Community perception in a vulnerable municipality in the Colombian Pacific

Controlling malaria is costly and epidemics have a negative impact on the socioeconomic development (1) (2). Colombia is endemic for this disease and related to social and economic vulnerability faced by rural areas (3) (4). As a multicausal disease, new approaches to control it must integrate individual participation, community empowerment and institutional leadership (5). Because in Colombia the programs to control the disease have been characterized by a low community participation (6) (7), we need to approach the social construction of health and disease in the endemic population, their collective imagination, needs, and projects (8) (9). Therefore, this study aims to provide a community and institutional view on these elements in relation to the disease and the vector in a community with a long history of social segregation and poverty. The great number of adolescents (55.73%), children (24.89%) and eldery (16.09%) in the community could affect the municipality’s economy, resulting in a small workforce or people forced to work from very early to very advanced ages. Public services are absent or deficient, especially drinking water (33.58%), garbage (65.67%) and sewage disposal (8.21%). All those combine with inequality in the social structure, low-income, gender with inequalities for women and an ethnic group that marks a whole territory of inequality, where Afro-Colombian mixes with the high rurality full of oversight and poverty (10). They know malaria is a disease transmitted by a mosquito and the responsibility to prevent it falls not only on government entities but also on individual and community level. They can identify signs and symptoms; this is in line with other studies in endemic settings from Colombia (11). Some of the field observations showed the lack of control measures and stagnant water, and the use of insecticides and mosquito nets as the most important control measures, being the same reported in other endemic countries (12) (13) (14). To prevent malaria, the health system performs community education; the population accepts it and the level of knowledge is acceptable. However, such methods will not resolve problems regarding the environment which are breeding grounds for high-risk conditions for the population’s health. There is a health center with first level basic care focused on treatment and rehabilitation with few resources. Accessing levels of greater complexity is very difficult due to economic, geographic, and communication barriers, without dismissing the violent actors that are part of daily life. The malaria control programs carried out by the government entities would be focused on effective interventions to address malaria specific risk factors. However, to ensure a health promoting environment in which these populations live and can then practice the appreciate a malaria prevention behaviours, probably a broader a primary care strategy involving a family and community approach is required.控制疟疾（malaria）的成本高昂，且疫情对社会经济发展具有负面影响(1)(2)。哥伦比亚为疟疾地方性流行区，且该疾病与农村地区面临的社会经济脆弱性息息相关(3)(4)。作为一种多病因疾病，疟疾的新型防控策略必须融入个体参与、社区赋权（community empowerment）与机构领导力(5)。鉴于哥伦比亚的疟疾防控项目长期以来存在社区参与度偏低的问题(6)(7)，因此我们亟需聚焦流行人群对健康与疾病的社会建构、群体的集体想象、需求与项目(8)(9)。故此，本研究旨在针对一个长期存在社会隔离与贫困历史的社区，就该疾病及其传播媒介（vector）的相关要素，提供社区与机构层面的视角。 该社区内青少年占比达55.73%、儿童占比24.89%、老年人（elderly）占比16.09%，这一人口结构可能对辖区经济造成负面影响：或导致劳动力规模缩减，或迫使民众从早年至高龄仍需务工。 公共服务缺失或不足，其中饮用水服务覆盖率仅33.58%、垃圾处理覆盖率仅65.67%、污水处理覆盖率仅8.21%。上述问题与社会结构不平等、低收入水平、女性性别不平等，以及遍布全地区的族群不平等问题相互交织，非裔哥伦比亚人（Afro-Colombian）与高度农村化且普遍缺乏监管与贫困的区域共存(10)。 当地民众知晓疟疾由蚊子传播，且防控责任不仅在于政府部门，亦需个体与社区层面共同承担。民众能够识别疟疾的症状与体征，这与哥伦比亚其他流行地区的相关研究结论相符(11)。部分实地观察结果显示，当地缺乏防控措施，存在积水（stagnant water）滋生蚊虫的情况，且民众将使用杀虫剂与蚊帐作为主要防控手段，这一情况与其他疟疾流行国家的报告结果一致(12)(13)(14)。 为防控疟疾，卫生系统会开展社区教育活动，当地民众对此予以接受，且健康知识掌握程度尚可。然而此类手段无法解决滋生健康风险的环境问题。辖区设有一所一级基本医疗卫生机构，主要提供治疗与康复服务，但资源匮乏。受经济、地理与通讯障碍，民众难以获得更高层级的医疗服务，且当地日常还受到暴力活动的影响。 政府部门推行的疟疾防控项目多聚焦于针对疟疾特定风险因素的有效干预措施。然而，若要打造健康促进型环境，使当地民众能够践行适宜的疟疾防控行为，或许需要制定更全面的初级卫生保健策略，涵盖家庭与社区参与的路径。