township

________________

Village tract/Village: _________________

State/Division ...............

_________________

Township

________________



_________________

Township

________________


Q74 For what reason did (NAME) travel to this village?

Work (arranged before arrival) ......... 1 Look for work .......... 2 Make new home ..... 3 Visit relatives .......... 4 Other ...................... 5 Spec_____________ Don't know .............. 8

Work (arranged before arrival) ......... 1 Look for work .......... 2 Make new home ..... 3 Visit relatives .......... 4 Other ...................... 5 Spec_____________ Don't know.............. 8

Work (arranged before arrival) ......... 1 Look for work ......... 2 Make new home ..... 3 Visit relatives .......... 4 Other ...................... 5 Spec_____________ Don't know 8

Q75 How long does (NAME) intend to stay here in this village?

< 2 weeks ............... 1 2-4 weeks ............... 2 1-3 months ............. 3 3-6 months ............. 4 6-12 months ........... 5 > 12 months ........... 6 Not sure .................. 8

< 2 weeks ............... 1 2-4 weeks ............... 2 1-3 months ............. 3 3-6 months ............. 4 6-12 months ........... 5 > 12 months ........... 6 Not sure .................. 8

< 2 weeks ............... 1 2-4 weeks ............... 2 1-3 months ............. 3 3-6 months ............. 4 6-12 months ........... 5 > 12 months ........... 6 Not sure ................. 8

Q76 Where does (NAME) plan to travel to next?

Return home (Q73) 1 Another place of work in this township ..... 2 Work in another township ............... 3 Other ...................... 4 Spec_____________ Don't know .............. 8 IF 1, SKIP TO 78

Return home (Q73) 1 Another place of work in this township ..... 2 Work in another township ............... 3 Other ...................... 4 Spec_____________ Don't know.............. 8 IF 1, SKIP TO 78

Return home (Q73) 1 Another place of work in this township .... 2 Work in another township ............... 3 Other ...................... 4 Spec_____________ Don't know ............. 8 IF 1, SKIP TO 78

Q77 What is the name of the place where (NAME) plans to travel to next? WRITE THE NAMES OF THE TOWNSHIP, AND VILLAGE OR TOWN. (FILL IN CODES LATER TO SAVE TIME)


_________________

Township

________________



_________________

Township

________________



_________________

Township

________________




Q78 Has (NAME) travelled abroad during 2011?

Yes ......................... 1 1. Thailand 2. India 3. China 4. Others (spfy)

No ........................... 2 Don't know .............. 8


No ........................... 2 Don't know.............. 8


No........................... 2 Don't know ............. 8

Q79 Has (NAME) taken any actions during their travels to avoid getting malaria? MULTIPLE RESPONSES, CIRCLE ALL MENTIONED

(IF MOSQUITO NET MENTIONED, ASK WHAT TYPE TO DETERMINE IF IT WAS AN INSECTICIDE-TREATED NET)


Traveled with a mosquito net ........... 1 Traveled with a treated net (ITN) ..... 2 Mosquito coil .......... 3 Repellant ................ 4 Boiled water ............ 5 Burned leaves ........ 6 Took medication ..... 7 Wore long clothes... 8 No action taken ...... 9 Boiled water ............ 5 Other .................... 10 Spec_____________ Don't know ............ 98

Traveled with a mosquito net ........... 1 Traveled with a treated net (ITN) ..... 2 Mosquito coil .......... 3 Repellant ................ 4 Boiled water ........... 5 Burned leaves ........ 6 Took medication ..... 7 Wore long clothes .. 8 No action taken ...... 9 Boiled water ........... 5 Other .................... 10 Spec_____________ Don't know............ 98

Traveled with a mosquito net .......... 1 Traveled with a treated net (ITN) ..... 2 Mosquito coil .......... 3 Repellant ................ 4 Boiled water ........... 5 Burned leaves ........ 6 Took medication ..... 7 Wore long clothes .. 8 No action taken ...... 9 Boiled water ........... 5 Other .................... 10 Spec_____________ Don't know ........... 98

Section 6: People who travel and sleep away from home


Q80 Has anyone currently staying in your household traveled away from home and stayed overnight during the past 6 months?

CHECK Q9 (SECTION 1) TO VERIFY THEIR ANSWER WITH WHAT THEY SAID BEFORE, AND CORRECT ANY INCONSISTENCIES

Yes .............................................................. 1 No ............................................................... 2

Q89

Q81 How many people in your household traveled away from home and stayed overnight during the past 6 months?

COUNT THE NUMBER OF LINE CODES WITH "YES" CIRCLED FOR Q9

Number of people: ........................................


Q82 WRITE THE NAME AND LINE CODE OF THOSE WHO TRAVEL AWAY FROM HOME

[Use additional sheets if more than 3 persons]

Name ____________

Line code: .................

Name ____________

Line code: .................

Name ____________

Line code: ................

Q83 When did (NAME) last travel away from home?

(don't include the last time that they were in the forest)



Last night ............... 1 < 1 week ................. 2 1 to < 4 weeks ........ 3 ≥ 4 weeks ............... 4 Not sure 8



Q84 Where did (NAME) last travel to?

WRITE THE NAMES OF THE TOWNSHIP, DISTRICT, AND VILLAGE OR TOWN. (FILL IN CODES LATER TO SAVE TIME)


_________________

Township

________________

Village tract/Village: _________________Not sure ................ 98

Township: ....................

_________________

District: .........................

_________________

Village/Town: _________________

Not sure ................ 98

Township: ....................

_________________

District: .........................

_________________

Village/Town: _________________

Not sure ............... 98

Q85 For what reason did (NAME) travel away from home?


PROBE: ANYWHERE ELSE?

Work in forest ......... 1 Work on farm .......... 2 Work on plantation . 3 Work in Thailand .... 4 Visit relatives .......... 5 Other ...................... 6 Spec_____________ Don't know .............. 8

Work in forest ......... 1 Work on farm .......... 2 Work on plantation . 3 Work in Thailand .... 4 Visit relatives .......... 5 Other ...................... 6 Spec_____________ Don't know.............. 8

Work in forest ......... 1 Work on farm ......... 2 Work on plantation . 3 Work in Thailand .... 4 Visit relatives .......... 5 Other ...................... 6 Spec_____________ Don't know ............. 8

Q86 In the past 3 months, how many times has (NAME) traveled away from home?

Trips: ........................

Not sure ................ 98

Trips: ........................

Not sure ................ 98

Trips: ........................

Not sure 98

Q87 Has (NAME) travelled abroad during 2011?


No ........................... 2 Don't know .............. 8


No ........................... 2 Don't know.............. 8


No........................... 2 Don't know ............. 8

Q88 Has (NAME) taken any actions during their travels to avoid getting malaria? MULTIPLE RESPONSES, CIRCLE ALL MENTIONED

(IF MOSQUITO NET MENTIONED, ASK WHAT TYPE TO DETERMINE IF IT WAS AN INSECTICIDE-TREATED NET)


Traveled with a mosquito net ........... 1 Traveled with a treated net (ITN) ..... 2 Mosquito coil .......... 3 Repellant ................ 4 Boiled water ............ 5 Burned leaves ........ 6 Took medication ..... 7 Wore long clothes... 8 No action taken ...... 9 Boiled water ............ 5 Other .................... 10 Spec_____________ Don't know ............ 98

Traveled with a mosquito net ........... 1 Traveled with a treated net (ITN) ..... 2 Mosquito coil .......... 3 Repellant ................ 4 Boiled water ........... 5 Burned leaves ........ 6 Took medication ..... 7 Wore long clothes .. 8 No action taken ...... 9 Boiled water ........... 5 Other .................... 10 Spec_____________ Don't know............ 98

Traveled with a mosquito net .......... 1 Traveled with a treated net (ITN) ..... 2 Mosquito coil .......... 3 Repellant ................ 4 Boiled water ........... 5 Burned leaves ........ 6 Took medication ..... 7 Wore long clothes .. 8 No action taken ...... 9 Boiled water ........... 5 Other .................... 10 Spec_____________ Don't know ........... 98

Section 7: Malaria Knowledge and Recognition


Q89 Have you ever heard of an illness called malaria? IF ANSWER IS "NO", REPEAT ASKING QUESTION IN LOCAL COLLOQUIAL WORD FOR MALARIA

Yes ............................................................. 1 No ............................................................... 2

Q108



Q90 What are the signs or symptoms of malaria? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


Fever .......................................................... 1 Chills ........................................................... 2 Headache ................................................... 3 Body ache ................................................... 4 Sweating ..................................................... 5 Fatigue ........................................................ 6 Loss of appetite .......................................... 7 Diarrhoea .................................................... 8 Other ........................................................... 9 Specify:_______________________________

Don't know ................................................ 98

Q93

Q91 How can you be sure that you or someone in your household with these signs and symptoms (read what he/she said) has malaria and not another illness?

Previous experience ................................... 1 Symptoms ................................................... 2 Doctor's examination .................................. 3 HA/LHV/MW/PHS examination…………… 4 Blood test (slide or dipstick) ....................... 5 Other ........................................................... 6 Specify:_______________________________

Don't know .................................................. 8

Q92 What signs and symptoms make you decide the illness is serious? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


Unconscious ............................................... 1 Convulsions ................................................ 2 Fast breathing............................................. 3 Very hot ...................................................... 4 Yellow eye color ......................................... 5 Very pale skin ............................................. 6 Not breastfeeding ....................................... 7 Not eating ................................................... 8 Frequent vomiting ....................................... 9 Diarrhoea .................................................. 10 Other ......................................................... 11 Specify:_______________________________ Don't know ................................................ 98

Q93 How do people get malaria? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


Mosquito bites ............................................ 1 Drinking dirty water ..................................... 2 Not boiling water ......................................... 3 Drinking spring/stream water ...................... 4 Bathing in spring/river water ....................... 5 Visiting forest .............................................. 6 Staying/sleeping in forest ........................... 7 Eating banana.............................................8 Bad food ..................................................... 9 Spirits ........................................................ 10 Poor hygiene ............................................ 11 Bad air ...................................................... 12 Bad talking ................................................ 13 Other ......................................................... 14 Specify:_______________________________ Don't know ................................................ 98



Q94 How do people prevent malaria? (NOTE: If they say "mosquito net", ask about the type of net to assess if they know about treated nets or not)



Sleep under a mosquito net ....................... 1 Insecticide-treated net ................................ 2 Mosquito coil ............................................... 3 Mosquito repellent ...................................... 4 Insecticide spray ......................................... 5 Burn leaves ................................................. 6 Boil water .................................................... 7 Wear covered clothing ................................ 8 Stay out of forest ........................................ 9 Other ......................................................... 10 Specify:_______________________________ Don't know ................................................ 98 (A few codes differ from above questions Q88 for inclusion of insecticide spray)

Q95 If you suspect someone in your household has malaria, where would you go for advice or treatment?

Village Health Volunteer ............................. 1 Village Malaria Volunteer ………………… 2 Rural Health Center/Sub Centre ................ 3 Township/Station Hospital .......................... 4 Private doctor's clinic .................................. 5 Private other health staff clinic ................... 6 Auxiliary midwife ……………………………7 Unlicensed practitioner (quack)…………....8 Pharmacy (sell drugs only) ......................... 9 Shop/market (sell goods etc.) ................... 10 Self treat with drugs at home .................... 11 Private laboratory ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12 Other source ............................................. 13 Specify:_______________________________

Don't know ................................................ 98

Q96 If you suspect someone in your household might have malaria, where would you go to get a test to find out if it really is malaria?

Malaria staff………………………………….1 Village Malaria Volunteer ………………… 2 Rural Health Center/Sub Centre ................ 3 Township/Station Hospital .......................... 4 Private doctor's clinic .................................. 5 Private other health staff clinic ................... 6 Auxiliary midwife ……………………………7 Unlicensed practitioner (quack)…………....8 Private laboratory ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12 Other source ............................................. 13 Specify:_______________________________

Don't know about malaria test .................. 97 Don't know where to get a test ................. 98

Q97 In the past 6 months, have you heard or seen any messages or information about malaria?

Yes ............................................................. 1 No ............................................................... 2

Q102

Q98 How long ago did you first see or hear these messages?

Months: .........................................................

Not Sure ................................................... 98



Q99 What messages or information related to malaria did you see or hear? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


Sleeping under a mosquito net is important ................................................... 1 Sleep under an insecticide-treated net (ITN) ................................................... 2 Carry and sleep under a mosquito net when traveling .................................... 3 Carry and sleep under a mosquito net when visiting the forest ....................... 4 Seek treatment for malaria from a VMW or health facility ............................... 5 Seek treatment for malaria promptly/within 24 hours .......................... 6 Complete antimalarial treatment ................ 7 Get a blood test before taking antimalarial drugs ..................................... 8 Malaria is dangerous .................................. 9 Malaria can kill .......................................... 10 Mosquitoes spread malaria ...................... 11 Other ......................................................... 12 Specify:_______________________________ Don't Remember ...................................... 98

Q100 Where or from whom did you see or hear these messages/information about malaria? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED

PROBE ONCE: ANYWHERE ELSE?

