The first major theme noted from the research data was social disparities in health in rural communities. Within this theme are five subthemes: (i) water access challenges increase malaria risk in rural areas; (ii) impact of limited access to electricity on malaria prevention in rural areas; (iii) unequal internet access in rural areas poses health risks; (iv) limited access to healthcare and resources in rural areas hinders malaria control; and (v) the neglect of community concerns, lack of policies and capacities that hinder malaria control. The next major theme is the livelihood challenges to malaria prevention due to local socio-economic structures and practices followed by environmental degradation and malaria risk in rural communities (Additional file 3).
Theme 1: Social disparities to health in rural communities
Subtheme: Water access challenges increase malaria risk in rural areas
Across communities, participants revealed that even though water pipes are present, treated water is not continuously supplied, resulting in limited access to water throughout the villages. Unfortunately, this issue could considerably increase the likelihood of malaria transmission due to mosquito exposure. A faith leader explained,
“People whose houses have piped water also have persistent water supply issues. Villagers have to seek a water source at the streams and rivers. There are many mosquitoes there. How do we avoid malaria?’’ [Faith leader, IDI05].
Furthermore, the participants from Kampung (Kg) Membatu Laut explained that since the lack of water has been ongoing for a long time, the communities have put effort into creating a water supply through a water gravity system, which has its main source point located in the forest. The gravity water requires a strong water current to supply to the houses. However, the system has limitations, as the supply issue remains when a house is far from the main water point. During the in-depth interview, a pastor noted however,
“Even though there is a gravity water system, when the water source is not strong, and many people are using the water, there are times when the supply is not enough for everyone.’’ [IDI05].
To address the lack of water pipes, participants from Kg Paradason revealed important insights and discussed “lokos”, a local term describing the water source in the forest, similar to a spring. Villagers are required to walk for almost 20 to 30 min to get to the area. They also pointed out that the area around the “lokos” and surrounding small ponds had many mosquitoes and larvae, making access to these areas a health risk (Fig. 2).
Subtheme 2: Impact of limited access to electricity on malaria prevention in rural areas
Participants from Kg Paradason drew attention to the critical issue of electricity supply in their village, which related to being able to control mosquitoes. Participants shared their experiences of constantly being surrounded by mosquitoes inside and outside their homes due to the dense forest covers that block out sunlight even during the day. This dark environment provides ideal conditions for An. balabacensis mosquitoes to fly indoors and bite humans, and return outside to rest . A female participant, who had lived in the area for over 30 years, expressed her concern:
“Our houses would be illuminated if we had access to electricity. However, unfortunately, we do not have electricity, and as a result, mosquitoes find their way inside our homes. It always feels like we are living in perpetual darkness here’’ [FGD P2] (Fig. 3).
Subtheme 3: Unequal internet access in rural areas poses health risks
Participants across all study sites described the inconsistency of communication signals in their villages due to the inaccessibility of internet lines, leading them to travel into areas where mosquitoes are present, which in turn put them at higher risk of malaria. This limitation leads villagers to search for “line hotspots” in various locations, such as near the forest, in the plantation area, or on the hills, for instance, in Kg Membatu Laut, villagers have sometimes been able to get an internet signal from Pitas, a district located on the right side of Kudat and separated by Marudu Bay (see map in Fig. 1).
They added that schools and workplaces were closed during the pandemic when movement restrictions policies were implemented in Malaysia. People, including schoolchildren, were at risk of malaria while searching for internet lines to attend classes. Adults were also affected while searching for access to be online for personal reasons. Despite the presence of line substations in or near the village, the signals were weak or sometimes unavailable, forcing them to travel into areas at higher risk of malaria. A village administrative officer described it this way,
“Some houses in certain areas around the village have no internet lines, even though there are substations nearby on the left or right side of the house’’ [IDI09].
Subtheme 4: Limited access to healthcare and resources in rural areas hinders malaria control
The participants noted that a major concern was the absence of a hospital in their villages. The nearest district hospital, without a specialist, is located around 30 to 40 min away by car (estimated 15 km). Primary healthcare services and malaria control were provided by a clinic located in Kg Lotong. However, participants expressed their worries that some people in the village might have difficulty seeking malaria diagnosis and treatment due to the distance to the healthcare facilities from home, time limitations, and unavailability of transport or assistance to send them to the clinic. A pastor from Kg Paradason stated,
“Do you know it is difficult for the villagers to visit the clinic? Some people do not have transport. The clinic is far. When it rains—it makes it more difficult. People could not walk there. The people must think about who will take care of the children if he or she goes to the hospital. So people will stay home and not go to the clinic.” [IDI05].
