Social Science & Medicine 56 (2003) 701–712

Rapid assessment procedures of malaria in low endemic

countries: community perceptions in Jepara district, Indonesia
Adi Utarinia,b,*, Anna Winkvistb, Fahmi Maria Ulfaa
a
Department of Public Health, Faculty of Medicine, Gadjah Mada University, Yogyakarta 55281, Indonesia
b
Department of Public Health and Clinical Medicine, Epidemiology, Umea University, S 901 85 Sweden

Abstract

Most studies on community perceptions toward malaria have been undertaken in high-endemic countries, and studies
from low-endemic countries have only recently been published. Similar information is also needed for hypoendemic
countries such as Indonesia, to cope with the persistence of foci-endemic malaria in these regions. An applied
qualitative method, Rapid Assessment Procedures, was employed during a 3-month intensive data collection period in
Jepara district, Central Java province. Data were retrieved from 38 free-listings, 28 in-depth interviews, seven focus
group discussions and unstructured observation. Qualitative thematic content analysis was applied. In this community,
malaria (known as katisen or panas tis) was considered a common but minor illness. Insufficient understanding of
malaria signs and symptoms in the subvillages likely leads to delay in illness recognition and treatment; not surprisingly
self-treatment is common and the dosage most likely below the recommended dose. The health center was used but
when it did not work, most people would shift back to traditional services due to cost considerations. Low
understanding and acceptance of the causal link between the mosquito and malaria, likely leading to poor
comprehension of preventive activities, as well as confusion of malaria with dengue fever, were identified. In conclusion,
this study highlights a consistent gap between the common understanding and the biomedical description of malaria. If
case management continues to be the main strategy in malaria control program, the emic perspective of the people
must be well-integrated into the program. Likewise, interventions to improve home-treatment should also be developed.
r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Rapid assessment procedures (RAP); Malaria; Community perception; Indonesia

Introduction (WHO, 1999), special attention to persistent foci of

Malaria is endemically low in Indonesia. Malaria has
been endemic for millenia in Java, the most populated
island in the country. Although Java largely is free from
endemic malaria nowadays, systematic case reporting
over the past 40 years reveals a history of chronic
endemicity where stable malaria persists (Baird et al.,
1996). In light of the worldwide reemergence of malaria
*Corresponding author at Department of Public Health,
Faculty of Medicine, Gadjah Mada University, Yogyakarta
55281, Indonesia. Tel.: +62-274-581679; fax: +62-274-561196.
E-mail address: a-utarini@yogya.wasantara.net.id
(A. Utarini).
endemic malaria is crucial.
This paper reports the findings from a rapid-assess-
ment-procedures (RAP) study on the community, aimed
at exploring knowledge and perceptions of different
aspects of malaria: diagnosis, causes, prevention, treat-
ment-seeking behavior, and consequences. Most studies
on this subject have been undertaken in countries with
high endemicity (see, e.g., Agyepong, 1992; Jayawar-
dene, 1993; Kengeya-Kayondo et al., 1994; Lipowsky,
Kroeger, & Vazquez, 1992). Studies carried out in
hypoendemic countries such as China and the Philip-
pines have only recently been published (see Espino,
Manderson, Acuin, Domingo, & Ventura, 1997; Espino
& Manderson, 2000; Miguel, Manderson, & Lansang,
1998; Miguel, Tallo, Manderson, & Lansang, 1999;

0277-9536/03/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 0 6 6 - 7
702 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712
Tang et al., 1995). More information is still needed to
cope with the persistence of endemic malaria in these
regions.
The study site: Jepara district, Central Java
Early diagnosis and case management are the main
approaches the Indonesian government used to reach an
annual parasite incidence 0.08/1000 population in the
Java and Bali regions between 1997 and 2001. In Central
Java, however, the incidence in 1998 was five-fold higher
than that intended and Jepara has been identified as the
third most endemic district. In fact, in 1996–1997 the
incidence in Jepara (and Purworejo district) was the
highest in the province. With a total population of
866,566 in 1997, the number of malaria-confirmed cases
was 3060, corresponding to an incidence of 3.5/1000
population. Anopheles Aconitus is a dominant vector,
with river, rice fields and irrigation ditches serving as the
main breeding places. The vector showed anthropo- and
exophilic behavior, with outdoor biting preferences
(Yoga, 1999).
Situated on the northern coast of Java island, the total
area of Jepara district is 1004 km2, divided into 12
subdistricts and 192 villages. This district is served by
two hospitals, 20 health centers at the subdistrict level,
41 auxiliary health centers, two entomologists, 21
microscopists and 35 malaria workers. Of all health
centers, Mayong I, Batealit, and Mlonggo II are the foci
of endemic areas, contributing up to 80% of the total
cases in the district (Soedarso, 1998).
This study was carried out in Mlonggo II health center
with a total population of 36,698 in six villages. The
subdistricts Mayong and Batealit were not included in
this study due to an ongoing research project on malaria
in pregnancy, which may have interfered with our RAP
study. The number of confirmed malaria cases in
Mlonggo II in 1998 was 215, with annual parasite
incidence of 5.9/1000 population. The incidence was
higher in males than females (6.9 and 4.9/1000 popula-
tion, respectively) and in those o15 years of age than in
adults (7.1 and 5.1/1000 population, respectively). Cases
were mostly located in three of the six villages—Tanjung
(54.0%), Lebak (27.4%), and Plajan (9.3%). Unlike the
previous years where P. falciparum dominated, in 1998
58% of cases were infected by P. vivax.