VMW/VHV .................................................. 1 Health facility staff ...................................... 2 Private health provider ............................... 3 Pharmacy ................................................... 4 Teachers ..................................................... 5 Religious leaders/Monks ............................ 6 Family members ......................................... 7 Friends/neighbours ..................................... 8 TV ............................................................... 9 Radio ........................................................ 10 Video ........................................................ 11 Posters ..................................................... 12 Leaflets/Brochures ................................... 13 Billboards .................................................. 14 NGO staff .................................................. 15 Other ......................................................... 16 Specify:_______________________________ Don't Remember ...................................... 98

Q101 What is the MOST common or popular source of information or advice on malaria? What is the SECOND most common or popular source of information or advice on malaria? WRITE "1" NEXT TO THE CATEGORY THAT IS THE MOST COMMON AND "2" NEXT TO THE CATEGORY THAT IS THE SECOND MOST COMMON

VMW/VHV .......................................... _____ Health facility staff .............................. _____ Private health provider ....................... _____ Pharmacy ........................................... _____ Teachers ............................................. _____ Religious leaders/Monks .................... _____ Family members ................................. _____ Friends/neighbours ............................. _____ TV ....................................................... _____ Radio .................................................. _____ Video ................................................. _____ Posters ............................................... _____ Leaflets/Brochures ............................. _____ Billboards ............................................ _____ NGO staff Other ................................................... _____ Specify:_______________________________ Don't Know ............................................... 98



Q102 Do you know the names of any specific antimalarial drugs?

Yes ............................................................. 1 No ............................................................... 2

Q104

Q103 Of the antimalarial drugs you know, tell me the names of the three that you are most familiar with? IF < 3, WRITE THE ONES THAT THEY KNOW (FILL IN THE DRUG CODES LATER TO SAVE TIME) IF THE NAME IS IN LOCAL TERMS (e.g. cross-tablet for mefloquine), ASK ENGLISH NAME FROM LOCAL STAFF TO WRITE DOWN. IF YOU DON'T KNOW, WRITE DOWN LOCAL TERM.

Name Code

Antimalarial 1: _________________ Antimalarial 2: _________________ Antimalarial 3: _________________

Q104 Do you know how many days most antimalarial drugs should be taken?

NOT SPECIFIC TO EACH DRUG THEY KNOW

Number of days: .............................................

Don't know .................................................. 98

Q105 What happens if you don’t take antimalarial drugs for the recommended number of days?

Nothing ...................................................... 1 Patient gets sick again ............................... 2 Patient does not recover ............................ 3 Other ........................................................... 4 Specify:_______________________________ Don't know .................................................. 8

Q106 What happens if you don’t take all the tablets (i.e., total number of tablets prescribed)?

Nothing ...................................................... 1 Patient gets sick again ............................... 2 Patient does not recover ............................ 3 Other ........................................................... 4 Specify:_______________________________ Don't know .................................................. 8

Q107 Do you know of any antimalarial drugs that should no longer be used to treat malaria?

Yes ............................................................. 1 No ............................................................... 2

Q109

Q108 What are the names of the drugs that should no longer be used to treat malaria? IF < 3, WRITE THE ONES THAT THEY KNOW (FILL IN THE DRUG CODES LATER TO SAVE TIME)

Name Code


Section 8: Malaria Diagnosis and Treatment


Q109 Has anyone in the household been ill with a fever during the last two weeks?

Yes .............................................................. 1 No ............................................................... 2

END

Q110 How many people in the household have been ill with fever during the last two weeks?

(Use additional sheets if more than 2 persons)

Number ill with fever: ....................................


NO. QUESTIONS Person 1 Person 2

Q111 Who was ill with fever in the last two weeks?

Name: __________________

Line code: .....................

Name: __________________

Line code: ..........................

Q112 Did (NAME) seek advice or treatment outside of the home for the fever?

Yes ........................................ 1 No .......................................... 2 Not sure ................................. 8 IF NO, SKIP TO Q121


Q113 Where did (NAME) first seek advice or treatment for the fever?

(1st facility/provider)

Facility/Provider code: ............

Other .................................... 97 Specify: ___________________

Not sure ................................ 98


Other .................................... 97 Specify: ___________________

Not sure ............................... 98

Q114 How long after the fever started did (NAME) first seek advice or treatment from this facility/provider?

Same day .............................. 1 Day after ................................ 2 Two days after ....................... 3 Three or more days ............... 4 Don't know ............................. 8


Q115 Did (NAME) seek advice or treatment for the fever anywhere else?



Q116 Where did (NAME) next seek advice or treatment for the fever?

(2nd

facility/provider)


Other .................................... 97 Specify: ___________________

Not sure ................................ 98


Other .................................... 97 Specify: ___________________

Not sure ............................... 98

Q117 How long after the fever started did (NAME) seek advice or treatment from this second facility/provider?



Q118 Did (NAME) seek advice or treatment for the fever anywhere else?



Q119 Where did (NAME) next seek advice or treatment for the fever?

(3rd

facility/provider)


Other .................................... 97 Specify: ___________________

Not sure ................................ 98


Other .................................... 97 Specify: ___________________

Not sure ............................... 98

Q120 How long after the fever started did (NAME) seek advice or treatment from this third facility/provider?


SKIP TO Q122


SKIP TO Q122



Q121 Why didn't (NAME) seek treatment outside the home?

Waited for fever to go ............ 1 No money for treatment ........ 2 No transport........................... 3 Not sure where to get drugs .. 4 Didn't feel ill enough .............. 5 Spiritual treatment ................. 6 Traditional medicine .............. 7 Other ..................................... 8 Specify: ___________________

Don't know ............................. 9

Waited for fever to go ............ 1 No money for treatment ........ 2 No transport........................... 3 Not sure where to get drugs .. 4 Didn't feel ill enough .............. 5 Spiritual treatment ................. 6 Traditional medicine .............. 7 Other ..................................... 8 Specify: ___________________

Don't know ............................. 9

Q122 Did (NAME) take drugs for the fever?



Q123 Where did these drugs come from? MULTIPLE RESPONSES CIRCLE ALL MENTIONED


(coding is the same as Q95

except omitting 12)

Village Health Volunteer…….1 Village Malaria Volunteer….. 2 Rural Health Center/Sub

Centre……………………3 Township/Station Hospital….4 Private doctor's clinic………..5 Private other health

staff clinic………………..6 Auxiliary midwife..……………7 Unlicensed practitioner

(quack)…………….…....8 Pharmacy (sell drugs only)…9 Shop/market

(sell goods etc.)……….10 Self treat with drugs at home………………. 11 Other source ……………….13 Specify:__________________

Don't know…………………..98

Village Health Volunteer…….1 Village Malaria Volunteer….. 2 Rural Health Center/Sub

Centre……………………3 Township/Station Hospital….4 Private doctor's clinic………..5 Private other health

staff clinic………………..6 Auxiliary midwife..……………7 Unlicensed practitioner

(quack)…………….…....8 Pharmacy (sell drugs only)…9 Shop/market

(sell goods etc.)……….10 Self treat with drugs at home………………. 11 Other source ……………….13 Specify:__________________

Don't know…………………..98

Q124 How long after the fever started did (NAME) first take drugs?



Q125 What drugs did (NAME) take for the fever?

(Include any drugs that were from self-medication and/or from a health service provider) RECORD THE DRUG CODE AND NAME, TICK THE BOX IF THE DRUG IS AN ANTIMALARIAL (AM)

Code Name AM?

Drug 1: _________

Drug 2: _________

Drug 3: _________

Drug 4: _________

Drug 5: _________

Code Name AM?

Drug 1: _________

Drug 2: _________

Drug 3: _________

Drug 4: _________

Drug 5: _________

GO THROUGH THE LIST ABOVE (Q125) AND NOTE THE ANTIMALARIAL DRUGS. IF ANTIMALARIAL DRUGS RECORDED, ASK THE FOLLOWING QUESTIONS ABOUT EACH ANTIMALARIAL DRUG TAKEN FOR EACH PERSON: IF NO ANTIMALARIAL DRUGS RECORDED, SKIP TO Q158.

Q126 What was the first antimalarial drug that (NAME) took?

Drug code: ..............................

Not sure ............................... 98

Drug code: ..............................

Not sure ............................... 98



Q127 What was the form of this first antimalarial drug?

Tablets ................................... 1 Syrup ..................................... 2 Suppository ........................... 3 Injection ................................. 4 Don't know ............................. 8


Q128 Where did (NAME) get this first antimalarial drug? (Should match the codes listed in Q113, Q116, or Q119)


Other .................................... 97 Specify: ___________________

Not sure ............................... 98


Other .................................... 97 Specify: ___________________

Not sure ............................... 98

Q129 How long after their fever began did (NAME) start taking this first antimalarial drug?



Q130 How many times a day did (NAME) take this first antimalarial drug?

Times per day:........................

Not sure ............................... 98

Times per day:........................

Not sure ............................... 98

Q131 How many tablets/spoons did (NAME) take each time?

Dose each time: .....................

Not sure ............................... 98

Dose each time: .....................

Not sure ............................... 98

Q132 For how many days did (NAME) take this first antimalarial drug?

Number of days: .....................

Not sure ............................... 98

Number of days: .....................

Not sure ............................... 98

Q133 Did (NAME) take all the prescribed/purchased tablets or syrup of this antimalarial drug?

Yes ........................................ 1 No .......................................... 2 Still taking the drug ................ 3 Not sure ................................. 8


Q134 What was the second antimalarial drug that (NAME) took? (CROSS CHECK WITH Q125)

Drug code: ..............................

Not sure ............................... 98

IF NO 2ND

DRUG, SKIP TO Q158

Drug code: ..............................

Not sure ............................... 98

IF NO 2ND

DRUG, SKIP TO Q158

Q135 What was the form of this second antimalarial drug?



Q136 Where did (NAME) get this second antimalarial drug? (Should match the codes listed in Q113, Q116 or Q119)


Other .................................... 97 Specify: ___________________

Not sure ............................... 98


Other .................................... 97 Specify: ___________________

Not sure ............................... 98

Q137 How long after their fever began did (NAME) start taking this second antimalarial drug?



Q138 How many times a day did (NAME) take this second antimalarial drug?

Times per day:........................

Not sure ............................... 98

Times per day:........................

Not sure ............................... 98




Dose each time: .....................

Not sure ............................... 98

Dose each time: .....................

Not sure ............................... 98

Q140 For how many days did (NAME) take this second antimalarial drug?

Number of days: .....................

Not sure ............................... 98

Number of days: .....................

Not sure ............................... 98

Q141 Did (NAME) take all the prescribed/purchased tablets or syrup of this antimalarial drug?



Q142 What was the third antimalarial drug that (NAME) took? (CROSS CHECK WITH Q125)

Drug code: ..............................

Not sure ............................... 98

IF NO 3RD

DRUG, SKIP TO Q158

Drug code: ..............................

Not sure ............................... 98

IF NO 3RD

DRUG, SKIP TO Q158

Q143 What was the form of this third antimalarial drug?



Q144 Where did (NAME) get this third antimalarial drug? (Should match the codes listed in Q113, Q116 or Q119)


Other .................................... 97 Specify: ___________________

Not sure ............................... 98


Other .................................... 97 Specify: ___________________

Not sure ............................... 98

Q145 How long after their symptoms began did (NAME) start taking this third antimalarial drug?



Q146 How many times a day did (NAME) take this third antimalarial drug?

Times per day:........................

Not sure ............................... 98

Times per day:........................

Not sure ............................... 98


Dose each time: .....................

Not sure ............................... 98

Dose each time: .....................

Not sure ............................... 98

Q148 For how many days did (NAME) take this third antimalarial drug?

Number of days: .....................

Not sure ............................... 98

Number of days: .....................

Not sure ............................... 98

Q149 Did (NAME) take all the prescribed/purchased tablets or syrup of this antimalarial?



Q150 What was the fourth antimalarial drug that (NAME) took? (CROSS CHECK WITH Q125)

Drug code: ..............................

Not sure ............................... 98

IF NO 4TH

DRUG, SKIP TO Q158

Drug code: ..............................

Not sure ............................... 98

IF NO 4TH

DRUG, SKIP TO Q158



Q151 What was the form of this fourth antimalarial drug?



Q152 Where did (NAME) get this fourth antimalarial drug? (Should match the codes listed in Q113, Q116 or Q119)


Other .................................... 97 Specify: ___________________

Not sure ............................... 98


Other .................................... 97 Specify: ___________________

Not sure ............................... 98

Q153 How long after their symptoms began did (NAME) start taking this fourth antimalarial drug?



Q154 How many times a day did (NAME) take this fourth antimalarial drug?

Times per day:........................

Not sure ............................... 98

Times per day:........................

Not sure ............................... 98


Dose each time: .....................

Not sure ............................... 98

Dose each time: .....................

Not sure ............................... 98

Q156 For how many days did (NAME) take this fourth antimalarial drug?

Number of days: .....................

Not sure ............................... 98

Number of days: .....................

Not sure ............................... 98

Q157 Did (NAME) take all the prescribed/purchased tablets or syrup of this antimalarial?



Q158 Did (NAME) have a blood test for malaria?



Q159 Did (NAME) have the malaria test before or after taking drugs?

Before taking drugs ............... 1 After taking drugs .................. 2 Not sure ................................. 8

Before taking drugs ............... 1 After taking drugs .................. 2 Not sure ................................. 8

Q160 What type of malaria test did (NAME) have?

RDT/dipstick .......................... 1 Blood slide/microscopy ......... 2 Not sure ................................. 8

Dipstick .................................. 1 Blood slide ............................. 2 Not sure ................................. 8

Q161 Where did (NAME) get the malaria test done?

