1 ENVIRONMENTAL DETERMINANTS AND RISK BEHAVIOR IN THE CASE OF INDIGENOUS MALARIA

2 Abstract

3 Introduction
4 Malaria is a significant public health concern in Indonesia. Muara Enim Regency is one of the districts
5 in South Sumatra with the most important number of indigenous malaria cases in the last three years
6 (2018-2020), spanning multiple locations. Very little had been done on determinants of malaria in
7 Muara Enim Regency. Therefore, this study aimed to identify determinants of malaria in the Muara
8 Enim Regency.
9
10 Methods
11 The design of this study was a case-control study. In the Tanjung Enim and Tanjung Agung Community
12 Health Center regions, a stratified random sample with strata in 2018, 2019, and 2020 with 49 cases and
13 49 controls was utilized. Using both bivariable and multivariable logistic regression models, malaria
14 determinants were discovered.
15
16 Result
17 The multivariable logistic regression model results show that mosquito repellent reduces malaria risk by
18 71% (OR=0.29, 95% CI: 0.11-0.64). Besides, the presence of wire mesh on ventilation reduces the risk
19 of malaria by 76% (OR=0.24, 95% CI: 0.10-0.57), and the distance from a breeding place near hundred
20 meters and less increases the risk of malaria by 3.88 fold (OR=3.88; 95% CI: 1.67-8.97).
21
22 Conclusions
23 Mosquito repellent, breeding site distance, and the presence of wire mesh on ventilation are
24 determinants of malaria in the Muara Enim Regency. Eliminating malaria in the Muara Enim Regency
25 requires boosting promotional efforts in mosquito prevention measures.
26
27 Keywords: E-SISMAL1, malaria2, resting mosquitoes site3.
28 Introduction

29 Malaria is a public health concern and one of the world's top causes of mortality; it is spread by the

30 Anopheles mosquito, which carries the Plasmodium parasite. In the last three years (2018-2020), the

31 global incidence of malaria reached 698 million cases, with an estimated 602,000 deaths. [1] Malaria

32 eradication by 2030 is one of the Sustainable Development Goals (SDGs) within the third target:

33 providing a healthy life and pursuing prosperity for all people. [2]

34 The 2018 Riskesdas statistics for malaria incidence in Indonesia indicate that 10.7 million people

35 continue to reside in medium and high malaria endemic areas. These territories consist of Papua, West

36 Papua, and NTT. In 2017, 266 districts/cities out of 514 in Indonesia were malaria-free, 172

37 districts/cities were low endemic, 37 districts/cities were medium endemic, and 39 districts/cities were

38 severely endemic. Malaria prevalence in Indonesia is 0.37%. Malaria is most prevalent in Papua and

39 least prevalent in East Java; its incidence in South Sumatra is 0.24 percent.[3]

40 According to the South Sumatra Provincial Health Office, eight districts/cities have an Annual Parasite

41 Incidence (API) of 0.01 per 1000 inhabitants in 2020. Most of these cases are local transmission. [4, 5]

42 Muara Enim Regency had the most malaria cases in the past three years (2018-2020). Tanjung Enim and

43 Tanjung Agung community health centers had the most cases in their operational areas. The Muara

44 Enim Regency could be a breeding location for Anopheles mosquitoes. Certain areas are open mineral

45 mining operations that may contain standing water and be a mosquito breeding risk. According to

46 published studies, there is a variety of factors that can affect malaria risk. [6-14] These include ambient

47 weather conditions (temperature and humidity); housing condition (presence of wire mesh on

48 ventilation, state of the floor and walls of the house); mosquito locations (presence of breeding and

49 resting places, distance to breeding places); domestic animals (presence of cattle pens, distance to cattle
50 pens); and community behavior (using mosquito nets, mosquito repellents, the habit of going out at

51 night, and the habit of hanging clothes on the walls of the house).

52 The research aimed to identify determinants of malaria in the Muara Enim Regency. The current study

53 determines this; Muara Enim malaria patients' environment and risk behavior will be analyzed and

54 compared to the behavior of matched cases without malarial (the controls). Following the analysis,

55 recommendations will be made for locations with environmental factors that favor malaria vector

56 proliferation and for eliminating malaria in the regency/city in 2023. Consider Muara Enim Regency,

57 one of South Sumatra's regencies/cities with the most Indigenous malaria cases.