Methodology
To gain understanding of the social and cultural
aspects of malaria from an emic perspective, an applied
qualitative method (Rapid Assessment Procedures or
RAP) was employed. This method is characterized by a
relatively narrow focus on a specific health or social
problem, small samples of key informants and respon-
dents, a short period of field research, interview guides
that direct research to specific topics, and multiple
methods of data collection. This study is part of a larger
project combining quantitative and qualitative methods
to examine the user–provider interface in early detection
and case management of malaria in Jepara district. The
RAP is presented in accordance to suggested criteria for
RAP studies in health (Utarini, Winkvist, & Pelto,
2001).
Data collection and field guide
Free-listing, in-depth interviews, focus group discus-
sions (FGD), and observation were used during 3
months of intensive data collection. Free-listing was
performed initially, to understand the pattern of illnesses
in the community as well as the community’s sense of
illness priority, through:
* ‘‘Can you tell me all the illnesses that occur in this
community?’’
* ‘‘If someone has malaria, what do they do?’’
* ‘‘Can you tell me how the community protect itself
from malaria?’’
For free-listing and in-depth interviews, similar
criteria of subject-selection were applied, representing
male and female, adult and youth, caretakers of the
under-fives, pregnant women, formal and informal
leaders, malaria and non-malaria cases, and people of
different occupations. The first three criteria were also
used for the FGDs. Two FGDs were not implemented
due to limited number of participants (pregnant women)
and lack of cooperation and lack of social networks
(younger girls). Group homogeneity was maintained in
terms of age and sex, and those holding any form of
authority in the village were excluded. With the
exception of six interviews, all FGDs and interviews
were tape-recorded. Unstructured observation was
carried out to observe the housing conditions while
conducting in-depth interviews (Table 1).
Table 1
Number of respondents for each data collection method in two
subvillages, Mlonggo II health center
Data collection Landak Gronggong Total
method subvillage subvillage
Free-listing 33 5 38
In-depth 17 11 28
interviews
Focus group 3 groups 4 groups 7 groups
discussion (54)
 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712
A modified version of the WHO RAP manual on
malaria (Agyepong, Aryee, Dzikunu, & Manderson,
1995; see Appendix A) was used for the interviews,
FGDs and observations. Accordingly, the following
themes were explored: symptom recognition, causation,
prevention, treatment-seeking behavior, taboos, conse-
quences, and malaria workers.
Selection of research sites
One village with 5394 inhabitants, Tanjung, was
selected and this village is classified as a high-incidence
area (>5/1000 population). Two subvillages in Tanjung
with the highest endemicity in 1997 and 1998, Grong-
gong and Landak, were selected to obtain maximum
variation of altitude, access to health facilities, trans-
portations, and roads. Gronggong subvillage has 806
inhabitants and represents a highly elevated and hard-
to-reach area, with limited access to health facilities and
public transportation. Most people work in agriculture,
two-thirds share Islam as their religion and the
remainder Buddhism. Some hamlets in this subvillage
can only be reached by foot. Landak subvillage,
occupied by 2340 inhabitants, is in a lowland area with
better access to transportation and health care facilities.
More teak wood industries are located in this subvillage
and most people are Moslem. Coastal areas within
Jepara district were not sampled due to low malaria
morbidity.
Informant selection
Informants were selected by a combination of
tentative lists of informants and the snow-ball techni-
que. A tentative list of informants was used to identify
formal leaders, malaria cases (confirmed by microscopic
examination obtained from health center records), and
pregnant women and caretakers of the under-fives based
on the integrated health post record. Informal leaders
were selected by a combination of tentative lists and
snow-ball technique. FGD participants were recruited
based on sex, age, and if they were caretakers of the
under-fives. In total, the groups consisted of two male-
adolescent groups, one female-adolescent group, two
male-adult groups, and two groups of caretakers of
under-fives. Each subhamlet was asked to select a
number of participants according to the above criteria,
excluding formal leaders, informal leaders, and health
care providers.
Subjectivity and staff
The principal investigator is a Javanese female doctor
with formal training in public health and a special
interest in women’s health (AU). Prior to this study, she
had performed a number of qualitative studies. She
initially spent 6 months in Jepara district. The second
703
author (AW), who guided study design, data collection
and analysis, is a Swedish nutritionist, with experience
using quantitative and qualitative methods for investi-
gating health issues in developing countries. The third
author (FMU) worked as a research assistant and lived
in the area for the length of the study. She is originally
from Jepara and holds a graduate degree in anthro-
pology. All data collection was performed by the first
and third authors using the local language.
Credibility
The trustworthiness of the research was ensured by
the following techniques: methodological triangulation
(multiple data collection methods and investigators),
member checking (discussing results with community
members or malaria workers from whom the data were
originally collected), and reflexive journals (using
personal diary) during the intensive period of data
collection. Prolonged engagement, to improve the
understanding of the context, was possible as the
research assistant lived in the area.