VMW ...................................... 1 Health facility (public) ............ 2 Pharmacy/Shop ..................... 3 Private health facility/lab ....... 4 Private doctor/nurse .............. 5 Other ..................................... 6 Specify: ___________________

Don't know ............................. 8

VMW ...................................... 1 Health facility (public) ............ 2 Pharmacy/Shop ..................... 3 Private health facility/lab ....... 4 Private doctor/nurse .............. 5 Other ..................................... 6 Specify: ___________________

Don't know ............................. 8

Q162 What was the result of the malaria test?

Positive .................................. 1 Negative ................................ 2 Don't know ............................. 8 IF NEGATIVE, SKIP TO Q164

Positive .................................. 1 Negative ................................ 2 Don't know ............................. 8 IF NEGATIVE, SKIP TO Q164



Q163 What type of malaria did (NAME) have?

Not told species ..................... 1 Falciparum (Pf) ...................... 2 Vivax (Pv) .............................. 3 Mixed (both Pf & Pv) ............. 4

Not told species ..................... 1 Falciparum (Pf) ...................... 2 Vivax (Pv) .............................. 3 Mixed (both Pf & Pv) ............. 4

Q164 Does (NAME) still have a fever? Yes ........................................ 1 No .......................................... 2 Not sure ................................. 8

Yes ........................................ 1 No .......................................... 2 Not sure ................................. 8

END INTERVIEW

Thank respondent for taking the time to be interviewed.


Code Facility / Provider Type

Public Sector:

1 State or Regional Hospital

2 Sub-Health Center

3 Station hospital

4 Village Malaria Worker

5 Village Health Volunteer

Private Sector:

6 Private hospital

7 Private clinic run by health staff

8 Private laboratory

9 Drug Store A or B (registered)

10 Drug store (unregistered)

11 Shop/Market

12 Grocery store

13 Traditional practitioner

14 Other

Code Drugs

Antimalarials:

1

2 A+M (Artesunate-Mefloquine)

3 Other Artesunate-Mefloquine (e.g., Artequin)

4 Duo-Cotecxin (DHA-piperaquine)

5 Other DHA-Piperaquine (e.g., Artekin or Artequick)

6 Cotecxin (dihydroartemisinin only)

7 Mefloquine (e.g., Lariam)

8 Artesunate

9 Artemether

10 Artemisinin

11 Quinine

12 Chloroquine

13 Primaquine

14 Drug cocktail for malaria

15 Other antimalarial drug

Non-malaria drugs:

16 Antibiotics

17 Paracetamol/Aspirin

Code Drugs

18 Vitamins/Tonics

19 Infusion/ IV fluids

20 Traditional herbs

21 Other non-malaria drugs


ANNEX 2. DRUG OUTLET QUESTIONNAIRE

Identification

Related cluster in household survey:

(01-80) Outlet number: ……………………………….

State/Region: ………………………………… Township ………………………………………

Village Tract: …………………………………………… Village: ………………………………………………….

Where is the outlet located? Village ..................................................................... 1

Town ....................................................................... 2

What is the sex of the respondent?

What is the age of the respondent?

Male ........................................................................ 1

Female .................................................................... 2

Age in years: .............................................................

What is the respondent's role?

NOTE: THE RESPONDENT MUST BE SOMEONE WHO

SELLS DRUGS IN THIS OUTLET

Owner ..................................................................... 1

Employee ................................................................ 2

Family member ....................................................... 3

Other ....................................................................... 4

Specify: ________________________________

What formal health training has the respondent had? Doctor ..................................................................... 1

Pharmacist .............................................................. 2

Health assistant ...................................................... 3

Nurse ...................................................................... 4

Midwife .................................................................... 5

Other health training ............................................... 6

Specify: ________________________________

No health training ......................................... 7 Q1

How long did you receive formal training? Years of training: .......................................................

Months of training: ...................................................


Section 1: Details of Outlet


Q1 Type of outlet Village drug outlet ...................................... 1

Private clinic ............................................... 2

Health cabinet/worker's home .................... 3

Pharmacy ................................................... 4

General store/shop..................................... 5

Other .......................................................... 7 Specify:_______________________________

Q2 Do you offer consultations? Yes ............................................................. 1

No ............................................................... 2

Q6

Q3 Approximately how many consultations do

you provide each day?

< 1 per day ................................................. 1

1 to 5 per day ............................................. 2

6 to 10 per day ........................................... 3

> 10 per day ............................................... 4

Don't know.................................................. 8

Q4 Do you offer consultations for malaria? Yes ............................................................. 1

No ............................................................... 2

Q6

Q5 Approximately how many consultations for

malaria do you provide each week?

< 1 per week............................................... 1

1 to 5 per week ........................................... 2

6 to 10 per week ......................................... 3

> 10 per week ............................................ 4

Don't know.................................................. 8

Q6 What are your normal hours of operation for

this drug outlet, that is what time do you

open and what time do you close?

AM/PM AM/PM

Open: __ __:__ __

Close: __ __:__ __

Open: __ __:__ __

Close: __ __:__ __

Q7

Do you distribute or display any information

for your clients about malaria?

Check this box if they were able to show

any education materials about malaria

Yes ............................................................. 1

No ............................................................... 2


Section 2: Knowledge, practice, inspections and training


Q8 What are the signs or symptoms of

malaria?

MULTIPLE RESPONSES POSSIBLE

CIRCLE ALL MENTIONED


Fever ............................................................. 1

Chills ............................................................. 2

Headache ...................................................... 3

Body ache ..................................................... 4

Sweating ....................................................... 5

Fatigue .......................................................... 6

Loss of appetite............................................. 7

Diarrhoea ...................................................... 8

Other ............................................................. 9 Specify:_______________________________

Don't know .................................................. 98

Q10

Q9 What do you do if you suspect the patient

has malaria?




Examine patient ............................................ 1

Sell/perform blood test (slide or dipstick) ...... 2

Refer to health facility ................................... 3

Sell antimalarial drugs .................................. 4

Other ............................................................. 5 Specify:_______________________________

Don't know .................................................. 98

Q11

Q10 Have you ever referred suspected cases of

malaria for treatment?

Yes ................................................................ 1

No ................................................................. 2

Q13

Q11 What types of cases do you refer?




Children < 5 years ......................................... 1

Children < 2 years ......................................... 2

Pregnant women ........................................... 3

Symptoms of severe malaria ........................ 4

Previously treated but symptoms persist ...... 5

Other ............................................................. 6 Specify:_______________________________

Q12 Where do you refer suspected cases of

malaria?

Referral/Provincial hospital ........................... 1

Health Center/FDH ....................................... 2

VMW ............................................................. 3

Private clinic/laboratory ................................. 4

Other ............................................................. 5 Specify: ______________________________

Q13 Do you keep records or a register of the

malaria cases that you diagnose or treat?

Check this box if they were able to show

records or a register

Yes ................................................................ 1

No ................................................................. 2

Q15



Q14 What type of records do you keep of

malaria cases tested and/or treated?




Age ................................................................ 1

Sex ................................................................ 2

Test result (pos or neg) ................................. 3

Type of malaria (species) ............................. 4

Severity of malaria ........................................ 5

Treatment given ............................................ 6

Referrals ....................................................... 7

Date of visit .................................................. 8

Other ............................................................. 9 Specify: ______________________________

Q15 During 2011, have you attended any

trainings or workshops about malaria?

Yes ................................................................ 1

No ................................................................. 2

Q18

Q16 What topics were discussed during these

trainings/workshops?




Diagnosis ...................................................... 1

RDTs ............................................................. 2

Treatment ...................................................... 3

ACTs ............................................................. 4

Drug resistance ............................................. 5

Ban on monotherapy .................................... 6

Signs and symptoms .................................... 7

How to recognize fake drugs ........................ 8

New treatment policies ................................. 9

Other ........................................................... 10 Specify:_______________________________

Don't know .................................................. 98

Q17 Who conducted these trainings?




Health Center/Hospital .................................. 1

Province (PHD)/OD ...................................... 2

Government-MoH/CNM ................................ 3

Government-DDF ......................................... 4

NGO .............................................................. 5

Other ............................................................. 6 Specify:_______________________________

Not sure ........................................................ 8

Q18 In your opinion, what is the most effective

antimalarial medicine?

Drug Name: _________________________

Drug Code: ......................................................

Don't know .................................................. 98

Q19 Which drug do you most recommend for

P. falciparum?

Drug Name: .....................................................

Don't Recommend ...................................... 87

Don't know .................................................. 98

Q20 Which drug do you most recommend for

P. vivax?

Drug Name: .....................................................

Don't Recommend ...................................... 87

Don't know .................................................. 98

Q21 What is the nationally recommended

drug for P. falciparum?

Drug Name: .....................................................

Don't know .................................................. 98

Q22 What is the nationally recommended drug

for P. vivax?

Drug Name: .....................................................

Don't know .................................................. 98

Q23 Have you heard about the activities to stop

the spread of drug?

Yes ................................................................ 1

No ................................................................. 2



Q24 Are you aware that some antimalarial drugs

are banned in Myanmar?

Yes ................................................................ 1

No ................................................................. 2

Q27

Q25 Do you know which antimalarial drugs are

banned in Myanmar?

Drug Name 1:..................................................

Drug Name 2:..................................................

Drug Name 3:..................................................

Other ........................................................... 87

Specify: ____________________________

Don't know .................................................. 98

Q26 Where did you hear about the ban on these

antimalarial drugs?




TV/Radio ....................................................... 1

Training ......................................................... 2

Health Center/Hospital staff .......................... 3

Provincial/OD staff ........................................ 4

NGO staff ...................................................... 5

Drug inspector............................................... 6

Other ............................................................. 7 Specify:_______________________________

Not sure ...................................................... 98

Q27 Have you heard about fake/counterfeit

drugs?

Yes ................................................................ 1

No ................................................................. 2

Q29

Q28 Have you seen any fake/counterfeit drugs? Yes ................................................................ 1

No ................................................................. 2

Q29 In the past 6 months, has anyone come to

inspect your outlet?

Yes ................................................................ 1

No ................................................................. 2

Q32

Q30 Who came to inspect your outlet?



PROBE ONCE: ANYONE ELSE?

Health authorities (PHD/OD/MoH) ................ 1

Inspection group ........................................... 2

DDF Inspector ............................................... 3

Police ............................................................ 4

NGO .............................................................. 7

Other government official .............................. 8

Other ............................................................. 9 Specify:_______________________________

Not sure ...................................................... 98

Q31 What action did they take if any?




Took away some drugs ................................. 1

Threw away some drugs ............................... 2

Administered a fine ....................................... 3

Discussed the problem of fake drugs ........... 4

Wrote a report ............................................... 5

Took photographs ......................................... 6

Did nothing .................................................... 7

Other ............................................................. 8 Specify:_______________________________

Not sure ...................................................... 98

Q32 Do you have a license to sell drugs?

Check this box if their license is

displayed on the wall:

Yes ................................................................ 1

No ................................................................. 2



Q33 Do you sell antimalarials?

(If No, probe the names of antimalarials

to make sure that the shop does not sell

antimalarials)

Yes ……………………………………………. 1

No …………………………………………….. 2

Q44

Q34 What are the three most common drugs

you sell for malaria? And how much do you

sell a single complete treatment course for?

USE DRUG CODES LISTED

Drug 1st : …………………………..

Price (Ks) : ________ Tablets : ……………

Drug 2nd

: …………………………..

Price (Ks) : ________ Tablets : ……………

Drug 3rd

: …………………………..

Price (Ks) : ________ Tablets : ……………

Q35 How do you typically decide which

antimalarial drugs to stock?




Most profitable .............................................. 1

Recommended by government ..................... 2

Lowest priced ................................................ 3

Drug company/Sales rep influence ............... 4

Consumer demand ....................................... 5

Brand reputation ........................................... 6

Dosage form ................................................. 7

Easily available ............................................. 8

Prescribed most often by doctors ................. 9

Other ........................................................... 10 Specify:_______________________________

Not sure ...................................................... 98

Q36 Where do you normally obtain your

antimalarial drugs?

Only one answer to be circled

Yangon wholesaler ....................................... 1

Province wholesaler ...................................... 2

Medical detailer ............................................. 4

Province pharmacy (government)................. 6

Non-government supplier ............................. 4

Other ............................................................. 5

Specify:___________________________

Don't know .................................................... 6

Q37 Do your customers usually ask for a

specific antimalarial drug by name?

If No, probe the names of the drugs

Yes ............................................................... 1

No - ask for recommendation ....................... 2

No - bring in prescription ............................... 3

Don't know .................................................... 8

Q38 Do you normally decide which antimalarial

drug customers receive?

If No, probe the names of the drugs

Yes ............................................................... 1

No - give what is requested .......................... 2

No - they bring in a prescription .................... 3

Don't know .................................................... 8

Q39 In the past week, approximately how many

people bought or were dispensed an

antimalarial drug from your outlet?

Number of people: ..........................................

Don't know ................................................ 888

Q40 Compared to this same time last year,

would you say that you are selling more

antimalarial drugs, about the same amount,

or fewer antimalarial drugs?

Selling more .................................................. 1

Selling same ................................................. 2

Selling less .................................................... 3

Don't know .................................................... 8

N/A (didn't sell last year) ............................... 9



Q41 In the past month, did you ever cut blisters

or sell partial packs of antimalarials for

customers who cannot afford to buy the

entire pack?

