In Cambodia, an estimated 2.65 million people are at risk of malaria . The Cambodian Ministry of Health estimates that 83,777 outpatient and 4,045 inpatient malaria cases were reported in 2009, with this disease accounting for 0.6% of all outpatient cases and 3.5% of all inpatient cases in the same year . Estimated prevalence rates range from 3.0% to 12.3% in malaria-prone provinces, with the epidemiology of malaria varying widely across the country. Prevalence is highest around the tropical forests located on the country borders, covering 60% of Cambodia’s landmass. Parasite prevalence rates vary and are reported to reach 15% to 40% in remote, forested areas, with much lower rates in the plains . In the northeast, malaria transmission is relatively high; the reported annual incidence rate lies between 11 to 50 cases per 1,000 habitants and Plasmodium falciparum, the deadliest strain of malaria, predominates . By contrast, along the western border with Thailand, P. falciparum malaria transmission is generally lower than the northeast and Plasmodium vivax predominates [5, 6]. Malaria transmission risk in Cambodia is associated with the rainy season, typically peaking in August and September. Unlike many areas of sub-Saharan Africa, the highest burden of malaria infection afflicts adults who work and stay overnight in the forests.
The border between Cambodia and Thailand serves as an epicentre of multidrug resistance [5, 7]. Since the 1970s, this area has been the hotspot for the development of anti-malarial resistant parasites; resistance to anti-malarials, including chloroquine and sulphadoxine-pyrimethamine, subsequently spread to other parts of Asia and Africa . In 2009, artemisinin-resistant P. falciparum malaria was confirmed in Cambodia’s Pailin province . Experts believe a number of factors have contributed to the emergence of drug resistance in Cambodia: 1) previously unregulated sales of artemisinin monotherapy; 2) limited access to artemisinin combination therapy (ACT); 3) ACT that are not co-formulated (facilitating continued use of artemisinin monotherapy); and 4) ubiquitous counterfeit and substandard medicines .
Over the past 10 years, the Cambodia National Malaria (CNM) programme has pioneered a number of innovative malaria control approaches, many of which have become accepted as standard practice in malaria-endemic nations. For example, since 2000, CNM has recommended using ACT (artesunate and mefloquine) as the first-line treatment for P. falciparum malaria and chloroquine as the first-line treatment for P. vivax malaria. Before treatment, the National Treatment Guidelines instruct providers to confirm malaria infection through microscopy or a rapid diagnostic test (RDT). In 2008, CNM changed the protocol for treating malaria in districts with confirmed multidrug resistance, switching to dihydroartemisinin + piperaquine (DHA + PPQ), a fixed-dose combination, as the first-line treatment. Under the Resistance Containment Programme, CNM launched multiple initiatives including a ban on the sale of artemisinin monotherapy  as well as community level services to facilitate rapid diagnosis and treatment with the correct first-line anti-malarials . Other national malaria control efforts include the provision of highly subsidized RDTs and ACT treatments in the private sector since 2003, the provision of these commodities for free in the public health sector [12, 13], and regular monitoring of the quality of anti-malarials in both the public and private health sectors at sentinel sites .
Despite these efforts, recent research in Cambodia shows that rates of diagnostic testing and prescription of first-line treatment for confirmed cases remains relatively low among persons with malaria fever. Supply side data from outlet surveys show that the availability of diagnostic tests and the first-line treatment is variable, with higher availability in the public sector, but lower stocking rates in the private sector . As such, when patients seek out treatment for malaria fever, the diagnostic tests and/or the first-line treatment may not be available. In addition, other supply side research has shown that many of the anti-malarials may be sub-standard or fake in Cambodia . Moreover, providers may prescribe unsuitable dosages, incorrect medicines and improper duration of treatment . In addition, household survey data suggest that many people with malaria fever rely on home remedies, such as sponge baths and traditional medicines made from a variety of herbal or plant sources, which they self-administer [17, 18]. This reliance on self-treatment with home remedies may delay patients from seeking proper care. In addition, while nearly half of all Cambodians who seek care for malaria symptoms receive a blood test, patients most commonly received medicines sold or dispensed by health providers as “drug cocktails” when treating these fevers , a finding supported by other quantitative research [11, 19]. Cocktails typically consist of a small plastic bag containing one or more tablets of various medicines including antipyretics, vitamins, anti-malarials, antihistamines and antibiotics .