Analysis
Timely analysis and feedback are seen as the most
critical features for RAP to be useful for program
managers. Therefore, qualitative thematic content ana-
lysis was applied (Burnard, 1991) focusing on describing
pre-determined themes of malaria (diagnosis, causation,
prevention, treatment, and consequence) as the frame-
work of analysis and demonstrating the discrepancies at
different levels, i.e. who says what (community vs.
community leaders), what is said and what is done
(knowledge vs. practice), what is done and what should
be done (actual vs. ideal practice). In addition, gender
differences were also scrutinized. Verbatim transcripts
were transcribed from taped interviews and FGDs, using
a word processor, concurrently to data collection
activities. Notes and open codes were generated and
organized manually, and similar codes were grouped
into categories—by the first and third authors individu-
ally. Disagreements were discussed between these two
authors to enhance consistency. Finally, sections with
similar codings were grouped according to the pre-
determined themes and pasted onto sheets.
Ethics
Any one person identified as having clinical symptoms
of malaria was reported to the malaria cadre, village
midwife, paramedics, or the nearest health care facilities
for investigation. Procedures for obtaining verbal
informed consent and ensuring anonymity were
followed. This study was approved by the Ethics
704 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712

Committees of the Faculty of Medicine, Gadjah Mada disappearance of symptoms after taking common cold
University, Indonesia, and Umea University, Sweden. drugs. When asked about malaria or the local terms for
it, none of the participants mentioned mriang or
nggregresi.
Results In the free-listing activity, women were in general able
to identify more types of illnesses than men. Men, on the
Sixty-six respondents were interviewed in the free- other hand, consistently mentioned the terms katisen,
listing and in-depth interviews, including 24 males and panas tis or malaria. The group least able to identify
42 females. The main subgroups were: pregnant women illnesses in the community was the young female group.
(10), caretakers of the under-fives (10), traditional health
providers (6), formal and informal leaders (10), cases or
Diagnosis and terminology used
caretakers of cases (13). According to occupation, eight
respondents in Landak subvillage worked in teakwood
As mentioned, malaria was not a commonly used
industries besides being farmers. All but the adolescent
term. More often, the local terms katis or katisen (cold)
groups in the FGDs were farmers and the adolescents
and panas tis or panas anyep (hot–cold) were used. While
worked in the teakwood industries. Most participants in
the latter two symbolize the hot (panas) and cold (tis or
all data collection activities had between 0 and 6 years of
anyep) phases of the illness, the former two loosely
education.
portray the sense of coldness. Katis was further classified
into four different forms:
‘‘In this community, you have to live with it!’’: Living with
malaria
1. Katis bintang: ‘‘you are healthy today, but tomorrow
Free-listing with many groups in the community, morning you will feel katisen, the next day you will be
validated by FGDs and interviews, revealed a shared healthy, and then you will be ill again the coming
attitude towards malaria as a common although minor day.’’ This term captures the intermittent fever in
illness in the community. Some of the expressions were: malaria. In addition, katis bintang also implies that
‘‘It’s a mild disease, does not get severey people don’t one could predict the time -when ‘‘they are going to
die from malaria’’ (FGD, mothers, Gronggong sub- have the guest (katisen) again.’’
village). ‘‘It’s spread outy, everyone gets malaria, men, 2. Katis sego: ‘‘if you get sick, you should eat lots of
women, the rich, the poor, healer, paramedicsy’’ rice, and you will be cured the next day.’’ This is the
(FGD, men, Gronggong subvillage).
Malaria was not immediately recognized as the most
common health problem by the community (see Table Table 2
2). This was partly due to the term malaria not being Common health problems identified by at least three commu-
nity members from free-listing ðn ¼ 38Þ
well-recognized in the community. In the free-listing,
only more educated men used that term. However, a few Health problems
local terms existed, which were in close agreement with
Javanese-Jepara English literal Number of times
the clinical case definition of malaria. These are katis,
dialect translation reported
katisen, panas tis and panas anyep. If these terms are
combined with the term malaria, malaria may be Katisen/katis Cold 21
regarded as the most common illness by the community Panas Fever 19
members. Except for the young-female group, most Pilek Runny nose 19
participants in the FGDs also felt that malaria was Mencret/diare Soft stools/ 13
common. Information from all three data collection diarrhea
Malaria Malaria 12
methods revealed that malaria was regarded as a
Batuk Cough 12
prevalent health problem especially in Gronggong Pusing Headache 9
subvillage. Rural and high altitude areas were associated Panas anyep Fever, being cold 8
with malaria. Gigi Toothache 7
Participants in the in-depth interviews and FGDs Kulit Skin problems 6
were able to differentiate between malaria and the Pegel-pegel Muscle ache 5
common cold based on their perception of symptoms Panas tis FEVER, feeling 4
and local terminology used. Mriang or nggregesi was cold
used to describe a mild sensation of cold or fever Kuning Yellow 4
without experiencing the stages of malaria symptoms Perut Stomach ache 4
Encok Backache 3
(e.g., cold stage, followed by the hot and sweat stage).
Tipes Typhoid 3
This is further confirmed by runny nose (pilek) and
 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712
mildest form of katis, as it was considered as a self-
limiting disease not needing any interventions.
3. Katis gepok sirah: This type of headache (gepok
sirah), i.e., throbbing, severe headache with watery
eyes, was seen as the most severe symptom of
malaria.
4. Katis ndrodog: Ndrodog represents chills during the
onset of malaria and was also considered as hard to
cope with, as illustrated in the quote ‘‘you won’t feel
anything even if you were beaten up by someone’’.