Yes ................................................................ 1

No ................................................................. 2

Don't know .................................................... 8

Q42 Do you sell drug cocktails for malaria? Yes ................................................................ 1

No ................................................................. 2

Don't know .................................................... 8

Q44


people bought or were dispensed a drug

cocktail from your outlet?

Number of people: ..........................................

Don't know ................................................ 888

Q44 Does your drug outlet provide diagnostic

testing for malaria?

Yes ................................................................ 1

No ................................................................. 2

Q49

Q45 Which type of diagnostic testing for malaria

does your outlet provide?

RDT/dipstick .................................................. 1

Blood slide .................................................... 2

Both RDT and Blood slide ............................ 3


people bought or were dispensed a RDT

from your outlet?

Number of people: ..........................................

Don't know ................................................ 888

Q47 What percentage (%) of customers to

whom you sell antimalarial drugs have a

parasite diagnosis first?

0% ................................................................. 1

Less than 10% .............................................. 2

10% to <50% ................................................ 3

50% to <100% .............................................. 4

100% ............................................................. 5

Don't know .................................................... 8

Q48 Compared to this same time last year,

would you say that you are selling more

RDTs, about the same amount, or fewer

RDTs?

Selling more .................................................. 1

Selling same ................................................. 2

Selling less .................................................... 3

Don't know .................................................... 8

N/A (didn't sell last year) ............................... 9

Q49 Do your customers ever ask for a malaria

test?

Yes ................................................................ 1

No ................................................................. 2

Q51

Q50 What do you do or tell your customers who

ask for a malaria test?

Only one answer to be circled

Sell them a RDT only .................................... 1

Sell AND test them with RDT ........................ 2

Take a blood slide ......................................... 3

Refer them to public health facility ................ 4

Refer them to private provider or lab ............ 5

Sell them drugs for malaria ........................... 6

Other ............................................................. 7 Specify:_______________________________

Not sure ......................................................... 8


Section 3: Artesunate, Artemether + Lumefantrine and Duo-Cotecxin

"I would first like to ask you about three specific drugs."


Q51 Have you heard of a drug called

Artesunate?

Yes ............................................................. 1

No ............................................................... 2

Q59

Q52 Do you sell Artesunate? Yes ............................................................. 1

No ............................................................... 2

Q58

Q53 How much do you sell one box of

Artesunate for? Ks: ................................................................

Q54 How much Artesunate did you sell last

week?

(i.e., number of blister packets)

Number of packets: ......................................

Number of tablets if <1packet ………………

Don't know.............................................. 888

Q55 When did you last buy stock of Artesunate? Within last week ......................................... 1

Within last month ........................................ 2

More than a month ago .............................. 3

Not sure ...................................................... 8

Q56 How much Artesunate did you buy the last

time you bought stock?


Note: one dispenser = 12 blister packets


Number of tablets / packet ………………

Don't know.............................................. 888

Number of bottles: ........................................

Number of tablets / bottle ………………

Don't know.............................................. 888

Q57 When will you buy your next stock of

Artesunate?

Within next week ........................................ 1

Within next month ...................................... 2

In more than a month ................................. 3

No plans to buy .......................................... 4

Not sure ...................................................... 8

Skip to

Q59

Q58 Why don't you sell Artesunate?


RECORD ALL MENTIONED


Not available .............................................. 1

Too expensive to buy stock ....................... 2

No demand ................................................. 3

People Don't know it .................................. 4

Don't know where to buy drug.................... 5

Other .......................................................... 6 Specify:_______________________________

Not sure ...................................................... 8




Artemether + Lumefantrine (Coartem;

etc:) ?

Yes ............................................................. 1

No ............................................................... 2

Q67

Q60 Do you sell Artemether + Lumefantrine?

(Please check antimalarials available in

the drug outlet- e.g. Coartem may be

understood by the seller as artemether)

Yes ............................................................. 1

No ............................................................... 2

Q66


Artemether + Lumefantrine for?

Ks: ................................................................

Q62 How much Artemether + Lumefantrine did

you sell last week?



Number of tablets if<1packet ……………….

Don't know.............................................. 888

Q63 When did you last buy stock of Artemether

+ Lumefantrine?

Within last week ......................................... 1



Not sure ...................................................... 8

Q64 How much Artemether + Lumefantrine did

you buy the last time you bought stock?



Don't know.............................................. 888


Artemether + Lumefantrine?

Within next week ........................................ 1



No plans to buy .......................................... 4

Not sure ...................................................... 8

Skip to

Q67

Q66 Why don't you sell Artemether +

Lumefantrine?



PROBE ONCE: ANY OTHER REASONS?

Not available .............................................. 1


No demand ................................................. 3



Other .......................................................... 6 Specify:_______________________________

Not sure ...................................................... 8


Duo-Cotecxin (Dihydroartemisinin +

Piperaquine)?

Yes ............................................................. 1

No ............................................................... 2

Q75

Q68 Do you sell Duo-Cotecxin? Yes ............................................................. 1

No ............................................................... 2

Q74


Duo-Cotecxin for? Ks: ................................................................



Q70 How much Duo-Cotecxin did you sell last

week?



Number of tablets if <1packet ………………

Don't know.............................................. 888

Q71 When did you last buy stock of

Duo-Cotecxin?

Within last week ......................................... 1



Not sure ...................................................... 8

Q72 How much Duo-Cotecxin did you buy the

last time you bought stock?



Don't know.............................................. 888


Duo-Cotecxin?

Within next week ........................................ 1



No plans to buy .......................................... 4

Not sure ...................................................... 8

Skip to

Q75

Q74 Why don't you sell Duo-Cotecxin?




Not available .............................................. 1


No demand ................................................. 3



Other .......................................................... 6 Specify:_______________________________

Not sure ...................................................... 8

Section 4: Antimalarials and diagnostics sold

"I would now like to ask you about all the antimalarial drugs and diagnostics you provide. I would like you to

list all the drugs and Rapid Diagnostic Tests (RDTs) that you sell. If possible can I check your current stock?"

Q75

Code

Drug / Test Name

Sold in past

6 months?

In stock

now?

Have you

ever been

out of stock

of this drug?

If YES, within the past

3 months, was this

drug/test out of stock

for more than 1 week?

Yes No Yes No Yes No Yes No Not

Known

01 COARTEM (A+L) (1-4 YEARS) 1 2 1 2 1 2 1 2 8

02 COARTEM (A+L) (5-9 YEARS) 1 2 1 2 1 2 1 2 8

03 COARTEM (A+L) (10-14 YEARS) 1 2 1 2 1 2 1 2 8

04 COARTEM (A+L) (>15 YEARS) 1 2 1 2 1 2 1 2 8

05 ARTEFAN (A+L) 1 2 1 2 1 2 1 2 8

06 DUO-COTECXIN (D+P) 1 2 1 2 1 2 1 2 8

07 ARTECOM (D+P) 1 2 1 2 1 2 1 2 8

08 ARTEQUIN (A+M) 1 2 1 2 1 2 1 2 8


Q75

Code

Drug / Test Name

Sold in past

6 months?

In stock

now?

Have you

ever been

out of stock

of this drug?

If YES, within the past

3 months, was this

drug/test out of stock

for more than 1 week?

Yes No Yes No Yes No Yes No Not

Known

09 ARFLOQUIN (A+M) 1 2 1 2 1 2 1 2 8

10 ARTEMODI (A+AD) 1 2 1 2 1 2 1 2 8

11 ARCO (A+N) 1 2 1 2 1 2 1 2 8

12 ARTESUNATE TAB 1 2 1 2 1 2 1 2 8

13 ARTESUNATE INJECTION 1 2 1 2 1 2 1 2 8

14 ARTEMETHER TAB 1 2 1 2 1 2 1 2 8

15 ARTEMETHER INJECTION 1 2 1 2 1 2 1 2 8

16 ARTEMISININ TAB 1 2 1 2 1 2 1 2 8

17 CHLOROQUINE 1 2 1 2 1 2 1 2 8

18 QUININE TAB 1 2 1 2 1 2 1 2 8

19 QUININE INJECTION 1 2 1 2 1 2 1 2 8

20 MEFLOQUINE 1 2 1 2 1 2 1 2 8

21 PRIMAQUINE 1 2 1 2 1 2 1 2 8

22 OTHER DRUG FOR MALARIA Specify ……………………………

1 2 1 2 1 2 1 2 8


1 2 1 2 1 2 1 2 8


1 2 1 2 1 2 1 2 8


1 2 1 2 1 2 1 2 8


1 2 1 2 1 2 1 2 8

27 DRUG COCKTAIL FOR MALARIA 1 2 1 2 1 2 1 2 8

28 ANTIBIOTICS (DOXYCYCLINE) 1 2 1 2 1 2 1 2 8

29 ANTIBIOTICS (CLINDAMYCIN) 1 2 1 2 1 2 1 2 8

30 ANTIBIOTICS OTHERS …………………………

1 2 1 2 1 2 1 2 8

31 PARACETAMOL / ASPIRIN 1 2 1 2 1 2 1 2 8

32 CARESTART (COMBO TEST) 1 2 1 2 1 2 1 2 8

33 PARACHECK 1 2 1 2 1 2 1 2 8

34 MALACHECK 1 2 1 2 1 2 1 2 8

35 OPTIMAL 1 2 1 2 1 2 1 2 8

36 OTHER TEST FOR MALARIA (1) …………………………..

1 2 1 2 1 2 1 2 8

(2) ………………………….. 1 2 1 2 1 2 1 2 8

(3) ………………………….. 1 2 1 2 1 2 1 2 8


A = Artemether L = Lumefantrine M = Mefloquine D = Dihydroartemisinin P = Piperaquine N = Naphthoquine AD = Amodiaquine

END INTERVIEW


ANNEX 3. HEALTH FACILITY QUESTIONNAIRE – PART 1 (FACILITY AUDIT)

Facility Identification Details

Health Facility Cluster: [____|____] (01-80)

Health Facility Name: ______________________ Service Type [______] (1: Public, 2 Private)

Date of interview: __ __ / __ __ / __ __ __ __

Health Facility Type: [______] Referral hospital(Sate/Region/District)…………..1 Township hospital…………………………………..2 Station hospital……………………………………..3 Rural Health center ………………………………..4 Rural health sub center……………………………5 Private specialist hospital………………………….6 Private polyclinic……………………………………7 General practitioner clinic(with beds)…………….8 General practitioner clinic (without beds)………..9 Other Specify:_________________________...10

Facility Code: [____|____] [____] Cluster Number Service Type (Example: Cluster Number = 01, Service Type = 1 so Facility Code = 011)

State/Region:_______________________________ S/R code: ...............................................................

Operational District: __________________________ OD code: ................................................................

Town/Village name: ________________________ GPS coordinates Latitude: ________________ Longitude: ________________

Primary respondent’s position Chief of Health Facility ........................................... 1 Deputy chief............................................................ 2 Acting officer in charge ........................................... 3 Other ....................................................................... 4 Specify :__________________________________

What is the sex of the respondent? Male ........................................................................ 1 Female .................................................................... 2

What is the age of the respondent? Age in years:.........................................................



Name: _______________ Code: Date: _ _ / _ _ / _ _

Name: _______________ Code: Date: _ _ / _ _ / _ _

Name: _______________ Code: Date: _ _ / _ _ / _ _

Name: _______________ Code: Date: _ _ / _ _ / _ _

What formal health training has the respondent had?

Doctor ..................................................................... 1 Health Assistant ..................................................... 2 Public Health Supervisor(1) .................................... 3 Lady health visitor .................................................. 4 Trained Nurse ......................................................... 5 Midwife ................................................................... 6 Public Health Supervisor(2) .................................... 7 Other health training ............................................... 8 Specify: _________________________

How many years of formal training did you receive? If it was less than one year, fill in month box.

Years of training: ....................................................... Month of training: .......................................................


Section 1: Description of the health facility


Q1 Is the facility public or private? Public facility ............................................... 1 Private facility (for profit) ............................. 2 Private facility (not for profit) ....................... 3 Other ........................................................... 4 Specify:_______________________________

Q2 Type of health facility:

Referral hospital(Sate/Region/District). Township hospital …………………….. Station hospital ………………………… Rural Health center ………………….. Rural health sub center ……………….. Private specialist hospital …………….. Private polyclinic ………………………. General practitioner clinic(with beds)… General practitioner clinic (without beds) …………………………………… Other ………………………………. Specify:________________________

1 2 3 4 5 6 7 8 9 10

Q3 What malaria related services does the health facility provide ? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED PROBE ONCE: ANY OTHERS?

Malaria case management ......................... 1 IPD .............................................................. 2 OPD ............................................................ 3 Malaria diagnosis ........................................ 4 ITN distribution/Tablet distribution .............. 5 Malaria health education............................. 6 Antenatal screening for malaria .................. 7 IMCI ............................................................ 8 Blood bank .................................................. 9 Referral of severe malaria ........................ 10 Other ......................................................... 11 Specify:_______________________________

Q4 How many days per week is the facility open?

Days: .............................................................

Q5 How many hours per day is the facility open?

Hours: ...........................................................