Additionally, participants described their challenges in obtaining new bed nets and explained that limited resources at the clinic could delay the distribution of bed nets to villagers. One female participant from the village shared her experience.
“I just returned from the clinic this morning to get the bed net. They (the healthcare worker) informed me they wanted to distribute to us, but they have not come, so I went there and took it myself” [Female, Kg Paradason] [FGD P1].
Moreover, despite the provision of bed nets, participants revealed that it was not easy to replace a bed net if it was torn. The affordability of purchasing extra bed nets and other anti-malaria items was viewed as an issue for many participants. Despite these limitations, the healthcare team continuously puts effort into providing the best healthcare to the villagers, even during the COVID-19 pandemic. Malaria officers were described as providing support through screening the villagers, conducting “house” spraying, and updating villagers with information if there were any malaria cases in the village.
Furthermore, participants explained that some villagers still seek care from traditional healers for their illnesses as an alternative to the formal health sector. This health-seeking practice offered support to some villagers despite the need to travel for the traditional healer living near the formal health clinic or neighbouring village.
Subtheme 5: The neglect of community concerns, lack of policies and capacities that hinder malaria control
Participants identified the lack of supportive policies, conflicting agendas, and limited government and institutional capacities to support their needs as barriers that hamper effective malaria prevention. Some participants said that various stakeholders would often ignore their concerns about the community’s exposure to malaria. Community leaders emphasized the importance of sharing research findings and the latest knowledge on malaria with their communities. Due to their ongoing concern, community leaders frequently raised concerns over water scarcity issues and monkeys near human settlements during district meetings.
Participants explained the critical need for better housing conditions to help reduce the risk of mosquito bites, as many villagers’ houses were built using bamboo, rattan, and forest materials. The structure of the walls, windows, and ceilings of their homes expose them to mosquito bites. Participants highlighted the importance of the government’s Projek Perumahan Rakyat Termiskin (PPRT) (Home Initiative for Extreme Poor). They described the PPRT as a unique government program to support the need of poor villagers to build a house for their families. Participants shared that the PPRT house could provide comfort to their family and prevent malaria by having brick walls with proper doors and windows. Electricity, water supply, and a bathroom were known to be provided. One female participant from Kg Paradason shared her hope that the government will approve their application for this program to improve the living conditions of their families and future generations, as shown in Fig. 4.
Participants also described their experiences of explaining their opinion to previous researchers who had visited their village. They highlighted how monkeys disturbed their crops, farms, and fruit trees, even entering their houses and kitchens. They used the term ‘kera’ or ‘monyet’ when describing such encounters with the long-tailed monkeys. The ‘monyet’ was also described as eating chicken eggs and fruits from the oil palm trees. A community leader from Kg Membatu Laut expressed his frustration, stating,
“I asked them (the researchers and officers from many organizations), can we shoot the monkeys? We wanted to kill them because these animals (monkeys) disturbed our farms. They replied, ‘You cannot kill them […], so when they answered as such, what can we do? So, you see, no one is taking care of this issue. Do we leave the issue here? Let the monkey disturb our farm. Can anyone help us and take some action? The paddy (padi) and corn took a year to grow and were supposed to be the food source for a year. However, they were destroyed by the monkeys.’’ [Community leader, Kg Membatu Laut] [IDI04].
Theme 2: The livelihood challenges to malaria prevention due to local socio-economic structures and practices
The second important theme generated from the research data was the challenges to malaria prevention due to local socio-economic structures and practices. The communities are commonly exposed to malaria based on the sections they work in. For example, most people worked in the agricultural sectors such as rubber tapping, picking coconuts, working in oil palm plantations, and farming. Other livelihood activities were fishing, finding non-timber products in the forest, and breeding chickens. These jobs expose community members to malaria, as shown in Fig. 5. A community leader from Kg Paradason explained,
“It is not easy to avoid malaria in this village. People need to go out, to search for vegetables, food, and their living. People do activities around the village. People who have chicken, they will feed them in the morning and the evening’’ [IDI02].
In general, most current vector controls are impractical for their working situations. The current bed net design could be re-designed into a more practical product, as currently, the bed nets are not suitable for outdoor activities or work (see Fig. 6).
“The bed net could be re-designed, making them into clothing that can be worn during work. The current bed net design was not feasible during outdoor activities […] How can someone wear the bed net in the forest and while working? The dressing would only make it get stuck to the trees and branches in the forest?’’ [Village administrative officer, Kg Paradason] [IDI08].