When people were asked about the consequences of
malaria for their family, most people said that they
were still able to carry out normal activities, except
when experiencing ndrodog.
All four forms of malaria were commonly described in
Gronggong subvillage, whereas all but katis sego were
described in Landak subvillage.
In Fig. 1, the overlap in meaning among the terms is
illustrated. Patterns emerged based on severity and
contagiousness. In general, panas tis and katisen were
associated with less severe and less contagious forms of
malaria. Malaria, on the other hand, can be more severe
and was frequently associated with mosquito as a vector.
Among the three terms used, the term malaria suggested
a wide variation of meaning, unlike panas tis and
katisen. In addition, the terms were linked to treatment
sought. Panas tis and katisen were regarded as illnesses
that could be self-treated, perhaps because they were
seen as less severe. Malaria, in contrast, was seen as
requiring consultations with both traditional and
modern health providers.
As illustrated in Fig. 1, panas tis and katisen were
often used interchangeably, unlike panas tis and malaria.
The recognition by some of katis malaria as a form of
severe
katisen
less severe
panas tis
less contagious
Fig. 1. Interrelations among katisen, panas tis, and malaria.
705
malaria illustrates the overlap between katisen and
malaria. ‘‘The term malaria is used by them (health
providers), we call it katisen.’’ The following examples
further illustrate the confusion in terminology:
Katisen is the same as panas tis and malaria. The term
katisen is used when referring to adults, whereas
panas tis is used when referring to children and
among doctors (FGD, male adolescent, Landak
subvillage)
Panas tis is a more severe form of katis with chills as
the main symptom (FGD, men, Gronggong sub-
village)
Katisen differs from malaria. Katisen malaria is the
same as malaria (Interview, pregnant women, Land-
ak subvillage)
You only experience fever in panas tis, but in katisen,
it’s not just fevery We have never heard of malaria
(FGD, female adolescent, Gronggong subvillage)
Malaria is a symptom of katisen (FGD, mothers,
Gronggong subvillage)
‘‘Everyone will get malaria, it’s just a matter of time’’:
from causation to prevention
Even though the community did mention the mosqui-
to as a vector of malaria, the causal link between
mosquito bites and the disease was not well-understood
(‘‘Nobody has katisen even though there were lots of
mosquitos’’). Observations of house structures and
indoor conditions as well as probing during the in-depth
interviews about the use of bednets further illustrate this
malaria
contagious
706 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712
lack of understanding:
Interviewer: I can see that you have bed-nets at home.
Why do you use it?
Respondent: My son is in school. If there are
mosquitoes, he won’t have a good sleepy If there
are lots of mosquitoes, he would scratch and kill the
mosquitoes, so that he won’t have a deep sleep.
(Interview, woman, Landak subvillage)
Some villagers recognized mosquitoes as the cause of
malaria. In addition, other causes were suggested, e.g.,
lack of hygiene, certain types of food, an empty
stomach, tiredness, flies and spirits. Common responses
also included ‘‘don’t know’’ as well as faith (takdir),
because people perceived the illness to ‘‘occur very
suddenly’’.
In the rainy season, most villagers go to the forest,
they get wet, tired, and feel katisen. You feel katisen
directly. It’s not because of mosquito bites. (Inter-
view, man, Landak subvillage)
Other than from mosquito bites, it’s also from the
foody maybe their hands are still dirty when they
eaty, lack of hygiene, when they are at school, they
play with dirty and they eat without washing their
hands. (FGD, men, Landak subvillage)
Katisen is different from being possessed y the spirit
does not speak, it wants a treatment or an offering.
The difference between panas tis and katisen is caused
by different spirits. (Interview, man, Landak sub-
village)
When mosquitoes were mentioned, mosquito bites
were not necessarily implicated. Sweat, in relation to or
independent of the mosquito as a vector, was one
common explanation of malaria transmission:
[Mosquito] is the ‘‘seed’’ of malaria. The mosquito
touches the skin and the sweat of the malaria person,
then the mosquito goes somewhere else and transmits
the diseasey (Interview, man, Landak subvillage)
If someone who has the same sweat visits a malaria
person and touches or massages the ill person, the
person could also get malaria. But if the person
doesn’t have the same sweat, he/she won’t get the
disease. (Interview, pregnant woman, Gronggong
subvillage)
Lack of understanding of the causal link between
mosquitoes and malaria leads to poor comprehension of
preventive activities: ‘‘If it is the season for malaria,
nothing that you do will make any differencey nothing
will work.’’ Commonly, ‘‘don’t know’’ or ‘‘none’’ were
the responses concerning prevention in the free-listing
(12/38), FGDs and interviews; particularly in the remote
areas of Gronggong subvillage, where people associated
malaria less with mosquitoes. Often, prevention was
confused with treatment: ‘‘Blood taken by malaria
workers to reduce malaria,’’ ‘‘take pills,’’ ‘‘get injec-
tion,’’ ‘‘white drug for the whole family to prevent
transmission.’’
Ideas concerning malaria prevention only emerged
after direct probing about on preventing mosquito bites.
Suggestions included activities to reduce the mosquito
population (cleaning the environment, stagnant water
especially during the wet season, water containers,
garbage, and spraying), and to prevent mosquito bites
(covering the body well, repellent, bednets, killing
mosquitoes). The importance of reducing the breeding
sites of mosquitoes by having a clean environment was
presented as a general idea to prevent malaria.