Q6 Does the facility provide on call services? Yes .............................................................. 1 No ............................................................... 2

Q7 Has this health facility received a supervisory visit in the last 6 months? IF PRIVATE FACILITY, SKIP TO Q14

Yes .............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8

Q12 Q12

Q8 Who came to supervise in the last 6 months? MULTIPLE RESPONSES, CIRCLE ALL MENTIONED

TMO/PHD ................................................... 1 Project manager ......................................... 2 Person responsible for supervising ............ 3 Other ........................................................... 4 Specify:_______________________________



Q9 When was the date of the last supervisory visit? IF THEY CAN'T REMEMBER THE DAY, JUST FILL IN THE MONTH

__ __ / __ __ / __ __ __ __ DD MM YYYY

Q10 What did the supervisor’s do during their visit? MULTIPLE RESPONSES, CIRCLE ALL MENTIONED

Checked records/reports ............................ 1 Checked supplies ....................................... 2 Observed work ............................................ 3 Provided feedback ...................................... 4 Gave praise ................................................ 5 Provided updates ........................................ 6 Discussed problems and solutions ............. 7 Other ........................................................... 8 Specify:_______________________________

Q11 Did you get any feedback about the results of the supervisory visit?

Yes .............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8

Q12 Does this facility supervise any health posts, or village malaria workers (VMWs), or mobile malaria workers (MMWs) or village health volunteers (VHVs)? PUBLIC HEALTH FACILITIES ONLY If None fill in 98.

Yes No No. Other health post ............... 1 2 __ __ VMW .................................. 1 2 __ __ MMW.................................. 1 2 __ __ VHV .................................... 1 2 __ __

IF NO, SKIP TO Q14

Q13 When was the date of the last VMW/MMW/VHV meeting at the health center? PUBLIC HEALTH FACILITIES ONLY

VMW/MMW: __ __ / __ __ / __ __ __ __ VHV: __ __ / __ __ / __ __ __ __

Q14 Does the health facility have a copy of the National Treatment Guidelines for Malaria?

Yes .............................................................. 1 No ............................................................... 2

Q16

Q15 What version of the National Treatment Guidelines for Malaria does this facility have? ASK THEM TO SHOW YOU A COPY OF THE GUIDELINES

__ __ / __ __ __ __ MM YYYY Shown a copy (tick this box) ..................

Q16 Does this facility treat severe or complicated cases of malaria?

Yes .............................................................. 1 No ............................................................... 2

Q17 Does this facility refer severe or complicated cases of malaria?

Yes .............................................................. 1 No ............................................................... 2

Q22

Q18 Do you issue the patient a referral card/letter? ASK THEM TO SHOW YOU A COPY OF THE REFERRAL CARD/letter

Yes .............................................................. 1 No ............................................................... 2 Shown a copy (tick this box) ..................

Q19 When you refer cases, do you provide transport?

Yes .............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8

Q21 Q21

Q20 Do the patients have to pay for this transport?

Yes .............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8



Q21 What type of transport is used?

Ambulance from health facility .................... 1 Ambulance from OD/referral hospital ......... 2 Self/patient organized transport .................. 3 Other ........................................................... 4 Specify:_______________________________

Q22 Where do you refer severe or complicated cases of malaria? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED PROBE ONCE: ANYWHERE ELSE?

Referral hospital(Sate/Region/District)……..1 Township hospital…………………………….2 Station hospital………………………………..3 Rural Health center…………………………..4 Rural health sub center………………………5 Private specialist hospital……………………6 Private polyclinic……………………………...7 General practitioner clinic(with beds)………8 General practitioner clinic (without beds)…………………………………………..9 Other …………………………… …….. Specify:_________________________... 10

Q23 Approximately how many miles away is the nearest referral hospital to this health facility? LEAVE BLANK IF REFERRAL HOSPITAL

Distance (miles): .....................................

Q24 Do you know the currently recommended drug for uncomplicated P.falciparum?

Yes .............................................................. 1 No ............................................................... 2

Q26

Q25 What is the currently recommended drug for uncomplicated P.falciparum?

Drug Code: ................................................ Drug Code: ................................................ Drug Code: ................................................ Other ........................................................ 97 Specify:_______________________________

Q26 Do you know the currently recommended drug for uncomplicated P.vivax?

Yes .............................................................. 1 No ............................................................... 2

Q28

Q27 What is the currently recommended drug for uncomplicated P.vivax?

Drug Code: ................................................ Drug Code: ................................................ Drug Code: ................................................ Other ........................................................ 97 Specify:_______________________________

Q28 During 2011, have you attended any trainings or workshops about malaria?

Yes .............................................................. 1 No ............................................................... 2

Q31



Q29 What topics were discussed during these trainings/workshops? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED PROBE ONCE: ANYTHING ELSE?

Case management ..................................... 1 Laboratory diagnosis .................................. 2 Rational antimalarial drug use .................... 3 Management of severe malaria .................. 4 Epidemiology .............................................. 5 ITN .............................................................. 6 Health education ......................................... 7 Microplanning ............................................. 8 VMW/MMW training .................................... 9 VHV training .............................................. 10 Other ......................................................... 11 Specify:_______________________________ Don't know ................................................ 98

Q30 Who conducted these trainings? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED PROBE ONCE: ANYONE ELSE?

Health Center/Hospital ................................ 1 State/Region (S/R HD) ............................... 2 Central Malaria Team ................................. 3 NGO ............................................................ 4 Other ........................................................... 5 Specify:_______________________________ Don't remember .......................................... 8

Q31 Have you heard about activities in the past year to stop the spread of drug resistance in Myanmar?

Yes .............................................................. 1 No ............................................................... 2

Q32 Are you aware that some antimalarial drugs are banned in Myanmar?

Yes .............................................................. 1 No ............................................................... 2

Q35

Q33 Which antimalarial drugs are banned in Myanmar? USE THE CODES FROM THE STOCK REVIEW IN SECTION 3.

NAME CODE Drug 1: _____________________ Drug 2: _____________________ Drug 3: _____________________ Other ......................................................... 97 Specify: ___________________________ Don't know ................................................ 98

Q34 Where did you hear about the ban on these antimalarial drugs? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED PROBE ONCE: ANYWHERE ELSE?

TV/Radio ..................................................... 1 Training ....................................................... 2 Health Center/Hospital staff ........................ 3 State/Region (S/R HD) staff........................ 4 NGO staff .................................................... 5 Committee for food and Drug control ......... 6 Other ........................................................... 7 Specify:_______________________________ Not sure .................................................... 98

Q35 Have you heard about fake/counterfeit drugs?

Yes .............................................................. 1 No ............................................................... 2

Q37

Q36 Have you seen any fake/counterfeit drugs? Yes .............................................................. 1 No ............................................................... 2 Don't know .................................................. 8

Q37 Have you heard about sub standard drugs? Yes .............................................................. 1 No ............................................................... 2

Section

2



Q38 Have you seen any sub standard drugs? Yes .............................................................. 1 No ............................................................... 2 Don't know .................................................. 8


Section 2: Review of health facility staff The interviewer should ask the head of the health facility about all current staff positions. For current staff details of length of service and training should be recorded. If referral hospital, list only health workers in the Outpatient Department (OPD).If the facility is a private one, list only health workers in Out Patient Department(OPD).

Q39 Q40 Q41 Q42 Q43 Q44

No.

Position

(list all posts even if

currently vacant)

Staff Name

(leave blank for vacant posts)

Highest Qualification Code for qualification: Doctor……………………….…….....1 Health Assistant………………….…2 Public Health Supervisor(1)……….3 Lady health visitor…………………..4 Trained Nurse……………………….5 Midwife………………………………6 Public Health Supervisor(2)……….7 Other health training……………….8 Specify: _________________________

Is the staff member present in the facility or engaged in field work today? 1 = Yes 2 = No

Years in service (Count from the first day of service as health care provider) (leave blank for vacant posts)

Last malaria-related in service training Code for type of training: 1 = Malaria laboratory 2 = Case management 3 = IBN 4 = Health education 5 = Epidemiology 6 = Other (specify)

Type of training

Date (MM/YY)

Duration (days)

1

2

3

4

5

6

7


Q39 Q40 Q41 Q42 Q43 Q44

Type of training

Date (MM/YY)

Duration (days)

8

9

10

11

12

13

14

15


Section 3: Pharmacy Stock Review The interviewer visits the facility’s pharmacy, and checks stock levels of all antimalarial drugs and expiry dates on each type.

Q43 Q44 Q45 Q46 Q47

Code Stock item

Usually in stock

In stock on day of

survey

Quantity in stock

Max. continuous

days stockout in last 3 months

Any items past

expiry?

Yes No Yes No Units Number

Yes No

1 Artemether-Lumefantrine (COARTEM 24)

1 2 1 2

1 2


1 2 1 2

1 2


1 2 1 2

1 2


1 2 1 2

1 2

5 DHA-piperaquine (DUO-COTECXIN)

1 2 1 2

1 2

6 ARTESUNATE TABLET 1 2 1 2 1 2

7 ARTESUNATE SUPPOSITORY 1 2 1 2 1 2

8 ARTEMETHER INJECTION(80mg)

1 2 1 2

1 2

9 ARTEMETHER INJECTION(40mg)

1 2 1 2

1 2

10 Artemethar Tab. 1 2 1 2 1 2

11 Artesunate + Amodiaquin 1 2 1 2 1 2

12 Artesunate + Mefloquin 1 2 1 2 1 2

13 Mefloquin Tab. 1 2 1 2 1 2

14 Quinine Inj. 1 2 1 2 1 2

15 Quinine Tab 1 2 1 2 1 2

16 Primaquin Tab. 15 mg) 1 2 1 2 1 2

17 Primaquin Tab. 7.5 mg 1 2 1 2 1 2

18 Chloroquin Tab 1 2 1 2 1 2

19 Doxycycline 1 2 1 2 1 2

20 Tetracycline 1 2 1 2 1 2

21 Clindamycin 1 2 1 2 1 2

22 Mixture of drugs for fever (or) Malaria

1 2 1 2

1 2

23 OTHER DRUG FOR MALARIA Specify: _____________________

1 2 1 2

1 2

1 2 1 2 1 2

1 2 1 2 1 2


Q43 Q44 Q45 Q46 Q47

Code Stock item

Usually in stock

In stock on day of

survey

Quantity in stock

Max. continuous

days stockout in last 3 months

Any items past

expiry?

Yes No Yes No Units Number

Yes No

1 2 1 2 1 2

1 2 1 2 1 2

24 Combo test(Care start) 1 2 1 2 1 2

25 Combo test (SD) 1 2 1 2 1 2

26 Paracheck 1 2 1 2 1 2

27 Other tests for malaria 1 2 1 2 1 2

1 2 1 2 1 2

1 2 1 2 1 2

28 MOSQUITO NETS Specify brand: ______________

1 2 1 2

1 2

29 K O tab 1 2 1 2 1 2

Give the maximum number of continuous days without the drug in the past 3 months



Q50 Did this health facility have stockout (more than 7 days without a drug) of any drugs during the past 3 months

Yes ............................................................. 1 No ............................................................... 2

Q52

Q51 What were the reasons for the stockouts?

No supply from CMS .................................. 1 No supply from State/Division health department ................................................. 2 Unexpected demand .................................. 3 Other .......................................................... 4 Specify:_______________________________

Q52 Are the stock records up-to-date? DO NOT ASK, OBSERVE ONLY

Yes ............................................................. 1 No ............................................................... 2

Q53 Do they tally with the stocks on hand? DO NOT ASK, OBSERVE ONLY

Yes ............................................................. 1 No ............................................................... 2

Q54 Does the facility use the principle of “First Expiry , first out” (FEFO) for managing their drug stocks?

Yes ............................................................. 1 No ............................................................... 2 Don’t know ................................................. 8

Section 4a: Review of outpatient services


Q55 Are there malaria-related summary tables or graphs displayed in the OPD? DO NOT ASK, OBSERVE ONLY

Yes ............................................................. 1 No ............................................................... 2

Q56 Does this health facility have an outpatient register or book?

Yes ............................................................. 1 No ............................................................... 2

Q61

Q57 Is the outpatient register in MOH or standard format? DO NOT ASK, OBSERVE ONLY

Yes ............................................................. 1 No ............................................................... 2

Q58 Is the outpatient register up to date? DO NOT ASK, OBSERVE ONLY

Yes ............................................................. 1 No ............................................................... 2

Q59 Is the health facility filling out the monthly line list of cases by village for CNM?

Yes ............................................................. 1 No ............................................................... 2

Q60 When did they last send a copy of the monthly line list to the PHD?

Date line list sent: __ __ / __ __ __ __ MM YYYY

Section 4b: Review of 2011 OPD and IPD register records Use the clinical case registers in the OPD and IPD to fill out the health facility case register sheet for all treated malaria cases from , up to the present, beginning with the most recent. Section 5a: Review of Laboratory Services (OPD)




Q61 Does the health facility provide laboratory services for malaria, meaning microscopy and/or RDTs? (Microscope or RDT)

Yes - microscopy & RDT ............................ 1 Yes - microscopy only ................................ 2 Yes - RDT only ........................................... 3 No ............................................................... 4

Q71 END

Q62 Do they have a trained lab technician who is able to perform microscopy?

Yes-full time ............................................... 1 Yes-part time .............................................. 2 No ............................................................... 3

Q64

Q63 In the past 3 months have you had more than a week without a trained lab technician who is able to perform microscopy?

Yes ............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8

Q64 Do they have a microscope in good working order?

Yes ............................................................. 1 No ............................................................... 2

Q66

Q65 In the past 3 months have you had more than a week without a microscope in good working order?

Yes ............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8

Q66 In the past 3 months have you had more than a week without enough slides?

