This study showed that two ethnic communities live in a malarious area had different protective behaviors against mosquito bites. Although awareness of both communities about malaria disease and the role of mosquitoes in transmission was relatively high (), their knowledge about mosquito biting and protection measures against malaria transmission did not affect their malaria prevention behavior. It is possible that malaria is not perceived as a major health problem in both communities.
In addition, most respondents were familiar with signs and symptoms associated with malaria but a diversity of knowledge about malaria causes was observed between the two communities. Some factors such as language barriers, mistrust of health services, and a fear of asking questions may increase the knowledge gap for malaria causes between Afghans and Baluchis.
Moreover, 65.84% of participants stated that they had never been infected with malaria. Therefore, past malaria infection should be considered a reason that may change the prevention behavior of inhabitants in malarious area. In addition, 77.4% of Afghanis and 52.0% of Baluchis had never had antimalaria treatment. In contrast, 31.2% of Afghanis and 95.1% of Baluchis went to health houses or local health centers for malaria treatment. Most Afghanis preferred private health services instead of public health services because they worried about being deported. In addition, the reason that Afghani residents (45.4%) had less access to health services than Baluchi residents (75.4%) could be explained by the fact Afghan refugees primarily live at the margin of cities and villages.
Although Afghani refugees are a minority population in Baluchestan, one-third of malaria cases occur among them (Department of Communicable Disease Control, unpublished data). Afghan culture and language are different from Baluchi culture and language. Therefore, differences in life style, lack of communication, and preventive behavior among Afghanis should be addressed to reduce the number of malaria cases among the entire population in Baluchestan.
The three main malaria vectors in Baluchestan (An. culicifaces
, An. fluviatilis
, and An. stephensi
) have developed resistance to some major groups of insecticides.18
Drug resistance of P. falciparum
has also been reported in the study area.16,19
Therefore, bed net use is a potential tool for malaria prevention in this area, given the confluence of drug and insecticide resistance and a deficient health infrastructure. In the present study, most respondents, both Afghanis and Baluchis (62%), stated that they did not have any bed nets and were not using any malaria household protection because malaria is not perceived as a priority health problem.
The Ministry of Public Health in Iran has a plan to use an integrated vector management program. This program includes insecticide residual spraying, larval control, and insecticide-impregnated bet nets to protect humans as part of the malaria elimination program in Baluchestan Province.11
Some Baluchi residents use bed nets mainly for personal protection against nuisance biting mosquitoes and other nuisance domestic insects. Although this approach can be used as a promotion tool for bed net use, it may have limitations because bed nets are used only when the mosquito density is high. For example, the biting of the three vectors in Baluchestan, especially An. culicifacies, occurred mainly in the early evening and may put the community at more risk of malaria infection because the relatively perceived low mosquito density may be large enough for malaria transmission.
The average number of vector bites was 147.8/human/night during this study (). This finding indicates that human–vector contact was relatively high in Baluchestan. As shown in , biting activities of vectors started by sunset, and most inhabitants stated that they used bed nets during the second quarter of the night. Therefore, mosquitoes have a greater chance to feed on humans for at least three hours if persons do not use bed nets after sunset.
The degree of mosquito vector and human contact is recognized as an important variable in determining the vectorial capacity of mosquito species.2
showed a large vectorial potential capacity in Baluchestan. This species is predominantly a zoophilic mosquito in India,20
and southern Iran.13
Similarly, An. stephensi
is predominantly a domestic vector and primarily a zoophilic species.22–24
In contrast, An. fluviatilis
has been reported to be highly anthropophilic and exophilic in Iran and India.25–27
However, environmental change may influence biting behavior of mosquitoes in Baluchestan. These changes may include biting behavior expressed by place and/or time of biting. Generally, mosquitoes may change their host preference because of unavailability of favorite hosts.20,26,28
These issues may explain why An. culicifacies
showed high tendency to feed on humans in Baluchestan than in neighbor countries.
Moreover, most Afghanis (91.8%) and Baluchis (63.4%) slept in indoors shelters without using window screens or bed nets. Because An. culicifacies
and An. stephensi
are mostly endophilic and endophagous species,29,30
both communities are exposed to mosquito bites.
In conclusion, although most participants were familiar with malaria and the role of mosquito bites on malaria transmission, ownership and use of bed nets was low among Afghanis and Baluchis communities. However, a bet net distribution plan by health authorities may fail to achieve desirable effect in the area because bet net users may receive infectious bites when they are outside the net during the early evening. Therefore, incorporating social, cultural, and economic aspects of both communities during design of elimination projects and their implementation is essential. This policy would enhance and ensure sustainability of malaria control interventions in southern Iran and neighboring countries. Delivery of health education to Afghan refugees and Baluchi residents has to be amended to achieve the required changes in current practice. In addition, information on biting periodicity will be useful in designing personal protection measures.