In Jepara, the mosquito population varies according
to the season. The rainy seasons and harvest periods
(dami rubuh) were associated with many mosquitoes.
However, mosquito density was not interpreted as
causing malaria unless the mosquito was the ‘‘malaria
type of mosquito’’. The community associated mosqui-
toes to a larger extent with dengue fever—a disease with
higher mortality in the area, common among children,
and which received greater attention at the national
level. ‘‘Cleaning the environment, stagnant water, you
knowy like those mentioned on television. Every
afternoon I tried to empty water containers in the
garden, and I don’t hang too many clothes’’ (Interview,
woman, Landak subvillage). Tablets put in wells or
water containers were also mentioned.
Several food items were considered taboo because
they were believed to be associated with malaria,
although the mechanism was unclear, e.g., sour food
(young mango, fermented rice), hot and spicy food, ice,
watermelon, cucumber, coconut water, and certain types
of banana. Some explanations were suggested from the
FGDs and interviews, e.g., watermelon interfering with
injection due to its watery consistency, sour food
working against vitamins, the effect of fertilizers,
cucumber reducing the blood (therefore, also used for
hypertension), and feeling of coldness (‘‘it speeds up the
disease and the disease gets severe’’).
Other traditional preventive measures existed in
parallel, e.g., eating vegetables, drinking herbs, getting
a massage, resting, or doing nothing. Massage and
enough rest were remedies for tiredness, which was
regarded as a cause of malaria.
‘‘Injection or finger injectiony’’: treatment and
treatment-seeking behavior
According to all data collection methods, the follow-
ing actions were taken by the community in case of
malaria: no actions, self-treatment (using both modern
and traditional medicine jakamantra), and consultations
 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712
(to traditional healer, katisen healer, malaria worker,
midwife, paramedics, doctor, health center, or hospital).
A mixture of very traditional practices (‘‘specially
treated’’ water, herbal drinks, massage) up to very
modern ones (pulver, tablets, and injection) were used
by the community. Use of traditional practice was more
common in areas with limited access to over-the-counter
drugs, e.g., in Gronggong subvillage.
Self-treatment was commonly the first resort, either
by buying drugs from a kiosk or using left-over
prescriptions. This was confirmed by different data
collection methods. The common drugs used were
common cold drugs (antipyretics and analgesics), anti-
malarials (chloroquine, sulfadoxine-pyrimethamine),
and drugs for muscle and joint aches (non-steroidal
anti-inflammatory drugs). In some areas in Gronggong,
access to antimalarial drugs (e.g., Sidar, the local term
for Fansidar) was only possible through a mobile street
vendor (i.e., usually a woman carrying a basket on her
back and selling vegetables, spices and other food items
door to door). Sidar used to be consumed frequently and
widely distributed, but was no longer provided because
the government had restricted it due to earlier inap-
propriate dosage.
Before the presence of malaria workers, we used to
buy Fansidar and it worked. Now, Fansidar is
abandoned by the government. It is available at
shops, but you cannot buy it openly. (Interview, man,
malaria case, Landak subvillage)
N [chloroquine] and Fansidar tablets were sold out
quickly in the malaria season. I told them to buy one
or two tablets as suggested. Don’t take many tablets
at once, it causes chills, take one a day. (Interview,
woman, Gronggong subvillage)
When self-treatment did not cure the illness, consult-
ing health care providers (at a private clinic, a health
center, or the hospital) was the next logical step. Timing
of consultation varied. Some would wait between 1 and
3 days before going to a health center. Alternatively,
people used other determining factors such as ‘‘if the feet
are cold and the head is very hot’’ or when the disease
was perceived as severe (katis gepok sirah). The
dynamics between traditional and modern medicine
were still visible when the health care facilities could not
cure the disease; this was regarded as the time to shift
back to traditional practices. If this also did not work,
people would rarely seek further treatment at hospital;
this was especially true for people in remote areas. ‘‘y if
the soul wants to go, it will go; if the disease wants to go,
it will go.’’
For many people a consultation with the health care
provider was simply described as ‘‘getting an injection.’’
In both the free-listing and interviews, injection was
equally suggested by men and women (in total 11
707
individuals out of 38). This was often cited as the
primary reason for people seeking care in public and
private facilities. Apparently, injections were more
widespread in the private practice of paramedics.
The role of malaria workers in treating malaria was
acknowledged and this was further described as ‘‘finger
injection’’ by participants of FGDs. However, finger
injection was not considered as a treatment, as the
purpose was ‘‘to get the blood checked’’. The task of
malaria workers was then described as ‘‘someone had
fever-cold y the malaria workers came, took blood
from the finger and gave pills. Often he conducted
household visits asking who has fevery’’
The effectiveness of malaria workers in treating
malaria was often described as jodo-jodo-any or ‘‘if it
suits youy’’ Conflicting opinions occurred: ‘‘Injections
will not cure the disease if you don’t seek malaria
workers.’’ ‘‘The needle was used for many people, he
doesn’t use a new one for other people. This can
transmit malaria. If the needle used for a malaria person
is used for a healthy person, the healthy person can get
ill’’ (Interview, woman, Landak subvillage).