58 Material and Methods

59 Study area

60 This study was conducted in the service area of Tanjung Enim and Tanjung Agung community health

61 centers, including ten villages with Indigenous cases. The two Community health centers were chosen

62 based on the highest number of Indigenous malaria cases in Muara Enim Regency over three years

63 (2018-2020). The area study shows in figure 1.

64

65 Figure 1. The study area

66 Research Design

67 The case-control study design was carried out in May and June of 2022. This study used stratified

68 random sampling to divide the population into groups using the year strata 2018, 2019, and 2020; simple

69 random sampling was conducted from each stratum. The computation results yielded a total of 98 case

70 and control samples. Respondents include Indigenous malaria patients of all ages residing in two

71 working zones of Tanjung Enim and Tanjung Agung community health center, which are recorded in E-

72 sismal data in the Malaria Control Program (2018-2020).

73 Estimated Sample Size

74 The sample size is calculated using the sample formula to test the two-proportion hypothesis,

75 namely[15]:

( √2 P ( 1−P ) + Z1− β √ P1 ( 1−P1 ) + P2 (1−P 2) )

2
Z a
1−
76 2
n= 2
( P1−P2 )

77 The number of samples by location for each year shows in table 1

78 Table 1. Sample size,

Year Village Number of Samples

Keban Agung 2
Lingga 5
Tegal Rejo 8
2018
Tanjung Enim Selatan 7
Tanjung Enim 8
Pasar Tanjung Enim 3
Tanjung Bulan 1
2019
Paduraksa 10
Keban Agung 1
2020 Talang Enim Selatan 1
Darmo 3
Total 49
79 Research variables

80 Indigenous malaria cases are the dependent variable. A case definition is an Indigenous person who was

81 positive for malaria based on data from the malaria E-sismal in Muara Enim Regency (2018-2020). The

82 control subject was a healthy person who was the case's nearest neighbor using gender-based matching.
 83 Validity and dependability of the questionnaire were tested before data collection. Health workers do

84 microscopic exams to diagnose the disease's prevalence, and Indigenous cases are recorded in E-sismal

85 (2018-2020). Respondents who said they had never experienced malaria were asked about other

86 illnesses—using questionnaires and E-Sismal to validate interview disease data. Indigenous malaria has

87 no value. Researchers did not study malaria, which is diagnosed microscopically and transmitted

88 electronically.

89 Independent variables included housing (the presence of wire netting, the condition of the floor of the

90 house, and the condition of the house's walls). Behavioral variables included mosquito nets, mosquito

91 repellents, walking out at night, and wall-hanging garments. Details of variables are shown in table 2.

92 All independent variables were recorded as one or two. If rarely, code one; if often, code two. Wire

93 netting, breeding places, resting places, cow pens, and mosquito larvae are code 1 if present and two if

94 not; house floor and wall conditions are coded one if they do not meet standards and two if they do;

95 breeding places and cattle pens are coded one if close and two if far. In the current study using logistic

96 regression, independent variables were normalized. They were all coded. For sample size and selected

97 variable, this study uses

98 P1: Proportion of respondents who have risk mosquito breeding distance in the malaria group (cases)

99 P2: Proportion of respondents have with risk mosquito breeding distance in the non-malaria group

100 (control)
101 Table 2 Sample size calculation

No Variable P1 P2 N References
1 The habit of using mosquito nets [16] 0.11 0.88 6 (Kristin and Astrid, 2017)
2 The habit of using mosquito repellent[17] 0.18 0.47 40 (Florentina et al., 2019)
3 The habit of going out at night [18] 0.79 0.20 11 (Nur Hamdani et al., 2020)
4 The habit of hanging clothes on the walls 0.13 0.61 15 (Fien Lumolo et al., 2015)
of the house [19]
5 Presence of wire netting on house 0.67 0.22 18 (Aurivan Harya and Samsar, 2016)
ventilation [20]
6 Condition of the floor of the house [21] 0.83 0.35 16 (Maria and Doondori, 2017)

7 Condition of the walls of the house [22] 0.62 0.16 17 (Pratiwi et al., 2016)

8 The existence of a breeding place [23] 0.35 0.65 43 (Yana Afriana et al., 2021)

9 Presence of resting place [24] (Laila Isnaini et al., 2019)

0.84 0.56 41
10 Breeding place distance [25] 0.60 0.31 46 (Hermanto Putra et al 2020)

