This study is the first to investigate the KAP on malaria in Peninsular Malaysia, which is directly essential to enhance community awareness of malaria. Findings of the present study indicated that there were significant differences between the aboriginal and rural communities in terms of their knowledge of malaria transmission, practices in treatment-seeking behaviour and their understanding of effective preventive measures. This could be explained by the better educational level and the higher number of health facilities reported among the rural population. In addition, cultural beliefs and traditions about diseases among the aboriginal population in the remote areas may contribute considerably to their poor knowledge of malaria. Generally, aboriginal people attribute diseases to ghosts and evil spirits, and this study found that more than one third of the sick aboriginal people normally consulted herbalists or sorcerers who provided remedies and rituals to fight the evil spirits.
The present study also reported many mistaken beliefs about the disease particularly in the aboriginal areas where a large number of the participants demonstrated a misconception about the transmission of malaria. This emphasizes the need for effective intervention to improve the level of knowledge in this community. A noteworthy number of participants believed that malaria is transmitted by stagnant water, walking in the forest, from human to human and nor others. Although most of the participants associated malaria with mosquito bites, none of them knew that Plasmodium is the causative agent responsible for malaria nor how mosquitoes acquire the parasite. The role of mosquitoes in malaria transmission was known to 50% and 70.7% of the aboriginal and rural participants, respectively. This figure was lower than that reported in Swaziland (Southern Africa), a country earmarked for malaria elimination . Accordingly, it is clear that the lack of knowledge, among the target population, about the aetiology of the disease as well as the role of mosquitoes in causing malaria may create an additional burden and costs for controlling the disease and may cause the failure of the malaria elimination programme.
Education plays an important role in people's perceptions and practices of treating and controlling malaria. Previous studies from Africa showed a positive correlation between the number of years of formal education and the perception of environmental management and use of bed nets to prevent malaria, and use of chloroquine to treat malaria [7, 8]. Moreover, as the number of years of formal education increased the perception that herbal medicine could be used to treat malaria decreased . In harmony with these findings, the present study showed that the better educational level of the rural community reflected a better knowledge of practices in malaria treatment and prevention than the aboriginal community. In addition, the level of education showed a significant impact on the population's KAP on malaria at the community level.
The findings of this study showed that most people in both communities had information about the symptoms of malaria and more than three-quarters of the participants recognized fever, chills/rigors and headache as most common symptoms. This was in agreement with the previous studies in tropical and subtropical malaria endemic countries [9, 10]. It should be noted that a considerable number of participants in both communities showed confusion between the symptoms of malaria and dengue fever which is also endemic in these areas. However, this may not affect the disease control in terms of mosquito control, but it may lead to serious complications in patients who believe that dengue fever can be cured by taking antipyretics and drinking fluids .
Promising results about treatment-seeking behaviour were reported; almost all the rural participants and two-thirds of the aboriginal participants seek treatment at health centres within 24 hours of the onset of symptoms. Previous studies in rural areas in Southeast Asia showed that more than half of the population opts for self-treatment without visiting a health facility [12, 13]. The better behaviour reported by the present study could be due to the availability of health facilities and access to their services to all Malaysians throughout the country. Most of the aboriginal people who use medicinal plants and believe in witchcraft as a treatment for febrile diseases go to health centres for treatment, either within 24 hours while at the same resorting to those exercising those practices to support the modern treatment or within 48-72 hours waiting for the outcome of traditional recipes for a short period of time and then seeking treatment from the health facilities. Waiting until the disease has worsened, and a belief that febrile diseases resolve spontaneously are among the reasons for not seeking modern treatment on the day of fever onset .
Regarding the understanding of the measures for the prevention of malaria, the present study showed that most of the participants were aware that malaria can be prevented. However, many misconceptions about malaria prevention measures were reported. In both communities, more than one-third of the participants do not use bed nets to prevent mosquito bites. This could be due to the reliance of these populations on the government in fighting the disease without taking enough personal precautions. The poor usage of mosquito bed nets might also be attributed to the cost and to the lack of knowledge that mosquitoes are the causative agents of malaria [15, 16]. The comparison between the forest-aboriginal and rural communities is of great benefit to determine the nature of the adaptations required in the plan for future intervention. Public awareness programmes to promote a better understanding of malaria transmission and the active participation of the aboriginal communities in malaria control activities are deemed necessary. Such awareness and participation will bring about positive changes and adaptation in their cultural beliefs and practices and this can help in reducing the incidence of malaria.