The notion of preference, as it is often used to explain
health-seeking behavior, is not the only factor to
determine the behavior. Often, ‘‘try them and see which
one suits you’’ was mentioned among people using
traditional medicine in conjunction with modern treat-
ment. When the disease was seen as related to faith,
treatment effectiveness was affected.
I took many pills. She bought different pills, I took
them all, but it stayed the samey. Even if I had 21
injections, if God doesn’t cure me, I’m not cured.
(Interview, man, Landak subvillage)
If he (the Prophet) says I give you this disease for
seven days, then even if you seek treatment every-
where, it won’t get cured until after seven days. If the
person doesn’t believe in God, he/she won’t be cured.
(Interview, man, Landak subvillage)
‘‘Two goats at leasty’’: consequences of the illness
‘‘What happens if you don’t go for treatment?’’
The response to this question revealed the following
understanding of the disease development: Katisen-
malaria-turn yellow-typhoid. Malaria fever was
differentiated from typhoid on the basis of its inter-
mittent pattern of fever. ‘‘In typhoid, the fever was
consistently high for many days.’’
Persons suffering from malaria were regarded as
temporarily disabled. Absence from work was not
necessary; in fact, work was sometimes considered a
treatment for malaria (‘‘you will sweat, and then feel
better’’). However, normal activities were possible when
people were in the ‘‘healthier period,’’ i.e., in the absence
708 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712
of katisen symptoms or chills. When women were asked
about their domestic responsibilities when they had
malaria, most of them said that they were still able to
perform all tasks when they felt ‘‘healthier’’. However, if
they could not carry out some housework, their
husbands would help. ‘‘Here, most men know how to
cook.’’ Sometimes, work was necessary also outside the
‘‘healthy period,’’ and this could be more hazardous:
‘‘Recently, when I was herding my sheep on the hill, I
had katisen, and I tumbled down the sheltery. No one
was around’’ (Interview, woman, Gronggong subvil-
lage).
When the illness gets severe, its impact on the family
cannot be underestimated. For agricultural laborers,
having cash at home may be a luxury. In this case,
selling their assets is unavoidable, as shown in the
following narratives with a Gronggong villager:
Interviewer: How many days are you not able to
work?
Respondent: You can never be sure of that y some
are severe, some are not.
Interviewer: If you were ill for a week, would you
spend as much as the price of one goat?
Respondent: That’s not enough! Two goats at least
and this is only for the injection, not for travely
(Interview, man, Gronggong subvillage)
Discussion and conclusion
RAP methodology
RAP offers several advantages compared to cross-
sectional surveys in evaluating indigenous knowledge,
attitudes, and practices re. health-related issues. The
main strength of RAP is its ability to reveal the emic
perspective (what people know about a health issue and
how they understand it) in a short period, as opposed to
checking people’s understanding of ‘‘what we know’’
(the biomedical description of health problems) in
surveys. With respect to health education interventions,
RAP is mostly useful in designing the intervention,
whereas surveys may be used to evaluate its coverage
and impact.
Further, RAP has advantages over in-depth qualita-
tive studies thanks to its capacity for generating
information on a particular health issue in a relatively
short period of time. The trade-off, however, is less
opportunity to take full advantage of the emergent
design. In this study, emergent design was partially
implemented by taking advantage of the sequence of
data collection activities and by conducting the analysis
concurrently to collecting the data. Also, this weakness
can partly be overcome by methodological and investi-
gator.
Overall, data collection was carried out in six and
four weeks in Landak and Gronggong respectively.
However, these differences likely did not influence the
quality of information obtained, as Gronggong villagers
had less variation in their descriptions of malaria.
Saturation was reached sooner in this area. Great
attention was also given to avoid the elite bias by
including people of different socioeconomic back-
grounds and different occupations, as well as from
isolated houses.
Only subvillages with high incidence were sampled.
Our study aimed to describe community understanding
of malaria in areas of high endemicity in a country of
low endemicity. It is likely that including subvillages
with low incidence would not reveal a different
‘‘culture’’ of malaria. Comparison between high- and
low-incidence areas was reported in two studies. A study
carried out in Purworejo district, Central Java province,
showed that differences in community perceptions of
malaria between high- and low-incidence villages were
due to the fact that the low-incidence village had easy
access to a health center, low demand for malaria drugs,
and used to have high incidence (Mukti, Triratnawati,
Hadi, Hartini, & Tjokrosonto, 2000). Similarly, in
Thailand, treatment-seeking behavior in a moderate-
and high-transmission area differed due to different
accessibility to the health center as well as to private
clinics (Kamolratanakul, Dhanamun, & Thaithong,
1992). In both studies, most people had a good
understanding of malaria symptoms but were unclear
about the nature of its transmission.
Lastly, a longitudinal health-seeking behavior study
followed the RAP study. This prohibited us from
providing a complete feedback to the district health
office and health centers, as this may have affected the
care seeking pattern. However, a general feedback was
given to raise awareness of the issue. As a result, a
survey on knowledge, attitudes and practices re. malaria
was initiated (Feries, Yunanto, & Umrotun, 2000),
which supported many of our findings.
Policy implications for malaria control program
In Southeast Asia, early diagnosis and prompt case
management is an effective approach to malaria control
(Greenwood, 1997), while biological and environmental
controls are very cost-ineffective (Miguel et al., 1998).
