A cocktail of factors, from financial to supernatural, are affecting the way Cambodians seek malaria treatment, with mistreated cases potentially leading to the spread of resistant strains, a new study has found.

The qualitative report, published late last week in the peer-reviewed Malaria Journal 2017, conducted 42 interviews and focus groups with an additional 49 villagers in Chheb and Chey Sen districts in Preah Vihear province.

Report author and social scientist Charlotte Gryseels, of the Institute of Tropical Medicine in Belgium, said Cambodians had a tendency to separate symptoms, such as fever and headache, and attempt to solve them individually with a mixture of treatments like coining, pills, indigenous healing practices and herbal remedies. “Sometimes when initial treatment options don’t cure the patient, people explore the potential for spiritual attacks, as this would explain why the given treatment isn’t working,” she said.

Interviews revealed that while most now considered malaria to be the result of a mosquito bite (unlike a punishment for offending a forest deity, as in the past), there was often a sense of “dual causality”: that an underlying supernatural cause, such as an angry ancestor spirit, influences the mosquito.

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Lack of results in treatment could serve “as proof that the illness is actually caused by something ‘invisible’,” the report reads. But a slew of factors, such as a lack of money to reach hospitals and a lack of trust in health professionals, limited patients’ access to prompt diagnoses and led to untreated or mistreated malaria cases.

Gryseels explained that this then enables transmission of resistant strains to continue. Earlier this month, the Ministry of Health reported that malaria cases plunged by more than 50 percent last year compared to 2015, with just one death recorded.

Experts, however, warned that the spread of resistant malaria parasites still poses a “serious threat” to efforts to eliminate the disease.

Ministry of Health and National Centre for Parasitology Entomology and Malaria Control spokespeople did not respond to requests for comment yesterday.

Gryseels stressed in an email yesterday that while volunteers who provide rapid tests were helping to eliminate the disease, they deserved extra support. “We need to remember that people do not avoid appropriate malaria treatments because of cultural illness perceptions, but that they would take appropriate malaria treatment if it were easily accessible to them from a trusted provider, at least if they can overcome the difficulty of recognising malaria at an early stage,” she said.

Doctor Mengly Quach said that in his experience of treating patients in Cambodia, it was common for those living in rural areas to seek out shamans instead of physicians.

“It is dangerous for the medical practice, because it does not work,” he said.

Some saw hospital as a last resort, which could be detrimental to their health or too late to save their lives, he added.

“The government should have health education in every school and encourage more health care providers in the younger generation to work in the rural areas,” he said.

“With malaria, the kind of medication can be a problem. There are a lot of issues to be concerned about, especially in relation to resistance – not just malaria but antibiotics, too.”