Yes ............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8

Q67 In the past 3 months have you had more than a week without enough Giemsa stain?

Yes ............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8

Q68 When did you last send slides for quality control?

Date sent slides: __ __ / __ __ __ __ MM YYYY

Q69 Where did you send slides for quality control?

Township hospital ...................................... 1 State health department ............................. 2 National programme................................... 3 Both Province & National programme........ 4 Other .......................................................... 5 Specify:_______________________________

Q70 Did you receive any feedback on the quality control of slides?

Yes ............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8

Q71 Which brand of RDT do you currently use? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED

Carestart (Combo) ..................................... 1 Paracheck .................................................. 2 Malacheck .................................................. 3 Carestart (SD) ............................................ 4 Other .......................................................... 5 Specify:_______________________________

Q72 In the past 3 months have you had more than a week without enough RDTs?

Yes ............................................................. 1 No ............................................................... 2 Not sure ...................................................... 8



Q73 Where do you keep the RDTs? OBSERVE

On the counter/table................................... 1 Inside cupboard .......................................... 2 In a cooler box ............................................ 3 In the refrigerator ........................................ 4 Other .......................................................... 5 Specify:_______________________________

Q74 Does this health facility have a laboratory register or book?

Yes ............................................................. 1 No ............................................................... 2

Q77

Q75 Is the laboratory register up to date? DO NOT ASK, OBSERVE ONLY

Yes ............................................................. 1 No ............................................................... 2

Q76 Is the laboratory register in MoH format? DO NOT ASK, OBSERVE ONLY

Yes ............................................................. 1 No ............................................................... 2

Q77 Does the health facility have National Laboratory Diagnosis Manual for Malaria? Ask to see a copy for verification

Yes ............................................................. 1 No ............................................................... 2 Shown a copy (tick this box) .......................

Section 5b: Review of 2011 Laboratory Register

NO. QUESTIONS AND FILTERS Month

August September October

Q78 Number of slides positive for P. falciparum

Q79 Number of slides positive for P. vivax

Q80 Number of slides positive for Mixed infections (Pf/Pv)

Q81 Number of negative slides

Q82 Number of RDTs positive for P. falciparum

Q83 Number of RDTs positive for P. vivax

Q84 Number of RDTs positive for Mixed infections

Q85 Number of negative RDTs


Section 6: List of malaria-related BCC/IEC materials at the health facility

Q86 Q87 Q88

No. Type of IEC material 1 = Poster 2 = Leaflet 3 = Calendar 4 = Flip chart 5 = T-shirt/hat 8 = Other (specify)

Message Malaria prevention = 1 Malaria case management = 2

Location 1 = Displayed on wall or table 2 = In store room 3 = Other (specify)


ANNEX 4. HEALTH FACILITY QUESTIONNAIRE – PART 2 (MALARIA FOLLOW-UP)

Patient Follow-up Interview Form

USE THIS FORM TO FOLLOW UP AND INTERVIEW PATIENTS WHO WERE TREATED FOR MALARIA AT THE HEALTH FACILITY IN THE PAST ONE MONTH


Health Facility Name: ______________________

Service Type [______] (1: Public, 2 Private) Date of interview: __ __ / __ __ / __ __ __ __

Health Facility Type: [______]

Referral hospital(Sate/Region/District)…………………1

Township hospital……………………………………......2

Station hospital……………………………………………3

Rural Health center ……………………………………...4

Rural health sub center…………………………………..5

Private specialist hospital………………………………..6

Private polyclinic………………………………………….7

General practitioner clinic(with beds)……………........8

General practitioner clinic (without beds)……………..9

Other Specify:_________________________.........10

Facility Code: [____|____] [____]

Cluster Number Service Type

(Example: Cluster Number = 01, Service Type = 1

so Facility Code = 011)

State/Region: ___________________________________

S/R code: ..............................................................

Operational District: __________________________ OD code: ...............................................................

Patient No.: ........................................................... USE THE LINE NUMBER FROM THE HEALTH FACILITY CASE RECORD SHEET

Patient ID:

O=outpatient I=inpatient

Patient’s name: ___________________________ Carer’s name: __________________________


Date:

Interviewer's Name:

Result code:

_ _ / _ _ / _ _

__________

_____

_ _ / _ _ / _ _

__________

_____

_ _ / _ _ / _ _

__________

_____

Date: __ __ / __ __ / __ __ Interviewer ID: Result code:

Next planned visit: Date:

Time:

_ _ / _ _ / _ _

_________

_ _ / _ _ / _ _

_________

Total number of visits:

− −



* Result Codes:

1 = Completed 5 = Patient away from village 2 = No one at home 6 = Could not locate patient 3 = Refused 7 = Other 4 = Dwelling not found


Name: _______________

Code:

Date: _ _ / _ _ / _ _

Name: _______________

Code:

Date: _ _ / _ _ / _ _

Name: _______________

Code:

Date: _ _ / _ _ / _ _

Name: _______________

Code:

Date: _ _ / _ _ / _ _


Section 1: Demographics of patient treated for malaria


Q1 How old is the patient who was treated for malaria at (HEALTH FACILITY NAME)? IF THE PATIENT IS A CHILD < 5 YEARS, RECORD THEIR AGE IN MONTHS

Age (years): ..................................................

Age (months): ...............................................

Q2 What is the sex of the patient?

Male ........................................................... 1

Female ....................................................... 2 Q4

Q3 Is the patient currently pregnant?

ONLY ASK IF THEY ARE FEMALES, AGED 15-49 YEARS

Yes ............................................................. 1

No ............................................................... 2

Don’t know ................................................. 8

Q4 Was the patient taken to (HEALTH FACILITY NAME) in the past month by a carer?

Yes ............................................................. 1

No ............................................................... 2

Q8

Q5 What is the age of the patient’s carer?

Age (years): ..................................................

Q6 What is the sex of the patient’s carer?

Male ........................................................... 1

Female ....................................................... 2

Q7 What is the relationship of the carer to the patient treated for malaria?

Parents ....................................................... 1

Spouse ....................................................... 2

Offspring ..................................................... 3

Sibling ........................................................ 4

Grandparents..............................................5

Other .......................................................... 6

Specify:_______________________________

Q8 Where does the patient currently live? WRITE THE NAMES OF THE STATE/REGION, DISTRICT, TOWSHIP, AND VILLAGE OR WARD. FILL IN CODES LATER TO SAVE TIME.

State/Region:

__________________________________

District:

__________________________________

Township:

__________________________________

Village/Ward: __________________________________

Not sure .................................................... 98

Q9 Is the patient’s current address also their permanent address?

Yes ............................................................. 1

No ............................................................... 2



Q10 How long has the patient been living at their current address?

< 2 weeks ................................................... 1

< 1 month ................................................... 2

1 to < 3 months .......................................... 3

3 to < 6 months ......................................... 4

6 months to < 1 year .................................. 5

≥ 1 year ..................................................... 6

Q11 What is the highest level of education attained by the patient?

Child <5 years, not in school ...................... 0

Never attended school ............................... 1

Primary(including Monastic+read/write) ... 2

Secondary .................................................. 3

High school ............................................... 4

University ................................................... 5

Other .......................................................... 6

Specify:_______________________________

Q12 What is the patient’s primary profession or job?

Child, not in school ..................................... 1

Student ....................................................... 2

Farmer ........................................................ 3

Laborer ....................................................... 4

Fisherman .................................................. 5

Merchant/Seller .......................................... 6

Housewife .................................................. 7

Soldier ........................................................ 8

Other .......................................................... 9

Specify: __________________________

Q13 In the past 6 months, did the patient ever go to the forest and sleep there overnight? (Including the travel through the forest)

Yes ............................................................. 1

No ............................................................... 2

Q18

Q14 When was the patient last in the forest?

Last night .................................................... 1

< 1 week ..................................................... 2

1 to < 2 weeks ............................................ 3

2 to < 4 weeks ............................................ 4

≥ 4 weeks ................................................... 5

Not sure ...................................................... 8

Q15 How many nights did the patient stay in the forest on their last visit?

Nights: ..........................................................

Not sure .................................................... 98

Q16 Did the patient sleep overnight in the forest in the two weeks before they became ill?

Yes ............................................................. 1

No ............................................................... 2

Don’t remember ......................................... 8

Q18

Q18

Q17 Was the patient in the forest when they became ill?

Yes ............................................................. 1

No ............................................................... 2

Don’t remember ......................................... 8



Q18 In the past 6 months, has the patient ever travelled away from home and stayed overnight?

Yes ............................................................. 1

No ............................................................... 2

Q23

Q19 When did the patient last travel away from home?

Last night .................................................... 1

< 1 week ..................................................... 2

1 to < 2 weeks ............................................ 3

2 to < 4 weeks ............................................ 4

≥ 4 weeks ................................................... 5

Not sure ...................................................... 8

Q20 For what reason(s) did the patient last travel away from home? MULTIPLE RESPONSES, CIRCLE ALL MENTIONED

Work in forest ............................................ 1

Work on agricultural fields/plantations ...... 2

Work in Thailand ....................................... 3

Work in other country ................................ 4

Visit relatives ............................................. 5

Other ......................................................... 6

Specify: ___________________________

Don't know................................................. 8

Q21 Did the patient travel away from home in the two weeks before they became ill?

Yes ............................................................. 1

No ............................................................... 2

Don’t remember ......................................... 8

Q23

Q23

Q22 Was the patient traveling away from home when they became ill?

Yes ............................................................. 1

No ............................................................... 2

Don’t remember ......................................... 8

Q23 Did the patient sleep under a mosquito net last night?

Yes ............................................................. 1

No ............................................................... 2

Not sure ...................................................... 8

Q24 Does the patient’s household own any mosquito nets?

Yes ............................................................. 1

No ............................................................... 2

Not sure ...................................................... 8

Section 2: Details of treatment seeking, symptoms, consultation and diagnosis


Q25 How long after the fever began did you/your child first seek advice or treatment?

Same day ................................................... 1

Day after ..................................................... 2

Two days after ............................................ 3

Three or more days .................................... 4

Don’t remember ......................................... 8

Q26 Did you/your child seek treatment anywhere else before going to (HEALTH FACILITY NAME)?

Yes ............................................................. 1

No ............................................................... 2

Don’t remember ......................................... 8

Q34

Q34



Q27 Where else did you/your child seek treatment? MULTIPLE RESPONSES POSSIBLE, CIRCLE ALL MENTIONED


Referral hospital(Sate/Region/District)……1

Township hospital…………………………...2

Station hospital………………………………3

Rural Health center …………………………4

VMW/ VHV…………………………………...5

Rural health sub center……………………..6

Private specialist hospital…………………..7

Private polyclinic…………………………….8

General practitioner clinic (with beds)…….9

General practitioner clinic (without beds)..10

Private laboratory………………………… 11

Drug store ……………………………12

Shop/market ……………………………13

Traditional practitioner…………………… 14

Other Specify:_________________________...15

Can’t remember 98

Q28 Why did you/your child go to that provider/facility/place for treatment? MULTIPLE RESPONSES POSSIBLE, CIRCLE ALL MENTIONED

To seek advice ........................................... 1

To buy/get medication ................................ 2

Because it is close to my house ................. 3

To get a test ............................................... 4

To get traditional treatment ........................ 5

Transport expensive to health facility......... 6

Other .......................................................... 7

Specify: ___________________________

Q29 Why didn’t you first go to (HEALTH FACILITY NAME) for treatment? MULTIPLE RESPONSES POSSIBLE, CIRCLE ALL MENTIONED

Too far away .............................................. 1

Transport expensive to health facility......... 2

Fees expensive at health facility ................ 3

Didn’t think illness was serious .................. 4


Other .......................................................... 6

Specify: ___________________________

Q30 Did you get drugs from that provider/facility/place?

Yes ............................................................. 1

No ............................................................... 2

Don’t remember ......................................... 8

Q32

Q32



Q31 Which drugs did you get from that provider/facility/place? INCLUDE ALL DRUGS, SUCH AS ANTIMALARIALS, ANTIBIOTICS, PARACETAMOL, ETC.

DON’T INCLUDE DRUGS THEY WERE PRESCRIBED FROM THE HEALTH FACILITY IF THEY DON’T KNOW OR CAN’T REMEMBER, WRITE “98” FOR THE DRUG 1 CODE

TICK THE CHECKBOX IF THE DRUG IS AN

ANTIMALARIAL

anti-

Code Name malarial?

Drug 1: _________________

Drug 2: _________________

Drug 3: _________________

Drug 4: _________________

Drug 5: _________________

Q32 How much did you pay to get treatment from that provider/facility/place?

Kyat: .............................................................

Not Sure ................................................... 98

Q33 How long after you went to the other provider/facility/place did you go to (HEALTH FACILITY NAME) for treatment?

Number of days: ...........................................

Not Sure ................................................... 98

Q34 Why did you decide to go to (HEALTH FACILITY NAME)? MULTIPLE RESPONSES POSSIBLE, CIRCLE ALL MENTIONED

Referred from public health facility ............. 1

Referred from private provider ................... 2


To get a test ............................................... 4

Symptoms were getting worse ................... 5

Other .......................................................... 6

Specify: ___________________________

Q35 What signs and symptoms did you/your child have when you went to (HEALTH FACILITY NAME)? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED

PROBE ONCE: ANY OTHER SYMPTOMS?