Its success in Indonesia, however, requires interactions
between the community and malaria workers or health
providers. This study explored the community’s under-
standing of malaria.
This study shows that the community has been
exposed to the term malaria, concurrently with the local
terminologies based on perceived signs and symptoms
 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712
(katisen, panas tis, and malaria). In Gronggong
subvillage, however, different categories of illness were
found and these are still used. Because this subvillage is
in a remote area with limited health facilities, its
community may be less exposed to the modern under-
standing of malaria, and consequently, local categories
of illness may be more prevalent than is the case in
Landak. When confronted with the local terms found in
Gronggong, the Landak villagers responded, ‘‘we used
to say that y’’ Studies from other countries have also
found vernacular terminology for malaria. These terms
may be associated with the perception of signs and
symptoms (e.g., in the study by Kengeya-Kayondo et al.,
1994), but can also have to do with classifying malaria
according to types of parasites (e.g., in Espino et al.,
1997; Miguel et al., 1998), the organ affected (e.g., in
Espino et al., 1997) and the severity (malaria and
cerebral malaria in Espino et al., 1997; Winch et al.,
1996).
Different understandings of malaria signs and symp-
toms may in turn lead to delay in illness recognition and
treatment. This problem was reflected by the gameto-
cytes found in 288 (23.8%) of all malaria cases between
1994 and 1998 in the Mlonggo II health center records,
indicating delayed treatment by about 10–15 days
(Utarini, Soedarso, Nystrom, & Chandramohan,
2001). The existence of gametocytes was more common
in Gronggong subvillage; not surprisingly, self-treat-
ment was frequently used in this subvillage.
Similar to findings from Ghana (Agyepong, 1992),
comparisons of knowledge among subgroups across
subvillages in Jepara revealed that young women were
unaware of health problems in general and malaria in
particular. Even so, the annual parasite incidence of
those below 15 years of age in the Mlonggo II health
center records was relatively higher than that of the
older age group (Utarini et al., 2001).
In as much as malaria is regarded as a cold type of
illness in Jepara and Purworejo districts (Mukti et al.,
2000), cold food such as sour food, watermelon,
cucumber, ice and coconut water are prohibited because
they do not balance the body’s internal temperature.
Instead, heat-producing interventions such as herbal
drinks or body massage are seen as remedies. This
suggests the role of humoral beliefs in the treatment of
malaria locally (Helman, 1994).
Consistent with findings in other studies, self-medica-
tion with modern medicine at home was usually sought
prior to seeking formal treatment, regardless of the use
of traditional treatment (Espino et al., 1997; Espino &
Manderson, 2000; Lipowsky et al., 1992; Miguel et al.,
1999; Mwenesi, Harpham, & Snow, 1995; Snow, Peshu,
Forster, Mwenesi, & Marsh, 1992). Even though fever
illnesses (including malaria) are to require immediate
action, studies have rarely shown the use of formal
health services as the first resort for self-diagnosed
709
malaria. An exception, however, was found in a study
conducted in Kenya by Munguti (1998), where public
health facilities were the first choice of care because of
their perceived effectiveness in malaria treatment. In
Jepara, only if the malaria does not respond to home
therapy or if it is perceived to present unusually, then—
subject to available resources—the villagers would
consult the health center.
Self-treatment may become a public health hazard
depending on the type and dosage of antimalarials
consumed. In Jepara, drug resistance to chloroquine is
currently not a problem. Chloroquine is commonly
available without prescription at the pharmacy or at the
grocery, and even Sidar can be ordered from street
vendors in remote areas such as Gronggong subvillage.
The dosage is determined individually based on disap-
pearance of symptoms and general well-being. It is most
likely to be below the recommended dose, due to lack of
information (as in the case of self-treatment) or poor
compliance. The rationale for the low dose is provided
by Bruce-Chwatt (1985): ‘‘For a semi-immune patient
with an acute attack, a single-dose treatment of 600 mg
chloroquine (4 tablets) can suppress the symptoms and
lead to clinical cure.’’
The decision to use formal treatment is affected by
perceived effectiveness of treatment and cost. In
Indonesia, it is common for patients at health centers
to receive one or two injections (Dwiprahasto, 1998;
Grace, 1998). With respect to cost, our study showed
that direct and indirect costs of malaria treatment
among people in remote areas can be substantial. As a
result, health care services often are used at a later point
in the development of the illness, and when these do not
provide relief, the community will shift back to
traditional services. A study in Ghana showed that for
a fever case, indirect costs incurred from seeking and
obtaining care represented as much as 79% of the total
cost (Asenso-Okyere & Dzator, 1997).
With the continuous role of self-treatment and shops
as source of drugs, lack of policies restricting antimalar-
ial distribution, and low government funding to pay
malaria workers to act as the backbone of a malaria
surveillance system, achievement of malaria control in
Jepara is likely to become more complicated in the
future. Some examples of the current trends are the
increase of P. vivax in Jepara district requiring a 5-day
presumptive treatment and five to 14 days of radical
treatment (hence, with more problematic compliance),
and the problems of late detection mentioned earlier
(Utarini et al., 2001).