Participants highlighted issues with the smells produced by mosquito control items that conflicted with their work. For example, some participants explained the difficulty of using repellents during activities like hunting. Participants explained that hunters often would not put on mosquito repellents as the products produced a smell that made the animals avoid the area as they could sense the smell from afar. Likewise, the hunters would not bring bed nets, as they need to be mobile.
Villagers who work on farms may spend their nights in small huts called “sulap”, which puts them at risk of malaria. As explained by one female participant from Kg Paradason,
“My husband, I think he was infected with malaria because he went to the forest to get the materials to build the “sulap” (English: hut).’’
When the villagers would go to protect their fruit trees and crops from wild animals, including monkeys, they exposed themselves to malaria (see Fig. 7).
The participants’ livelihoods depended on their daily income. Despite knowing the malaria risk, participants highlighted that working and earning a living is more important for the villagers. They use protective clothing, long trousers, and repellents to minimize the risk of mosquito bites. However, some still get infected with malaria.
“Everyone knows about malaria. Villagers who go for rubber tapping go to their farm early in the morning, around 3 or 6 o’clock. Some even go during the midnight hours. Time is crucial because it affects the production of latex. Everyone knows that we need to avoid mosquitoes. However, what can we do? I always think about how we can avoid this contact with mosquitoes. These people, the villagers, still need to go out, work, and live. We open the farm, do rubber tapping, and search for vegetables. How could people prevent it? Of course, wearing protective clothing, long pants, covering the head, putting on the repellents, but some people still got infected by malaria.’’ [Community leader, Kg Membatu Laut] [IDI04].
Many participants described the difficulty of measuring household income because they needed to work multiple sources of income to support their families. One participant said her daily routine involved going to the farm in the morning before seven o’clock, sending her kids to school, and returning to the farm afterward. These activities could be influenced by season and year as some individuals will go to a different district to work. Thus, household income was difficult to measure; moreover, it differs according to gender.
Theme 3: Environmental degradation and malaria risks in rural communities
The communities in the study sites have a close relationship with the natural environment, where forests, plantations, and farms are integral parts of their everyday lives. However, community leaders have noted that the natural forests have been diminishing over the years due to the conversion of land into plantation and farming areas. This loss of habitat may have contributed to the presence of monkeys in and around their villages, which in turn has increased the risk of “monkey malaria.” The risk is further amplified due to the lack of proper roads in the villages, which creates temporary water pools suitable for mosquitoes to breed. To minimize the risk of “monkey malaria,” one community leader advised,
“To avoid monkey malaria, do not plant fruit trees or oil palms near the village. Monkeys nowadays eat oil palm fruit. If we talk about the monkeys, this is a very complex and challenging issue. It is not easy to keep them away from us. There are many of them, and as time passes, their quantity can get higher than today.’’ [Community leader, Kg Tagumamal Darat] [IDI03].
Similarly, another community leader noted,
“There are many water ponds in our village, especially from the tire track, where mosquitoes could breed” [Community leader, Kg Paradason] [IDI02].
Another community leader expressed concerns about the impact of projects around their village, as there have been no detailed discussions with the community. They worry about the future generations of the village and urge those with decision-making power to listen to their voices and address the challenges faced by the villagers,
“I do not want to focus on those lands that have undergone deforestation directly, but I hope those with the power will listen to our voices. Listen to the challenges faced by the villagers. It is not easy for us to feed our family, dealing with health issues and the challenges of living life nowadays. This is critical to discuss, not for our benefit, but for future generations. This is not just for today but for years to come. People need to think what will happen here, in ten years in the future” [Female, Village administrative officer, Kg Manduri] [IDI01].
Recommendations by the study participants
Improving the infrastructure and access to necessities, promoting good health, and government support
Participants expressed their aspirations for a better social environment, including access to treated water and internet/communication lines. However, one participant mentioned that the road’s poor condition hindered the sewage system and water supply development. He stated:
“There is no proper road for the tractors to come here. There is no road here. But small, village road. I frequently sent my application to those in charge to send their support to these needs. However, they answered, ‘You have to wait’. Wait. Wait. So, I waited. And I waited until now, but nothing was done here in our village” [Male, Village administrative officer, Kg Paradason] [IDI08].
They requested the government to continue the piped water project that had been stopped for a long time and to support building brick houses, which could reduce the risk of mosquito bites:
“The government could continue the project that was stopped. Please continue with the piped water project that has been stopped for a long time. When they complete the project, villagers will get a good water source. The government also can support building brick houses that could reduce the risk of mosquito bites. For example, a proper toilet in the house reduces the risk of malaria as people do not have to go out for the toilet. This way could help to ensure people would not go out to seek for a water source for many other reasons.’’ [Pastor, Paradason] [IDI02].