Fever .......................................................... 1

Chills .......................................................... 2

Sweating .................................................... 3

Headache ................................................... 4

Body ache/Joint pain .................................. 5

Fatigue ....................................................... 6

Loss of appetite .......................................... 7

Diarrhoea ................................................... 8

Vomiting ..................................................... 9

Other ........................................................ 10

Specify: ___________________________

Don't remember ....................................... 98



Q36 By what means did you travel to (HEALTH FACILITY NAME)? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


Walked ....................................................... 1

Motorcycle .................................................. 2

Car.............................................................. 3

Boat ............................................................ 4

Ambulance ................................................. 5

Taxi............................................................. 6

Other .......................................................... 7

Specify: ___________________________

Q37 How long did it take you/ health personnel to travel to/from (HEALTH FACILITY NAME)?

Time (minutes): ............................................

Q38 How much did you pay to travel to (HEALTH FACILITY NAME)?

Travel cost (Kyat): ........................................

If there was no cost, fill up 99999.

Not Sure ................................................... 98

Q39 When you/your child arrived at the health facility, how long did you wait to see the nurse/doctor?

Time (minutes): ............................................

Don’t remember ----- 98

Q40 How long did the consultation take, that is how much time did you/your child spend with the nurse/doctor?

Time (minutes): ............................................


Q41 During the consultation did the nurse/doctor ask about your/your child’s fever and travel history?

Yes No

Fever history ............................... 1 2

Travel history ............................... 1 2


Q42 During the consultation did the nurse/doctor take your/your child’s temperature or blood pressure or weight or height? ASK ABOUT EACH AND CIRCLE "YES" (1) IF IT WAS DONE OR "NO" (2) IF IT WASN’T

Yes No

Temperature ................................ 1 2

Blood pressure ............................ 1 2

Weight ......................................... 1 2

Height .......................................... 1 2

Q43 Did the nurse/doctor give you a diagnosis for your/your child’s illness?

Yes ............................................................. 1

No ............................................................... 2

Not sure ...................................................... 8

Q45

Q45

Q44 What diagnosis did the nurse/doctor give you/your child? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED

PROBE ONCE: ANY OTHERS?

Malaria ....................................................... 1

Anaemia (short of blood) ............................ 2

Dehydration ................................................ 3

Respiratory infection .................................. 4

Cold/Flu ...................................................... 5

Dengue ....................................................... 6

Malnutrition ................................................. 7

Other .......................................................... 8

Specify:_______________________________



Q45 Were you/your child given a blood test for malaria at the health facility?

Yes ............................................................. 1

No ............................................................... 2

Q49

Q46 What type of test? RDT/dipstick ............................................... 1

Blood slide/microscopy .............................. 2

Not sure ...................................................... 8

Q47 Do you know the result of the test? Positive ....................................................... 1

Negative ..................................................... 2

Not told result ............................................. 3

Not sure ...................................................... 8

Q49

Q49

Q49

Q48 Do you know what type of malaria you/your child had?

Not told ....................................................... 1

Falciparum ................................................. 2

Vivax .......................................................... 3

Mixed (Pf & Pv) .......................................... 4


Section 3: Details of treatment


Q49 Did you/your child get an infusion?

Yes ............................................................. 1

No ............................................................... 2

Q50 Did the doctor/nurse/basic health staff prescribe any drugs for you/your child?

Yes ............................................................. 1

No ............................................................... 2

Q63

Q51 What drugs were prescribed for you/your child? INCLUDE ALL DRUGS, SUCH AS ANTIMALARIALS, ANTIBIOTICS, PARACETAMOL, ETC. IF THEY DON’T KNOW OR CAN’T REMEMBER, WRITE “98” FOR THE DRUG 1 CODE

anti-

Code Name malarial?

Drug 1: _________________

Drug 2: _________________

Drug 3: _________________

Drug 4: _________________

Drug 5: _________________

Q52 Can you tell me why you/your child were prescribed these drugs?


To treat malaria .......................................... 1

To reduce the fever .................................... 2

To reduce body pain/joint ache .................. 3

To make stronger ....................................... 4

Other .......................................................... 5

Specify:_______________________________

Don’t know .................................................. 8

Q53 Were you given any information about the drugs you/your child were prescribed by the doctor/nurse/basic health staff?


Yes (verbally) ............................................. 1

Yes (written) ............................................... 2

Yes (verbally & written) .............................. 3

No ............................................................... 4

Not sure ...................................................... 8

Q54 (For antimalarials only) Were you told how to take/administer the drug by the doctor/nurse/basic health staff?

CHECK Q51 AND MENTION THE DRUGS BY NAME TO THE PATIENT/CARER

Yes ............................................................ 1

No .............................................................. 2

Not sure ..................................................... 8

Q55 Can you show me the drugs you/your child were prescribed from (HEALTH FACILITY NAME)?

Yes ............................................................. 1

No .............................................................. 2

No more, take all ........................................ 8



Q56 Did you get these drugs from (HEALTH FACILITY NAME) or from another place?

Didn’t buy antimalarials .............................. 0

Referral hospital ......................................... 1

Health centre or FDH ................................ 2

Health post ................................................. 3

VMW/ VHV ................................................. 4

Polyclinic .................................................... 5

Private laboratory ....................................... 6

Drug store ................................................... 7

Shop/market ............................................... 8

Traditional practitioner ................................ 9

Other ........................................................ 10

Specify: ___________________________

Q62

Q57 How many tablets per dose did you/your child take of the antimalaria medicine?

WRITE “98” IF THEY DON’T KNOW

No. tablets: ...................................................

Q58 How many times per day did you/your child take the antimalaria medication?


No. times/day: ..............................................

Q59 How many days in total did you/your child take of the antimalaria medicine?


No. days: ......................................................

Q60 Did you/your child finish taking all of the antimalaria medicine that you were prescribed by (HEALTH FACILITY NAME)?

Yes ............................................................. 1

No ............................................................... 2

Q63

Q61 Why didn’t you/your child finish taking all of the antimalaria medicine that you were prescribed?

Still taking the medication ......................... 1

Had side effects ......................................... 2

Felt better ................................................... 3

Other .......................................................... 4

Specify: ___________________________

Don’t know ................................................. 8

SKIP TO Q63

Q62 Why didn’t you get the antimalarial medicine that you/your child were prescribed at (HEALTH FACILITY NAME)?

Not available at health facility .................... 1

Didn’t have enough money ........................ 2

Didn’t know where to buy ........................... 3

Afraid of side effects ................................... 4

Other .......................................................... 5

Specify: ___________________________

Don’t know ................................................. 8



Q63 What happens if you don’t take antimalarial drugs for the recommended number of days or don't take all of the tablets as prescribed?


Nothing ...................................................... 1

Parasite remains in the body...................... 2

Patient will continue to transmit malaria ..... 3

Parasite will become resistant.................... 4

Patient gets sick again ............................... 5

Patient does not recover ............................ 6

Other .......................................................... 7

Specify:_______________________________

Don't know .................................................. 8

Q64 Why do you think you/your child became sick? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


.................................................................. 10

Mosquito bites ............................................ 1

Didn’t sleep under net ................................ 2

Stayed/slept in forest .................................. 3

Stayed/slept in plantation ........................... 4

Drank dirty water ........................................ 5

Didn’t boil water .......................................... 6

Bathed in river ............................................ 7

Bad air ........................................................ 8

Bad talking .................................................. 9

Spirits ....................................................... 10

Bad food ................................................... 11

Poor hygiene ............................................ 12

Other ........................................................ 13

Specify:_______________________________

Don't know ................................................ 98

Q65 Has anyone else in your household been sick with fever in the past two weeks?

Yes ............................................................. 1

No ............................................................... 2

Q66 Did you return to (HEALTH FACILITY NAME) for more treatment or advice after your/your child’s first visit?

Yes ............................................................. 1

No ............................................................... 2

Q69

Q67 How long after the first visit to (HEALTH FACILITY NAME) did you/your child return?

No. days: ......................................................

Don’t remember-----------98

Q68 Why did you/your child return to the health facility? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


Fever returned ............................................ 1

Didn’t feel better/symptoms got worse ....... 2

To get a test ............................................... 3

To get more medicine ................................ 4

Health worker told me to return .................. 5

Other .......................................................... 6

Specify:_______________________________

Don't know .................................................. 8

Q69 Have you/your child recovered from the illness? Have you/your child been able to return to your normal activities and work/study?

Yes ............................................................. 1

No ............................................................... 2

Q73



Q70 What symptoms do you/your child still have? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


Fever .......................................................... 1

Chills ........................................................... 2

Sweating ..................................................... 3

Headache ................................................... 4

Body ache/Joint pain .................................. 5

Fatigue ....................................................... 6

Loss of appetite .......................................... 7

Diarrhoea .................................................... 8

Vomiting ..................................................... 9

Other ........................................................ 10

Specify: ___________________________

Don't remember ........................................ 98

Q71 Were you given any health education about your illness by the doctor/nurse/basic health staff at (HEALTH FACILITY NAME)?

Yes (verbally) ............................................. 1

Yes (written) ............................................... 2


No ............................................................... 4

Not sure ...................................................... 8

Q72 How much did you pay for your/your child’s treatment?

Cost of treatment (Kyats): ............................

Not Sure ................................................... 98

Q73 Were you satisfied with the services that you/your child received at (HEALTH FACILITY NAME)?

Yes ............................................................. 1

No ............................................................... 2

Q74 Are there any improvements that you would like to see at (HEALTH FACILITY NAME)? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


None, no improvements needed ................ 0

Reduce waiting times ................................. 1

Reduce/eliminate user fees ........................ 2

More explanation about illness................... 3

Better staff attitude toward patients ........... 4

More time with health worker ..................... 5

More detailed exam by health worker ........ 6

Availability of the prescribed drugs ............ 7

Better quality drugs .................................... 8

Longer opening hours ................................ 9

Cleaner facility or nicer building ............... 10

Other ........................................................ 11

Specify: ______________________________

Don't know ................................................ 98

END INTERVIEW



Patient Information from the clinical register:

THIS INFORMATION SHOULD BE PROVIDED AND FILLED IN BY THE SUPERVISOR FROM THE HEALTH FACILITY CASE RECORD SHEET


Q75 Line number/ID from the case record sheet: Line No. _____

Q76 Register number from the case record sheet:

Register No. ______________

Q77 Date of treatment at health facility Treatment date: . __ __ / __ __ / __ __ __ __

Q78 Age of the patient

IF THE PATIENT IS A CHILD < 5 YEARS, RECORD THEIR AGE IN MONTHS

Age: .............................................................. Age (months): ...............................................

Q79 Sex of the patient Male ........................................................... 1

Female ....................................................... 2

Q80 Diagnosis Simple malaria ........................................... 1

Severe malaria ........................................... 2

Other .......................................................... 3

Specify: __________________________

Q81 Was the diagnosis confirmed by a blood test?

Yes ............................................................. 1

No ............................................................... 2

Don’t know ................................................. 8

if no skip to Q 84

Q82 What type of test was used to confirm the patient had malaria?

RDT/dipstick ............................................. 1

Blood slide/microscopy ............................. 2

Don’t know ................................................. 8

Q83 What species of malaria did the patient have?

Falciparum ................................................ 2

Vivax ......................................................... 3

Mixed (Pf & Pv) ......................................... 4

Don’t know ................................................. 8

Q84 What drug(s) was the patient treated with? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED

AS-MQ ....................................................... 1

DHA-Pip ..................................................... 2

Chloroquine ................................................ 3

Quinine ....................................................... 4

Artemether ................................................. 5

Infusion ....................................................... 6

Paracetamol ............................................... 7

Antibiotics ................................................... 8

Other .......................................................... 9

Specify: __________________________

Don’t know ............................................... 98


ANNEX 5. HEALTH FACILITY QUESTIONNAIRE – PART 3 (EXIT INTERVIEW)

Patient Exit Interview Form

USE THIS FORM TO INTERVIEW PATIENTS WHO WERE TREATED FOR FEVER AT THE SELECTED PUBLIC HEALTH FACILITY


Health Facility Name: ______________________

Service Type [______] (1: Public, 2 Private) Date of interview: __ __ / __ __ / __ __ __ __

Health Facility Type: [______]

Referral hospital(Sate/Region/District)…………..1

Township hospital…………………………………..2

Station hospital……………………………………..3

Rural Health center ………………………………..4

Rural health sub center……………………………5

Private specialist hospital………………………….6

Private polyclinic……………………………………7

General practitioner clinic(with beds)…………….8

General practitioner clinic (without beds)………..9

Other Specify:_________________________...10

Facility Code: [____|____] [____]

Cluster Number Service Type

(Example: Cluster Number = 01, Service Type = 1

so Facility Code = 011)

State/Region: ___________________________________

S/R code: ..............................................................

Operational District: __________________________ OD code: ...............................................................

Patient No.: ...........................................................

Interviewer’s name: ________________________ Interviewer’s code: ..............................................


Name: _______________

Code:

Date: _ _ / _ _ / _ _

Name: _______________

Code:

Date: _ _ / _ _ / _ _

Name: _______________

Code:

Date: _ _ / _ _ / _ _

Name: _______________

Code:

Date: _ _ / _ _ / _ _


Section 1: Demographics of patient with fever


Q1 How old is the patient with fever? IF THE PATIENT IS A CHILD < 5 YEARS, RECORD THEIR AGE IN MONTHS

Age (years): ..................................................

Age (months): ...............................................

