Lwin et al.

Malaria Journal 2014, 13:5

http://www.malariajournal.com/content/13/1/5

RESEARCH

Open Access

Improving malaria knowledge and practices in

rural Myanmar through a village health worker
intervention: a cross-sectional study
Moh Moh Lwin1, May Sudhinaraset2*, Aung Kyaw San1 and Tin Aung1

Abstract
Background: Since 2008 the Sun Primary Health (SPH) franchise programme has networked and branded
community health workers in rural Myanmar to provide high quality malaria information and treatment. The
purpose of this paper is to compare the malaria knowledge level and health practices of individuals in SPH
intervention areas to individuals without SPH intervention
Methods: This study uses data from a cross-sectional household survey of 1,040 individuals living in eight rural
townships to compare the knowledge level of individuals in SPH intervention areas to individuals without SPH
intervention.
Results: This study found that the presence of a SPH provider in the community is associated with increased
malaria knowledge and higher likelihood of going to trained providers for fevers. Furthermore, the study found a
doseresponse, where the longer the duration of the programme in a community, the greater the community
knowledge level.
Conclusion: The study suggests that community health workers might have significant impact on malaria-related
mortality and morbidity in rural Myanmar.
Keywords: Social franchise programme, Rural, Community health workers, Malaria, Intervention

Background
Malaria causes approximately 500 million infections and
about 650,000 deaths every year worldwide [1,2]. In
Myanmar, an estimated 37 million people live in malaria
endemic areas, where 70% of malaria-risk people live in
rural areas [2]. Late diagnosis and inappropriate treatment of malaria can lead to complications and death
[3,4]. Early diagnosis and effective treatment can be improved through the use of health workers. Numerous
programmes in low- and middle-income countries that
utilized trained health workers in rural settings demonstrated improvements in rural populations access to
accurate diagnosis and treatment [5-11]. Since 2004,
community-based malaria control projects have gained
popularity in Myanmar. For example, village health
* Correspondence: sudhinarasetm@globalhealth.ucsf.edu
2
Global Health Group, University of California, San Francisco, San Francisco,
CA, USA
Full list of author information is available at the end of the article

volunteers in 160 remote villages provided insecticidetreated mosquito nets (ITNs) and early diagnosis and
appropriate treatment, resulting in reported positive
health impacts [6,12].
Health workers help to improve early diagnosis and effective treatment for malaria by increasing access to and
provision of quality services and products such as RDTs
(rapid diagnostic test kits) and ACT (artemisinin-based
combination therapy). RDTs provide an easy and accurate confirmation of symptomatic diagnosis of malaria in
resource-poor settings [9,10,13]. In several studies conducted in Thailand, Ethiopia, and Uganda, communitybased malaria care services combined with RDT use
have been shown to reduce malaria transmission and
lower malaria morbidity and mortality in rural populations [10,14,15]. ACT is the most effective for uncomplicated malaria cases, using RDT to correctly diagnose
patients reduces presumptive treatments, limiting the

2014 Lwin et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Lwin et al. Malaria Journal 2014, 13:5

http://www.malariajournal.com/content/13/1/5

overuse of ACT, lowering programme costs, and delaying the emergence of drug resistance [10,13,16,17].
Intervention

Launched in 2008 in eight townships, the Sun Primary

Health (SPH) network was scaled up in 2009 to 19
townships where 338 SPH providers were trained, 20
townships in 2010 where 280 SPH were supported for
malaria services, and 37 townships in 2011 where 557
SPH providers were requested to give malaria services to
their communities (see Figure 1). The SPH malaria
programme was implemented according to areas in need

Page 2 of 5

and getting appropriate approval from local division directors or township medical officer.
As part of SPH, PSI/Myanmar and the Myanmar government township medical officers recruited volunteer
health workers to provide basic health services such as
diagnosis and treatment of uncomplicated malaria
cases. Health workers recruited into SPH were trained
and provided with RDTs for malaria diagnosis and differentiation of Plasmodium falciparum, Plasmodium vivax and/
or mixed infection. Training topics covered malaria counseling, malaria transmission, use of RDTs, treatment, and
prevention and control of malaria by using impregnated bed nets. Health workers were also awarded with
performance-based incentive schemes based on malaria tested or treated cases per month.
While the SPH network has served thousands of populations, the impact of the programme in increasing community knowledge and services is unknown. The study
analysed data from a cross-sectional household survey of
1,040 individuals living in eight townships of rural areas
to compare the knowledge level of individuals in SPH
intervention areas to individuals without SPH intervention. The study hypothesized that individuals living in
SPH communities have higher knowledge and correct
treatment levels compared to non-SPH areas.

