title: Local constraints to access appropriate malaria treatment in the context of parasite resistance in Cambodia: a qualitative study.
abstract: Despite emerging drug resistance in Cambodia, artemisinin-based combination therapy (ACT) is still the most efficacious therapy. ACT is available free of charge in the Cambodian public sector and at a subsidized rate in the private sector. However, un- and mistreated cases in combination with population movements may lead to the further spread of resistant parasites, stressing the importance of understanding how the perceived aetiology of malaria and associated health-seeking behaviour may delay access to appropriate treatment. A qualitative study explored these factors after an epidemiological survey confirmed parasite resistance in Preah Vihear province.
  
  
  
  In Cambodian cosmology, illnesses can be inflicted by supernatural beings or originate from 'natural' causes because of disorder in the social, domestic or outdoor environment. Initial treatment options consist of cheap and accessible home-based care (manual therapy, herbs and biomedical medication) targeting single symptoms. If there is no steady recovery or if the condition quickly aggravates, care will be sought from 'village doctors', public health facilities, private pharmacies or, in case of suspicion of a supernatural cause, from a specialized indigenous healer. The choice of provider is mostly based on the family's financial situation, access to and trust in the provider, and the congruence between the suspected aetiology of the illness and the treatment offered by the provider. Different treatment options are often combined during the same illness episode through a serial process of trial and error guided by the observable improvements in the patient's condition.
  
  
  
  Cambodian perceptions of illness that focus on single symptoms and their perceived severity may lead to the identification of one or multiple illnesses at the same time, rarely suspecting malaria from the start and implying different patterns of health seeking behaviour and treatment choice. However, decisions to self-diagnose and treat at home are also pragmatic and must be understood in the context of poverty, a major barrier to seeking prompt and appropriate care for malaria in an area characterized by parasite resistance.
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Phnom Penh, Cambodia.
authors.forename: Jesse
authors.initials: J
authors.lastname: Verschuere
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Medical Department, Brussels, Belgium.
authors.forename: Tom
authors.initials: T
authors.lastname: Decroo
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Phnom Penh, Cambodia.
authors.forename: Dara
authors.initials: D
authors.lastname: Lim
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Medical Department, Brussels, Belgium.
authors.forename: Jean-Marie
authors.initials: JM
authors.lastname: Kindermans
authors.affiliation: Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia.
authors.forename: Chea
authors.initials: C
authors.lastname: Nguon
authors.affiliation: Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia.
authors.forename: Rekol
authors.initials: R
authors.lastname: Huy
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Medical Department, Brussels, Belgium.
authors.forename: Yasmine
authors.initials: Y
authors.lastname: Alkourdi
authors.affiliation: Medical Anthropology Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Koen
authors.initials: K
authors.lastname: Peeters Grietens
authors.affiliation: Medical Anthropology Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium. cgryseels@itg.be.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Gryseels
mesh_terms: D000962:Antimalarials / Q000494:pharmacology*; D002160:Cambodia; D004351:Drug Resistance; D006297:Health Services Accessibility; D008288:Malaria / Q000188:drug therapy*; D010961:Plasmodium / Q000187:drug effects; D036301:Qualitative Research
chemical_list: D000962:Antimalarials