Q2 What is the sex of the patient? Male............................................................ 1

Female ....................................................... 2

Q4

Q3 Is the patient currently pregnant?

ONLY ASK IF THEY ARE FEMALE, AGED 15-49 YEARS

Yes ............................................................. 1

No ............................................................... 2

Q4 Is the patient visiting the health facility today with a carer?

Yes ............................................................. 1

No ............................................................... 2

Q8

Q5 What is the age of the patient’s carer? Age (years): ..................................................

Q6 What is the sex of the patient’s carer? Male............................................................ 1

Female ....................................................... 2

Q7 What is the relationship of the carer to the patient with fever?

Parents ....................................................... 1

Spouse ....................................................... 2

Offspring ..................................................... 3

Sibling......................................................... 4

Grandparents..............................................5

Other .......................................................... 6

Specify:_______________________________

Q8 Where does the patient currently live? WRITE THE NAMES OF THE STATE/REGION, DISTRICT, TOWSHIP, AND VILLAGE OR WARD. FILL IN CODES LATER TO SAVE TIME.

State/Region:

__________________________________

District:

__________________________________

Township:

__________________________________

Village/Ward: __________________________________

Not sure .................................................... 98

Q9 Is the patient’s current address also their permanent address?

Yes ............................................................. 1

No ............................................................... 2



Q10 How long has the patient been living at their current address?

< 2 weeks ................................................... 1

< 1 month ................................................... 2

1 to < 3 months .......................................... 3

3 to < 6 months ......................................... 4

6 months to < 1 year .................................. 5

≥ 1 year ..................................................... 6

Q11 What is the highest level of education attained by the patient?

Child <5 years, not in school ...................... 0

Never attended school ............................... 1

Primary(including Monastic + read/write) . 2

Secondary .................................................. 3

High school ............................................... 4

University ................................................... 5

Other .......................................................... 6

Specify:_______________________________

Q12 What is the patient’s primary profession or job?

Child, not in school ..................................... 1

Student ....................................................... 2

Farmer ........................................................ 3

Laborer ....................................................... 4

Fisherman .................................................. 5

Merchant/Seller .......................................... 6

Housewife .................................................. 7

Soldier ........................................................ 8

Other .......................................................... 9

Specify: __________________________

Q13 In the past 6 months, did the patient ever go to the forest and sleep there overnight?

Yes ............................................................. 1

No ............................................................... 2

Q16

Q14 When was the patient last in the forest?

Last night .................................................... 1

< 1 week ..................................................... 2

1 to < 2 weeks ............................................ 3

2 to < 4 weeks ............................................ 4

≥ 4 weeks ................................................... 5

Not sure ...................................................... 8

Q15 How many nights did the patient stay in the forest on their last visit?

Nights: ..........................................................

Not sure .................................................... 98

Q16 In the past 6 months, has the patient ever travelled away from home and stayed overnight?

Yes ............................................................. 1

No ............................................................... 2

Q19



Q17 When did the patient last travel away from home?

Last night .................................................... 1

< 1 week ..................................................... 2

1 to < 2 weeks ............................................ 3

2 to < 4 weeks ............................................ 4

≥ 4 weeks ................................................... 5

Not sure ...................................................... 8

Q18 For what reason(s) did the patient last travel away from home? MULTIPLE RESPONSES, CIRCLE ALL MENTIONED

Work in forest ............................................ 1

Work on plantations .................................. 2

Work in Thailand ....................................... 3

Work in other country ................................ 4

Visit relatives ............................................. 5

Other ......................................................... 6

Specify: ___________________________

Don't know ................................................. 8

Q19 Did the patient sleep under a mosquito net last night?

Yes ............................................................. 1

No ............................................................... 2

Not sure ...................................................... 8

Q20 Does the patient’s household own any mosquito nets?

Yes ............................................................. 1

No ............................................................... 2

Not sure ...................................................... 8

Section 2: Details of treatment seeking, symptoms, consultation and diagnosis


Q21 When did you/your child’s fever begin? Today ......................................................... 1

Yesterday ................................................... 2

Two days ago ............................................. 3

Three days ago .......................................... 4

> 3 days ago............................................... 5

Don’t remember ......................................... 8

Q22 Did you/your child seek treatment anywhere else before coming here today?

Yes ............................................................. 1

No ............................................................... 2

Don’t remember ......................................... 8

Q25

Q25



Q23 Where else did you/you child seek treatment?



Referral hospital(Sate/Region/District)……1

Township hospital…………………………...2

Station hospital………………………………3

Rural Health center …………………………4

VMW/ VHV…………………………………...5

Rural health sub center……………………..6

Private specialist hospital…………………..7

Private polyclinic…………………………….8

General practitioner clinic(with beds)……..9

General practitioner clinic (without beds)..10

Private laboratory ..................................... 11

Drug store ................................................ 12

Shop/market ............................................. 13

Traditional practitioner.............................. 14

Other Specify:_________________________...15

Can’t remember ...................................... 98

Q24 Why did you/your child go to that provider/facility/place for treatment? MULTIPLE RESPONSES POSSIBLE, CIRCLE ALL MENTIONED

To seek advice ........................................... 1

To buy/get medication ................................ 2


To get a test ............................................... 4


Transport expensive to health facility ......... 6

Other .......................................................... 8

Specify: ___________________________

Q25 Why did you/your child come to (HEALTH FACILITY NAME) today?

Referred from public health facility ............. 1

Referred from private provider ................... 2


To get a test ............................................... 4

Symptoms were getting worse ................... 5

To get medication ....................................... 6

Other .......................................................... 7

Specify: ___________________________



Q26 What signs and symptoms do you/your child have today? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


Unconscious ............................................... 1

Convulsions ................................................ 2

Fast breathing ............................................ 3

Very hot ...................................................... 4

Yellow eye color ......................................... 5

Very pale skin ............................................. 6

Not breastfeeding ....................................... 7

Not eating ................................................... 8

Frequent vomiting ...................................... 9

Diarrhoea ................................................. 10

Coughing .................................................. 11

Other ........................................................ 12

Specify: ___________________________

Don't know ................................................ 98

Q27 By what means did you travel to this health facility today?

Walked ....................................................... 1

Motorcycle .................................................. 2

Car .............................................................. 3

Boat ............................................................ 4

Ambulance ................................................. 5

Taxi ............................................................. 6

Other .......................................................... 7

Specify: ___________________________

Q28 How long did it take you to travel to this health facility today?

Time (minutes): ............................................

Don’t remember--------98

Q29 How much did you pay to travel to this health facility today?

Travel cost (Kyat): ........................................


Q30 When you/your child arrived at the health facility today, how long did you/your child wait to see the doctor/nurse/basic health staff ?

Time (minutes): ............................................


Q31 How long did the consultation take, that is how much time did you/your child spend with the doctor/nurse/basic health staff?

Time (minutes): ............................................


Q32 During the consultation did the doctor/nurse/basic health staff ask about your/your child’s fever and travel history?

Yes No

Fever history .............................. 1 2

Travel history .............................. 1 2

Don’t remember----------98



Q33 During the consultation did the doctor/nurse/basic health staff take your/your child’s temperature or blood pressure or weight or height? ASK ABOUT EACH AND CIRCLE "YES" (1) IF IT WAS DONE OR "NO" (2) IF IT WASN’T

Yes No

Temperature ............................... 1 2

Blood pressure ........................... 1 2

Weight ........................................ 1 2

Height ......................................... 1 2

Q34 Did the doctor/nurse/basic health staff give you/you child a diagnosis for your/your child’s fever?

Yes ............................................................. 1

No ............................................................... 2

Not sure ...................................................... 8

Q36

Q36

Q35 What diagnosis did the doctor/nurse/basic health staff give you for your/your child’s fever?

Malaria........................................................ 1

Acute respiratory infection.......................... 2

Upper respiratory infection ......................... 3

Cold/Flu ...................................................... 4

Dengue ....................................................... 5

Diarrhoea ................................................... 6

Anaemia (short of blood) ............................ 7

Dehydration ................................................ 8

Malnutrition ................................................. 9

Other ........................................................ 10

Specify:_______________________________

Q36 Did you/your child have a blood test for malaria?

Yes ............................................................. 1

No ............................................................... 2

Q40

Q37 What type of test? RDT/dipstick ............................................... 1

Blood slide/microscopy .............................. 2

Not sure ...................................................... 8

Q38 Do you know the result of the test? Positive ....................................................... 1

Negative ..................................................... 2

Not told result ............................................. 3

Not sure ...................................................... 8

Q40

Q40

Q40

Q39 Do you know what type of malaria you/your child have?

Not told ....................................................... 1

Falciparum ................................................. 2

Vivax........................................................... 3

Mixed (Pf & Pv) .......................................... 4

Section 3: Details of treatment




Q40 Did the doctor/nurse/basic health staff give you/your child an infusion today?

Yes ............................................................. 1

No ............................................................... 2

Q41 Did the doctor/nurse/basic health staff prescribe any drugs for you/your child today?

Yes ............................................................. 1

No ............................................................... 2

Q51

Q42 What drugs were prescribed for you/your child today? INCLUDE ALL DRUGS, SUCH AS ANTIMALARIALS, ANTIBIOTICS, PARACETAMOL, ETC. TICK THE CHECKBOX IF THE DRUG IS AN ANTIMALARIAL.

anti-

Code Name malarial?

Drug 1: _________________

Drug 2: _________________

Drug 3: _________________

Drug 4: _________________

Drug 5: _________________

Don’t know the name of drug given------98

Q43 Can you tell me why you/your child were prescribed these drugs today? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED

To treat malaria .......................................... 1

To reduce the fever .................................... 2

To reduce body pain/joint ache .................. 3

To reduce coughing ................................... 4

To make stronger ....................................... 5

Other .......................................................... 6

Specify:_______________________________

Don’t know ................................................. 8

Q44 Were you given any information about the drugs you/your child were prescribed by the doctor/nurse/basic health staff?

Yes (verbally) ............................................. 1

Yes (written) ............................................... 2


No ............................................................... 4

Not sure ...................................................... 8

Q45 Can you show me the drugs you/your child were prescribed?

Yes ............................................................. 1

No ............................................................... 2

Q46 (For antimalarials only)Were you told how to take/administer the drug? CHECK Q42 AND MENTION THE DRUGS BY NAME TO THE PATIENT/CARER

Yes ............................................................. 1

No ............................................................... 2

Not sure ...................................................... 8

Q47 How many tablets per dose? FOR ANTIMALARIALS ONLY

No. tablets: ...................................................

Q48 How many times per day? FOR ANTIMALARIALS ONLY

No. times/day: ..............................................



Q49 How many days? FOR ANTIMALARIALS ONLY

No. days: ......................................................

Q50 What happens if you don’t take antimalarial drugs for the recommended number of days or don't take all of the tablets as prescribed? MULTIPLE RESPONSES POSSIBLE, CIRCLE ALL MENTIONED

Nothing ....................................................... 1

Parasite remains in the body ..................... 2

Patient will continue to transmit malaria ..... 3

Parasite will become resistant ................... 4

Patient gets sick again ............................... 5

Patient does not recover ............................ 6

Other .......................................................... 7

Specify:_______________________________

Don't know .................................................. 8

Q51 Do you know of any antimalarial drugs that should no longer be used to treat malaria?

Yes ............................................................. 1

No ............................................................... 2

Q53

Q52 What are the names of the drugs that should no longer be used to treat malaria? IF < 3, WRITE THE ONES THAT THEY KNOW (FILL IN THE DRUG CODES LATER TO SAVE TIME)

Name Code


Q53 Why do you think you/your child became sick with fever? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED PROBE ONCE: ANY OTHER REASONS?

Got malaria ................................................. 1

Slept in forest ............................................. 2

Slept in plantation ....................................... 3

Family member had fever .......................... 4

Family member had cold ............................ 5

Slept in forest without net ........................... 6

Spirit ........................................................... 7

Got wound .................................................. 9

Other ........................................................ 10

Specify: ______________________________

Don't know ................................................ 98

Q54 Has anyone else in your household been sick with fever in the past two weeks?

Yes ............................................................. 1

No ............................................................... 2

Q55 Were you given any health education about your/your child’s illness by the doctor/nurse/basic health staff?

Yes (verbally) ............................................. 1

Yes (written) ............................................... 2


No ............................................................... 4

Not sure ...................................................... 8

Q56 How much did you pay for your/your child’s treatment today?

Cost of treatment (Kyat): ..............................

Not Sure ................................................... 98



Q57 Were you satisfied with the treatment you received at the health facility today?

Yes ............................................................. 1

No ............................................................... 2

Q58 What sort of improvements would you like to see at this health facility? MULTIPLE RESPONSES POSSIBLE CIRCLE ALL MENTIONED


None, no improvements needed ................ 0

Reduce waiting times ................................. 1

Reduce/eliminate user fees ....................... 2

More explanation about illness .................. 3

Better staff attitude toward patients ........... 4

More time with health worker ..................... 5

More detailed exam by health worker ........ 6

Availability of the prescribed drugs ............ 7

Better quality drugs .................................... 8

Longer opening hours ................................ 9

Cleaner facility or nicer building ............... 10

Other ........................................................ 11

Specify: ______________________________

Don't know ................................................ 98

END INTERVIEW


Documents

Myanmar Artemisinin Resistance Containment Project Baseline … · 2018-04-09 · Myanmar Artemisinin Resistance Containment Baseline Survey 6 1.4 Malaria treatment Table 1.4.1 Household