Community acceptance and understanding of the role
of the vector may also be a contributory factor. Our
study found a lack of understanding of the causal link
between the mosquito as the etiological agent, the
mosquito bite as the mode of transmission, and
malaria as an outcome. Studies exploring community
710 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712
perceptions of malaria in different regions (e.g.,
Africa, Southeast Asia, Latin America, and China)
support our finding of this low understanding irrespec-
tive of study design, level of endemicity, or the existence
of health education intervention (Agyepong, 1992;
Aikins, Pickering, & Greenwood, 1994; Alilio, Eversole,
& Bammek, 1998; Kamolratanakul et al., 1992; Ken-
geya-Kayondo et al., 1994; Lipowsky et al., 1992;
Miguel et al., 1999; Miguel et al., 1998; Munguti,
1998; Shein et al., 1998; Tang et al., 1995; van
Geldermalsen & Numochiveyi, 1995). Even if the
reasons for an intervention are not well-understood,
this does not necessarily lead to poor compliance. In five
West African countries, where only half of the
respondents considered mosquitoes as the cause of
malaria, people still frequently used bed nets due to
the sociocultural value of bed nets in their society
(Aikins et al., 1994).
The lack of understanding of the mosquito-malaria
causal relationship can impede control programs in such
a way that preventive measures could be unacceptable to
the community. Behaviors against preventive activities
are well-known (Lipowsky et al., 1992; Masendu, Sharp,
Appleton, Chandiwana, & Chitono, 1997; Miguel et al.,
1999). In Colombia, aggressive behaviors existed, such
as refusal to spraying the home and hostility towards the
spraying brigades (Lipowsky et al., 1992). The fatalistic
view which puts that ‘‘nothing can be done to prevent
malaria’’ and ‘‘any action of avoidance is futile’’ has
been documented in Central Java, Indonesia (Mukti
et al., 2000) and Liberia (Jackson, 1985). Further,
studies have found the opinion that malaria forms an
integral part of life and therefore ‘‘it can strike anybody
at any time y’’ (Agyepong, 1992; Lipowsky et al.,
1992). Both these views are common also in Jepara
district, leading to perceived low effectiveness of
preventive measures and a lack of felt individual
responsibility for prevention. As malaria workers men-
tioned in Jepara, ‘‘when they [the community] speak of
dengue fever, they worry about the disease, while for
malaria, it is us [the health officials] who worry a lot.’’
This quote further reflects the competition between the
two diseases, especially in areas with a high case fatality
rate for dengue fever, such as Jepara district. Strategies
to prevent dengue fever (e.g., emptying water containers
and putting tablets in wells in order to reduce A. Aegypti
larvae) were mistakenly seen as prevention against
malaria. In Jepara, case fatality rate for dengue fever
was 2.8% in the year 2000 (Jepara District Health
Office, 2000). Due to its fatal consequences, health
education messages for dengue fever have been extensive
in Indonesia using different medias (leaflets, television,
radio, etc.). This is in contrast to malaria, where a poster
containing signs and symptoms of malaria was simply
distributed in the study area. As has been found in many
other studies, malaria control in Jepara is expected by
the community to be the sole responsibility of the
government (Alilio et al., 1998; Winch et al., 1996).
These examples illustrate the confusion between malaria
and other diseases as well as a consistent gap in
perceptions between health providers and the commu-
nity.
This study demonstrates a low understanding of
malaria in the endemic areas in Jepara district. It
also highlights the consistent lag between community
understanding and biomedical description of malaria
signs, symptoms, causes, prevention, and treatment. If
early diagnosis and case management continue to be the
main strategy for the malaria control program, then
integration of perceived understanding of the commu-
nity into the program is critical. The need for such
integration will be even more important if the future
policy of malaria surveillance is to be shifted into
passive case detection. The content of health education
interventions targeted at illness recognition and prompt
treatment should incorporate traditional beliefs so that
the community is aware that their perception is
acknowledged. Similarly, although there are disadvan-
tages to the current practice of home treatment
using modern medicine, its existence cannot be ignored.
Rather, this should be integrated into the existing
system by the development of interventions to improve
home treatment. Finally, this study also suggests a
limited role of prevention and vector control due to
lack of understanding of the vector in the commun-
ity; hence, low acceptability and misconceptions be-
tween the community and health providers. Unless these
misconceptions are clarified and resolved, the role of
vector control in malaria control programs may suffer.
This further underscores the importance of early
detection and case management in areas of low
endemicity.
Acknowledgements
We acknowledge the Swedish Foundation for Inter-
national Cooperation in Research and Higher Educa-
tion (STINT) and the Research Training Grant of the
WHO Tropical Disease Research program for financial
support. Without a sincere cooperation from the
community of Mlonggo subdistrict, the staff and
malaria workers of the Mlonggo II health center, and
the staff of the Jepara district health office, this project
would not have been possible.
Appendix A
Rapid assessment procedures for malaria is shown in
Table 3.
 A. Utarini et al. / Social Science & Medicine 56 (2003) 701–712 711

Table 3 Table 3 (continued)

Rapid assessment procedures for malariaa
3. Acceptability and use of impregnated bednets
I. Introduction 4. Where there are no nets
1. Malaria as a public health problem 5. Assessing use and acceptance: spot checks and
2. Social aspects of malaria spot observation
3. The mosquito and the environment
a
4. Epidemiological and clinical aspects Adapted from Agyepong et al. (1995) to Jepara district.
5. Clinical presentation of malaria
6. Chemotherapy of malaria
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