Methods
Recruitment and study subjects

The cross-sectional quantitative household survey was

conducted by researchers from Population Services
International/Myanmar (PSI/M) in January 2012 and
recruited 2,080 study participants from eight townships
in five states/divisions including Mon, Eastern Shan,
Northern Shan, Southern Shan and Tanintaryi Division.
Townships were randomly selected from a list of 92
townships classified as malaria endemic townships according to Unicef and the Vector Borne Disease Control
Team (VBDC) in Myanmar. The survey covered 11,491
communities in 2009, 21,973 communities in September/
October 2011, and 2,041 communities in December 2011,
and the primary sampling unit was households. In total, the
analysis included 1,040 respondents. The inclusion criteria
was 18 years of age or older, and caregivers were asked
about childrens fever in the last two weeks.
Measurements

Figure 1 Map of SPH Interventions of 8 rural townships in

Myanmar.

The primary outcome of interest was malaria knowledge

and treatment. The study measured malaria knowledge
with two indicators: knowledge on prevention of malaria
by using ITNs and ever heard of malaria RDT (all binary
outcomes, yes/no). The study measured malaria treatment categorically by whether they receive treatment
from trained providers, buy and take medicine from
drug store, or take treatment at home.

Lwin et al. Malaria Journal 2014, 13:5

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Page 3 of 5

The main predictor of interest was whether individuals received the SPH intervention in their communities or did not receive SPH intervention, measured as a
binary variable. The study calculated doseresponse of
the intervention by looking at the duration of the
programme in communities (measured categorically
from 2009, 2010, 2011). Demographic characteristics
include age of study participations (categorical); education level (categorical); gender (binary); and occupation (categorical).
Analyses

Four sets of analyses were conducted. First, simple

chi-2 statistics and t-tests were used to test statistical
differences of demographic characteristics between SPH
versus non-SPH communities. Second, bivariate analyses
were used to test associations between demographic
characteristics and the malaria knowledge and treatment. Third, multivariable analyses were conducted to
control for potential confounders. Due to lack of statistical significance of demographic characteristics across
SPH and non-SPH communities (Table 1), only bivariate
analyses are shown in the paper. Lastly, to test for
doseresponse effects of the intervention, the analysis
stratified provider malaria knowledge and treatment outcomes by the timing of intervention, or duration in
which the intervention has been in the community (i.e.

2009, Sep Oct 2011, Dec 2011). The study stratified all
analyses by SPH versus non-SPH communities and used
STATA 12MP.
Ethical approval

Population Services Internationals (PSI) Ethical Review

Board approved this study.

Results
In total, 1,040 participants were included in the study,
with 321 respondents in communities that received an
SPH and 719 respondents living in communities that did
not have the intervention. Analyses of basic demographic characteristics suggest that there were no statistically significant differences between SPH and non-SPH
communities. Approximately 32% of the study sample
was between 1535 years, 33% between the ages of 35
50 years, 28% between 5065 years, and 7% older than
65 years (see Table 1). There was no statistically significant difference in age between SPH and non-SPH communities (p = 0.694). The majority of respondents had at
least a middle school education or higher (approximately
75%), while 28.6% reported having no schooling. The
majority of respondents in both the SPH and non-SPH
communities were female (73.2% vs. 67.6%, respectively,
p = 0.07). Overwhelmingly, respondents reported working in manual labor (88.3%), followed by owning a

Table 1 Demographic characteristics of household members by SPH vs non-SPH communities

SPH communities (n = 321)

Non-SPH communities (n = 719)

Chi2, p-value

Total (N = 1040)

15 35

104 (32.40)

227 (31.57%)

35 50

103 (32.09%)

245 (34.08%)

50 65

88 (27.41%)

202 (28.09%)

>65

26 (8.10%)

45 (6.26%)

No schooling

85 (26.48%)

212 (29.49%)

Middle school

224 (69.78%)

461 (64.12%)

High School

10 (3.12%)

39 (5.42%)

49 (4.71%)

Graduate School

2 (0.62%)

7 (0.97%)

9 (0.87%)

Female

235 (73.21%)

486 (67.59%)

Male

86 (26.79%)

233 (32.41%)

Higher management

3 (0.93%)

5 (0.70%)

Own business/shopkeeper

20 (6.23%)

70 (9.74%)

Age (years)
331 (31.83%)
348 (33.46%)
1.4484, 0.694

290 (27.88%)
71 (6.83%)

Education Level
297 (28.56%)
4.6095,0.2030

685 (65.87%)

Gender
3.2902, 0.070

721 (69.33%)
319 (30.67%)

Occupation
5.9039, 0.116

8 (0.77%)
90 (8.65%)

Manual labourer

287 (89.41%)

631 (87.76%)

918 (88.27%)

Retirement

11 (3.43%)

13 (1.81%)

24 (2.31%)

Time of implementation:
2009;
2010;
2011 32(9.97%), 190(59.19%) and 99(30.84%).