Participants also highlighted the significance of the government and other sectors in managing garbage disposal and environmental cleanliness issues. They emphasized the importance of reducing mosquito breeding sites by regularly cleaning areas such as the roadside and river:
“I would like to highlight the importance of reducing the mosquito breeding sites in and around our village. These areas require regular cleaning. This includes the roadside and the river. It could help with the stagnant water issue and reduce the mosquito breeding sites.” [Male, Village administrative officer, Kg Paradason] [IDI08].
Addressing disparities, reimagining innovative approaches, and collaborating for effective solutions
The participants hold varying opinions on innovative approaches to malaria control, influenced by factors such as socio-economic status, lifestyles, or socio-cultural activities. For example, one participant suggested cream and lotions:
“I suggest the government provide free items such as creams or lotions to avoid mosquitoes to the villagers. The bed net is not helpful. People go to the farm, and they get bitten by mosquitoes. These people have already tried to avoid mosquitoes by using repellents or any do-it-yourself- measures. But, when the wind blows there, the smoke follows. If the cream is provided for us, I suggest we use them. We can apply it on the neck, on our hands” [Male, Farmer, Kg Tagumamal Darat] [FGD TD3].
While participants acknowledged the importance of taking preventive measures against malaria, they also recognized that significant disparities exist. A community leader from Kg Membatu Laut emphasized medical intervention,
“I believe the most effective way could be by vaccination. Why can they design the COVID-19 vaccine rapidly but not for this disease (malaria)?’’ [IDI04].
Participants emphasized the importance of government and stakeholders’ support in addressing malaria-related issues. Although they appreciated the government’s efforts, they highlighted the need for more equitable social and economic policies to reduce the risk of malaria in their village. Participants believed that a collaborative approach involving government, stakeholders, and community members could be an effective strategy for improving malaria control in the villages and facilitating communication of the needs of everyone.
Community empowerment and cross-sectoral collaboration for effective malaria prevention
Participants emphasized the need for their voices to be heard and called for greater cross-sectoral collaboration on malaria prevention. While they appreciated the current malaria program’s efforts to assist disease prevention in their villages, they suggested that more could be done. Participants felt that the current relationship between community members and healthcare workers could be expanded to improve malaria control in the villages. For example, some participants expressed excitement at the prospect of being part of a research project that used photo exhibitions as a creative platform to raise their voices and concerns to a broader audience.
Participants highlighted the Ministry of Health and government sectors as the primary contacts to encourage and facilitate collaborations with different sectors. Participants also felt that their voices were often unheard due to their social status. For example, participants understood the need for malaria control by focusing on mosquitoes, but they also highlighted the need to find a solution to the monkey presence around their village. The monkeys were disturbing and destroying their fruit trees and crops, making them a significant obstacle to malaria prevention efforts. Participants made specific recommendations for improving malaria control in their village. For example, one community leader mentioned the quality of mosquito control products and the issues with monkeys:
“The government needs to find ways to check on the quality of the given bed net, whether there is a need to change more frequently or design more likable bed net. Likable, I mean, not heaty, has airflow, and is easy to put on before sleep. Secondly, the house spraying. Maybe they need to check on that. Is it effective? I can still see mosquitoes flying even after the spraying. Thirdly, the monkeys. Someone needs to get rid of them. Or move them elsewhere. The villagers know about malaria […], but we are dependent on the government, or other sectors, anyone that could help us – to kill the “kuman malaria” [English: malaria agent] and to control the disease” [Community leader, Kg Tagumamal Darat] [IDI03].
Another participant pleaded for support to address the monkeys and stagnant water as related to the risk of malaria by explaining:
“If we want to make an effort to control this infection in our village, please do something about the monkey presence. Catch the monkey, I understand that it is impossible in a way, but please do something about it. These monkeys are the “perumah” (English: reservoir), and they come near to us humans […] This issue is very complex. The mosquitoes are here too, and they keep breeding around our village. Here, they have all the areas to breed, ponds, plantations, and farms. What I want to highlight here is that stagnant water is everywhere. Someone has to do something” [Pastor, Kg Paradason] [IDI05].
Participants felt that collaboration between community members and stakeholders is crucial to develop effective malaria control solutions. They also emphasized the need to address the issue of the monkey presence in their village, in addition to traditional malaria control methods. Overall, their recommendations are critical for developing targeted interventions that address local realities and socio-economic factors.