Early diagnosis and effective treatment of all malaria cases is an essential component of an elimination campaign . This not only requires appropriate infrastructure and resourcing at primary health care facilities, but also active engagement and participation of communities to recognize malaria symptoms and access treatment at formal health facilities in order to reduce the reservoir of malaria parasites . Tafea Province, Vanuatu, has been targeted for elimination of malaria by 2014 in the Government of Vanuatu Malaria Action Plan (MAP). Support for the MAP is provided through the National Vector Borne Disease Control Programme (NVBDCP) and Ministry of Health (MoH), with assistance from 'The Global Fund' to fight AIDS, Tuberculosis and Malaria, World Health Organization (WHO) and the Australian Government's AusAID Pacific Malaria Initiative (PacMISC) . The focus of this paper is to explore the community perspectives of malaria within Tannese communities and how local constructions of health and illness impact on treatment-seeking behaviour for malaria. This investigation is part of a larger research project examining community perceptions on Tanna Island, Vanuatu of prevention and treatment-seeking behavior for malaria, in order to identify key strategies for sustained community participation for malaria elimination in the context of a low transmission setting . An analysis of health priorities and acceptability of prevention practices has been described previously . This work was conducted at the request of the Government of Vanuatu in order to inform community engagement and health promotion activities to be undertaken by NVBDCP and the MoH.
Challenges to the elimination of malaria in low transmission settings, such as Tanna Island, include the inability to sustain control programs due to community perceptions and practice for malaria prevention and physical and socio-cultural factors that may impact upon treatment-seeking behavior . The consequence of not sustaining elimination is the risk of resurgence of more severe malaria as a result of lowering naturally acquired partial immunity to the disease . Previous studies from Africa and South East Asia show treatment-seeking behaviour for malaria relies on a number of factors including gender; past experience of the disease, health services and treatments; knowledge from others; familiarity with the term malaria and other introduced knowledge [[6–8]]. These factors in turn are affected by health service determinants, such as physical access to facilities, cost of and levels of satisfaction with health centre services; beliefs in, acceptability of and satisfaction with traditional medicines; availability of other treatments at home such as left-over medications; and indigenous interpretations of fever and other malarial symptoms [9, 10].
The success of the global smallpox eradication campaign was dependent on the availability of a vaccine and a successful campaign of surveillance and containment in the context of favorable epidemiological characteristic of the virus, notably a low level of infectiousness . Surveillance consisted of case-finding through systematic searches, improved reporting systems, and active source tracing . This also required a high level of community engagement including identification of smallpox cases and support of affected people to report promptly and appropriately seek treatment, to maintain and sustain long term community surveillance .
Malaria, with no vaccine and relatively less distinct symptomatology compared to smallpox presents a more complex challenge for elimination. Early case detection and treatment relies heavily on an individual's or their caretaker's ability to identify symptoms and access appropriate treatment in a timely manner. Correct diagnosis and access to treatment is important not only for clinical reasons but also for public health purposes to enable the effective design, implementation and evaluation of effective health interventions . Community engagement in active case detection (ACD) for malaria, including accessing appropriate treatment and maintenance of preventative activities, such as utilization of mosquito nets, management of vector breeding sites and continued epidemiological surveillance, is also complex and requires long-term commitment and active participation from communities to prevent malaria re-introduction following successful elimination .
Identification of malaria cases by health staff and community members can be difficult and highly variable due to the absence of distinct symptoms and multiple differential diagnosis possibilities [14, 15]. This, combined with variations in cultural perceptions and interpretations of symptoms, (which may also be held by community-based health staff), have resulted in health promotion for malaria usually focusing on encouraging early presentation for all fever episodes . Diagnosis of malaria-like illnesses has been described in many societies to be subsumed either under one large illness category or several terms based on the different manifestations of the illness [[17–19]]. Vanuatu, with a rich Melanesian history coupled with the archetypal advent of traders, missionaries and colonizers, has its own unique and varied traditions of health and illness interpretation [[20–23]]. These traditions are also prominent within communities of Tanna Island, Tafea province.
Malaria has played a major part in Vanuatu's history and likely influenced population distribution [12
]. In the late 19th
century numerous reports of malarial fever and deaths from missionaries in Vanuatu began to emerge, including a number from Tanna Island [25
]. John Paton, a Presbyterian missionary in Kwamera and Port Resolution South Tanna, from 1858 until 1862, wrote extensively in his autobiography of his struggles with "fever and ague
" (the colonial description of malaria), including the death of his wife and child at Port Resolution from the illness [25
]. As Paton described:
'Unfortunately we learned, when too late, that both houses were too near the shore, exposed to unwholesome miasma, and productive of the dreaded fever and ague, the most virulent and insidious enemy to all Europeans in those Southern Seas.' 
Perceptions about disease aetiology and appropriate treatment are well grounded in the culture, history and traditions of most people [4, 14]. On Tanna, as is the case in many traditional societies of the Pacific Islands, causal events are given a spiritual dimension, such as the breaking of taboos, links to internal emotions, sorcery, spiritual figures and "garden magic" (Traditional belief that rituals of growing crops, types of plants and other objects within small family farms have a link to determining health, illness and misfortune of people, families and communities) . These have all been identified as underpinning health, illness and misfortune [12, 26]. These customary beliefs have been intertwined with Christian belief systems in spite of missionary efforts to encourage movement away from beliefs based on Kastom, the Bislama word used to refer to traditional culture, including religion, economics, art and magic in Melanesia .
On Tanna, people draw a distinction between what they define to be traditional knowledge, practice and object (kastom), and what they perceive as foreign or innovative (nariitoga, foreign thing: narumnarime sei ni-pitoga, things of foreigners) [20, 22]. Although the health facilities (hospitals, health centres and aid posts) which exist on nearly every island of Vanuatu are equipped to provide modern Western models of health care, kastom medicine still thrives, especially on the more remote islands including Tanna . It has been suggested that modern and kastom medicine do not compete with one another; but rather, are used as complementary systems . Traditional healers (also known as 'Clevers') combine plant knowledge with knowledge of the supernatural and operate as true health therapists within their communities [23, 28].
Determining how best to encourage the community to present for early treatment of fever or to participate in ACD (surveillance activities) requires an understanding of indigenous forms and interpretations of the disease that influences decision making processes for treatment-seeking [14, 29]. Tanna Island has a history of entwined biomedical and traditional approaches to health and illness. The impact that this has on early diagnosis and treatment of a target disease - one of the cornerstones of malaria elimination programs - needs further exploration. Particularly, how interpretations of health and illness affects the sequencing of treatment-seeking behaviour within a low transmission setting such as Tanna.
This investigation is Part II of a larger research project examining community perceptions on Tanna Island, Vanuatu of prevention and treatment-seeking behaviour for malaria with community health priorities and acceptability of prevention interventions already described in Part I . The purpose of this study was to explore the social, cultural and spiritual underpinnings of malaria knowledge in Tanna and understand how these beliefs influence treatment-seeking behaviours. Structural barriers to treatment-seeking such as access, cost and availability of health workers and other resources were also explored.