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Table 2 Comparison of malaria knowledge and treatment between SPH vs. non-SPH
SPH communities
(n = 321)

Non-SPH communities
(n = 719)

Chi2,
p-value

Total
(N = 1040)

Key determinants of knowledge

Knowledge on prevention of malaria by using ITN

107 (33.33%)

185 (25.73%)

6.3529, 0.012

292 (28.08%)

Ever heard of malaria diagnostic blood test (RDT)

220 (68.54%)

440 (61.20%)

5.1558, 0.023

660 (63.46%)

Take treatment from trained providers

254 (79.13%)

500 (69.54%)

16.6445, 0.000

754 (72.50%)

Buy and take medicine from drug store

61 (19%)

165 (22.95%)

226 (21.73%)

Take treatment at home

6 (1.87%)

54 (7.51%)

60 (5.77%)

Intent to treat

business/shopkeeper (8.7%), retired (2.3%), and less than

1% reported being in higher management (see Table 1).
Across a number of malaria knowledge and treatmentrelated questions, SPH communities scored higher compared to non-SPH communities. Respondents living in
SPH communities were more likely to correctly identify
using ITN as prevention of malaria (33.3% vs. 25.7%, p >
0.05), and more likely to have ever heard of RDTs for
malaria (68.5% vs. 61.2%, p = 0.023). Moreover, respondents in communities with SPH providers were also
more likely to be treated from a trained provider compared to those without a SPH provider (79.1% vs. 69.5%,
p > 0.05). Respondents in non-SPH communities, on the
other hand, were more likely to buy and take medicine
from drug stores or take treatment at home compared
to respondents in SPH communities (23% vs. 19%, p < 0.01)
(see Table 2).
The study found a doseresponse effect -the longer
the time the intervention had been in place in communities, the greater the malaria knowledge and treatment
behaviours across a number of indicators (i.e. knowledge
of mosquitoes as causes of malaria, ITN use, treatment
with trained provider). For example, communities with a
longer intervention period (2009) reported almost 49%
knowledge of ITN use compared to only 15.6% of respondents with the shortest intervention period (2011).

Figure 2 Duration of programme exposure and malaria knowledge.

The two-year time period of the intervention increased

the knowledge score by more than three times. This was
the case across practically all knowledge and treatment
indicators (see Figure 2).

Discussion
This study was the first to evaluate the impact of the
Sun Primary Health (SPH) intervention on malaria
knowledge and behaviours among rural populations in
Myanmar. The study found that the presence of a SPH
provider in the community is associated with increased
malaria knowledge, such as knowledge of use of ITN
and RDT, and higher likelihood of going to trained
providers for fevers. Lack of statistically significant differences in basic demographic characteristics between
SPH and non-SPH groups strengthens the finding that
there is an association between a SPH provider and
higher knowledge levels. Furthermore, the study also
found that communities with a longer duration of intervention (intervention introduced in 2009) had better
knowledge score and treatment behaviours compared to
communities with more recent introduction of providers
(in 2011).
There are a number of limitations to the study. First,
the study was not able to assess characteristics regarding
patient-provider relationship, such as the quality of the

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providers, the frequency of visiting providers, or whether

respondents interacted with SPH providers. Future studies should examine the quality of health workers and
how that relates to patient practices and knowledge
levels. Second, because the study uses cross-sectional
data, the study cannot infer causality. However, these
analyses take advantage of the stepped design of the
intervention and examine doseresponse, a criteria for
causal inference.
Despite the limitations, this study demonstrates the
critical and potential role of health workers in improving
health in rural Myanmar. There is a dearth of studies on
promising interventions in Myanmar, particularly in
rural areas, and this study not only demonstrates a
change in knowledge score between SPH and non-SPH
communities, but also suggests that there are cumulative
effects over time. Future studies should concentrate on a
better understanding of the direct and indirect effects of
SPH providers, how training impacts the quality of
health workers, and explore whether greater frequency
and contact with SPH providers result in better health
outcomes. Moreover, future studies should concentrate
on the health impact of communities, going beyond
knowledge indicators to measure malaria prevalence, incidence, morbidity, and mortality. This study highlights
the opportunity to engage with rural health workers in
improving malaria knowledge, care, and practices.

Consent
Written informed consent was obtained from the patients
guardian/parent/next of kin for the publication of this
report and any accompanying images.

Page 5 of 5

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Competing interests
The authors declare that they have no competing interests.
16.
Authors contributions
ML carried out analyses and drafted the manuscript. MS oversaw data
analysis and participated in drafting the manuscript. AS participated in the
design of the study. TA conceived of the study, and participated in its design
and coordination. All authors read and approved the final manuscript.
Acknowledgements
The authors would like to acknowledge Willi McFarland and Dominic
Montagu for helping with interpretation of study results.
Author details
1
Population Services International/Myanmar, Yangon, Myanmar. 2Global
Health Group, University of California, San Francisco, San Francisco, CA, USA.
Received: 4 June 2013 Accepted: 29 December 2013
Published: 4 January 2014
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doi:10.1186/1475-2875-13-5
Cite this article as: Lwin et al.: Improving malaria knowledge and
practices in rural Myanmar through a village health worker intervention:
a cross-sectional study. Malaria Journal 2014 13:5.