11 The presence of cattle pens [26] 0.73 0.38 31 (Kukuh Purwo Saputro et al., 2015)

12 Distance from house to the barn [27] 0.95 0.08 04 (Eyanoer PC, 2018)

13 Presence of mosquito larvae [28] 0.59 0.19 23 (Mila Sari, 2018)

102

103 After obtaining the values of P1 and P2 from prior studies, the initial sample size was calculated using

104 the Sample Size program; the greatest sample size was 46 samples. Case sampling employs stratified

105 random sampling, i.e., separating the population into groups based on the year strata 2018, 2019, and

106 2020. From each stratum, simple random sampling was conducted with the annual sample distribution

107 calculated as follows:

108 Table 3 Stratified Random Sampling Calculation Results

Distribution
Actual Number of Minimum Sa
No Year sample (d)
Cases per Year (a) mple (c)
= (a/b) x c
1 2018 56 56/83 x 46 = 31
2 2019 19 46 19/83 x 46 = 10
3 2020 8 8/83 x 46 = 4
Total 83 (b) 45
109
110 Table 3 shows that 45 case samples were calculated for this investigation. An additional 10%

111 were added to eliminate dropouts and missing data, bringing the total number of case samples to 49. It

112 uses a 1:1 ratio; the control sample also had 49 totaling 98 samples.

113

114 Descriptive analysis

115 The descriptive analysis seeks to identify behavioral and environmental factors (the habit of using

116 mosquito nets, the practice of using mosquito repellent, the pattern of going out at night, and the habit of

117 hanging clothes indoors).

118 Bivariate analysis

119 The Chi-square test was used to assess the independent-dependent relationship. Ho is rejected if p-value

120 is <0.05, showing a significant association between behavioral and environmental factors (using

121 mosquito nets, applying mosquito repellent, going out at night, and hanging clothes) (presence of wire

122 screens, condition of house floors, condition of the wall of the house, the existence of a breeding place,

123 and the existence of a receptacle).

124

125 Multivariable analysis

126 The objective of the multivariable analysis was to identify significant variables in a logistic regression

127 model. If the bivariate analysis yielded a p-value (sig.) of 0.25, the research variables were included in

128 the modeling for the multivariate analysis. Alternatively, if the bivariate analysis yielded a p-value (sig.)

129 greater than 0.25, the variable were not included in the multivariate modeling.
130 Results

131 Characteristics of the participants and demographics

132 Univariate analysis was used to examine each research variable, including behavioral factors (the habit

133 of using mosquito nets, the habit of using mosquito repellent, the habit of going out at night, and the

134 habit of hanging clothes) and environmental factors (the habit of going out at night, the habit of hanging

135 clothes, and the habit of going out at night) (the presence of wire netting, the condition of the floor of the

136 house, the condition of the walls of the house, the presence of breeding place, presence of resting place,

137 a distance of breeding place, presence of cattle pens, a distance of cattle pens, and presence of mosquito

138 larvae). Next, bivariate analysis was used to examine the associations between behavioral factors (the

139 habit of using mosquito nets, the habit of using mosquito repellent, the habit of going out at night, and

140 the habit of hanging clothes) and environmental factors (the habit of going out at night, the habit of

141 hanging clothes indoors) (the presence of wire netting, the condition of the floor of the house, the

142 condition of the walls). homes, the presence of breeding sites, the presence of resting sites, the distance

143 between breeding sites, the presence of cow pens, the distance between cattle pens, and the presence of

144 mosquito larvae) on incidences of Indigenous malaria. In addition, a multivariate analysis was

145 performed to identify the predominant risk factors for instances of Indigenous malaria.
146 Table 4. Univariate and Bivariate Analysis (n=98 Significant variables are in bold

OR;
Research variables Indigenous Malaria 95% CI (lb-ub)a 95% CI (lb-ub)b P-value