The widespread use of cocktails creates challenges and dangers for combating malaria in Cambodia. First, as it is the provider who decides on the composition of the cocktail, it is unclear what patients receive in their plastic bags and whether they even receive an anti-malarial. If an anti-malarial is provided, it may be an incomplete dose or an oral artemisinin monotherapy – both of which lead to parasite drug resistance . The variation in the number of cocktail packets bought from the provider adds another threat to combating drug resistance. Even though providers often present multiple packets or pills as a full course of treatment, some patients do not always choose to purchase a full course; factors such as affordability and illness severity sometimes limit the number of cocktail packets that patients buy . For these reasons, Cambodian national malaria control efforts have also focused on increasing consumer awareness of the dangers of cocktail medicines through behaviour change communication (BCC) campaigns.
Efforts to change how Cambodians approach malaria treatment face notable challenges. In general, treatment-seeking behaviour for illness is a highly complex process. Around the globe, people frequently seek multiple sources of treatment and many self-medicate or undergo some type of treatment at home, outside of a medical facility. People also often have specific perceptions of medicines, believing that some are more effective than others. Moreover, specific cultural beliefs, norms and attitudes are likely to influence the treatment-seeking process [21–24]. Numerous research studies, primarily conducted in sub-Saharan Africa, have extensively documented a number of demand-side factors associated with treatment-seeking behaviour, including perceptions about the cause and severity of the illness, quality of care at health facilities, affordability of treatment, proximity of services to patients, and positive manner of the providers [21–25].
In Cambodia, the epidemiology of malaria and the specifics of the treatment environment make the malaria treatment-seeking process vastly different than that found in other parts of the globe, particularly the process in sub-Saharan Africa where most research on this topic has focused thus far. Cambodian adults – specifically forest workers – are most afflicted by malaria, unlike in much of Africa where children under five are most at risk. As a result, caretaking responsibility rests with the individual rather than the caregiver of a young child and access to care is limited, factors which often guide treatment-seeking decisions in Cambodia. Moreover, while self-treatment of fever at home is common worldwide, the practice in Cambodia appears to be much higher than in surveyed sub-Saharan Africa countries . Cocktail medicines are also more commonly used in Cambodia and the Southeast Asia region [11, 20], a negligible practice in sub-Saharan Africa . Finally, malaria treatment practices in Cambodia are complicated by the multiple definitions and cultural understandings of “fever”. Cambodia’s main language, Khmer, uses a variety of terms and definitions for fever such as: fever with chills (krun janh) or hot body (krun ngak) known as “malaria fever”; dengue fever (krun chhiem); or other types of fever or symptoms, such as night fever (krun yop), high temperature (kdao gadow/kdao kluan) or sweating (krung loap). Such variety may further complicate treatment practices.
To date, only a few unpublished papers provide a descriptive picture of the factors that tend to influence malaria treatment in Cambodia [28, 29]. One of these studies, a qualitative study from 2004, suggests that a number of factors influence provider decisions in Cambodia . These include stock outs of test kits and financial incentives to sell medicines rather than test before providing treatment, since a confirmed diagnosis may diminish medicine sales due to negative test results. Results also revealed that patients may prefer to spend money on medicines rather than a test, and may prefer to self-treat based on their symptoms until they become more seriously ill .
To expand the limited evidence base, this study uses qualitative methods to explore the demand-side factors that influence malaria treatment-seeking behaviours and patient-provider interactions among Cambodian patients. It aims to shed light on findings from quantitative research studies and offer programmatic recommendations to increase the uptake of appropriate malaria case management in Cambodia. It asks three key questions: 1) Why do people first treat at home and what types of medicines are used? 2) Why do patients take drug cocktails for malaria and what are their perceptions of these medicines? and 3) Why do some patients with malaria fever receive a diagnostic test while others do not? The study findings aim to provide a more nuanced understanding of the patient-provider interaction at a health facility or outlet where malaria treatment is sought, including a patient’s perception of the provider. Such findings may prove useful in guiding the design of interventions focused on increasing informed demand for effective malaria case management services in Cambodia.