Case Control Total

(n=49) (n=49) (n=98)
Indigenous Malaria
Yes 50.0
No 50.0
Using Mosquito Net
Yes 34.0 66.0 48.0
(0.12-0.64) 0.28 (0.12-0.64) 0.005
No 64.7 35.3 52.0
Using Mosquito Repellent
Yes 32.6 67.4 43.9
(0.11-0.64) 0.27 (0.11-0.64) 0.004
No 63.6 36.4 56.1
Out of the House at Night
Yes 56.8 43.2 37.8
(0.68-3.52) 1.54 (0.68-3.52) 0.405
No 45.9 54.1 62.2
Hanging Clothes
Yes 54.4 39.5 80.6
(0.89-7.49) 2.58 (0.89-7.49) 0.125
No 31.6 68.4 19.4
Wire Mesh on Ventilation
Yes 30.0 70.0 40.8
(0.10-0.57) 0.24 (0.10-0.57) 0.002
No 63.8 36.2 59.2
House Floor Condition
Not eligible 48.1 51.9 78.6
(0.54-3.81) 1.44 (0.54-3.81) 0.622
Qualify 57.1 42.9 21.4
House Wall Condition
Not eligible 46.6 53.4 74.5
(0.68-4.33) 1.72 (0.68-4.33) 0.354
Qualify 60.0 40.0 25.5
The existence of Breeding
Place
There is 61.8 38.2 56.1
(1.31-6.93) 3.02 (1.31-6.93) 0.015
There is not 34.9 65.1 43.9
Presence of Resting Place
There is 61.2 38.8 50.0
(1.10-5.61) 2.49 (1.10-5.61) 0.043
There is not 38.8 61.2 50.0
Breeding Place Distance
Near 100m 66.7 33.3 49.0
(1.67-8.97) 3.88 (1.67-8.97) 0.002
Far >100 m 34.0 66.0 51.0
The Presence of the Cattle Cage
There is not 43.9 56.1 58.2
(0.24-1.24) 0.55 (0.24-1.24) 0.219
There is 58.5 41.5 41.8
Cattle Cage Distance
Near 10m 55.6 44.4 36.7
(0.62-3.24) 1.42 (0.62-3.24) 0.530
Far >10 m 46.8 53.2 63.3
The Presence of Mosquito
Larvae
There is 44.1 55.9 34.7
(0.30-1.60) 0.69 (0.30-1.60) 0.524
There is not 53.1 46.9 65.3
147
148 Table 4 shows that six variables were significantly different between case and control subjects.

149 The association indicated some relevance to malaria risk. The connections are noted next for these six

150 variables. They were: net use (64.7% of cases did not use nets; 66 % of the controls did); Use of
151 mosquito repellents (63.6 of cases did not; 67.4 of the controls did; having wire mesh on ventilation

152 (63.8% of cases did not; 70% of controls did); the existence of mosquito Breeding Place (61.8% of cases

153 did have; 65.1% of controls did not); Presence of mosquito resting place (61.2% of cases did have,

154 61.2% of control did not): Distance to mosquito breeding place nearby (100m) (66.7 % of cases were

155 near breeding places, 66% of controls were not near, were > 100 m away). The remainder of these

156 analyses' variables were insignificant and will not be further described (refer to Table 4). Bivariable

157 analysis revealed a correlation between the use of mosquito nets (p-value 0.005), the use of mosquito

158 repellent (p-value 0.004), the presence of wire netting in ventilation (p-value 0.002), the presence of

159 breeding places around the house (p-value 0.015), the presence of resting places around the house (p-

160 value 0.043), and the distance between the breeding place and the house (p-value 0.002) for cases of

161 Indigenous malaria in the study area.

162

163 Table 5 Multivariable Analysis

Simple logistic regression analysis Multiple logistic regression analysis

Research variables
OR (95% CI)a P-value AOR (95% CI)b P-value
Using Mosquito Repellent
No 1 1
Yes 0.28 (0.08-0.90) 0.034 0.29 (0.09-0.91) 0.035
wire mesh screen on ventilation
Yes 0.17 (0.05-0.62) 0.007 0.18 (0.05-0.62) 0.007
No 1 1
Breeding sites
Near 100m 3.54 (1.12-11.1) 0.031 3.45 (1.11-10.7) 0.032
Far >100 m 1 1
164

165 The multivariable logistic regression model results show that mosquito repellent reduces malaria risk by

166 71% (OR=0.29, 95% CI: 0.11-0.64). Besides, the presence of wire mesh on ventilation reduces the risk

167 of malaria by 76% (OR=0.24, 95% CI 0.10-0.57), and the distance from a breeding place near hundred

168 meters and less increases the risk of malaria by 3.88 fold (OR=3.88; 95% CI 1.67-8.97).

169
170 Discussion

171 Malaria and other infectious mosquito borne diseases can be reduced with the use of coils, vaporizers,

172 mats, and lotions. Although evidence for their effectiveness is weak, they are touted as a complementary

173 technique to insecticide-treated nets for mosquito control. Education and socioeconomic status affect

174 their use. Effectiveness and counseling on choice can promote rational usage.[29] In another study,

175 mosquito coils did not diminish malaria incidence. Repellent distribution and exchange had higher

176 operational expenses than long-lasting insecticidal net (LLIN) distribution.[30] Such effort could be

177 acceptable in the context of malaria elimination, where these interventions are temporary.[31] Therefore,

178 understanding the resting sites is crucial to provide information for implementing vector control

179 strategies.[32] Malaria vector management requires knowledge of Anopheles resting habitats. Using

180 Google Earth, Landsat, or other remotely sensed data, this technique can be performed at many

181 geographic scales to analyze malaria vector resting habitats where outdoor control activities can reduce

182 the disease's Burden in Africa and elsewhere. [11] Understanding the feeding and resting habits, as well

183 as the transmission potential, of adult vectors in the area is crucial for proper planning and implementing

184 enhanced vector control strategies.[33]

185 Wire mesh screens are a practical way to reduce exposure to malaria-transmitting insects. Screening

186 protects indoor sleepers from mosquito-borne infections.[34] House improvements included covering

187 eaves, other wall gaps, and doorways with locally available materials, and screening ventilation

188 holes/spaces, including windows, with wire mesh. All other items, such as nails, brick, and mud for

189 fixing eaves, wall gaps, and door frame adjustments, were donated by communities.[35] Depending on

190 climate, geography, and human activity, each Anopheles species has its preferred oviposition site.

191 Natural or man-made water bodies, large or small, in rushing or stagnant water, shady or sunny,

192 permanent or transitory. Variations in Anopheles densities affect malaria risk spatially and temporally.
193 When blood meal sources are abundant in cities, vector dispersion is low, and malaria transmission is

194 focal.[36] Sleeping under nets, knowledge about mosquito breeding areas and malaria, previous malaria

195 history, distance from health centers, and family size predict early treatment-seeking for malaria.[37]

196 Another study highlighted the diversity of malaria vector resting and feeding behavior and the

197 maintenance of Plasmodium infections despite using long-lasting insecticidal nets (LLIN).[38] Housing

198 improvements offer a viable strategy for vector control in low-transmission environments that may

199 impart a similar protective benefit to current vector control strategies.[39] Good housing construction

200 limits mosquito vector access, reducing malaria risk. Ugandan housing design affects mosquito ingress

201 and malaria risk.[40]

202

203 Conclusion and Recommendation

204 Mosquito repellent, breeding site distance, and the presence of wire mesh on ventilation is determinants

205 of malaria in Muara Enim Regency. Eliminating malaria in the Muara Enim Regency requires boosting

206 promotional efforts in mosquito prevention measures.

207
208 Abbreviations

209 API: Annual Parasite Incidence; CI: confident interval; E-SISMAL: Electronic System Information

210 Surveillance Malaria; Kemenkes: Ministry of health; NTT: East Nusa Tenggara; OR: odds ratio;

211 RISKESDAS: Baseline Health Research; SDGs: Sustainable Development Goals; WHO: World Health

212 Organization

213

214 Ethics approval

215 On March 22, 2022, this research was approved by the health research ethics committee, Faculty of

216 Public Health, University of Sriwijaya, under the number 312/UN9.FKM/TU.KKE/2022. Participation
217 was, and there was no financial incentive. Before participation, the respondents provided written

218 informed consent that all methods were to be carried out following relevant guidelines and regulations in

219 the manuscript

221 Availability of data and materials

222 The authors have full access to all the data in the study and take responsibility for the data integrity

223

224 Conflict of Interest

225 The authors declare that the research was conducted without any commercial or financial relationships

226 construed as a potential conflict of interest.

227

228 Authors' Contribution

229 These authors contributed equally to this work and shared their first authorship: HH, RIZ, DS, and GP,

230 conceptualization, investigation, draft writing, and study validation. MAI, FF, and FEM are collecting

231 the data. HH, ZTT, MM, FEM, and PD wrote the main manuscript text. DS, HH, and PD edited the

232 draft, and all authors contributed to interpreting the results. All authors read and approved the final

233 manuscript.

234

235 Funding

236 The PNBP of Universitas Sriwijaya 2022 funded the research of this article. Following the Rector's

237 Decree Number: 0017/UN9.3.1/SK.LP2M.PT/2022, On June 15, 2022.

238 Acknowledgments

239 The authors would like to thank the Muara Enim District Health Office for approving the research and

240 the pertinent community health center for facilitating and assisting the investigation. The authors would

241 like to thank the reviewer for the constructive feedback.

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