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Methods and Findings This qualitative study was conducted via focus groups and interviews with 84 participants, and included tribal villagers, traditional healers, community health workers (CHWs), medical officers, and district officials. Questions assessed knowledge about malaria, behavior during early stages of infection, and experiences with prevention among tribal villagers and traditional healers. CHWs, medical officers, and district officials were asked about barriers to treating and preventing malaria among tribal populations.

Data were inductively analyzed and assembled into broader explanation linking barriers to geographical, cultural and social factors. Findings indicate lack of knowledge regarding malaria symptoms and transmission. Fever cases initially present to traditional healers or informal providers who have little knowledge of malaria or high-risk groups such as children and pregnant women. Tribal adherence with antimalarial medications is poor. Malaria prevention is inadequate, with low-density and inconsistent use of insecticide-treated nets (ITNs). Malaria educational materials are culturally inappropriate, relying on dominant language literacy. Remote villages and lack of transport complicate surveillance by CHWs.

Costs of treating malaria outside the village are high. Conclusions Geographic, cultural, and social factors create barriers to malaria control among tribal communities in India. Efforts to decrease malaria burden among these populations must consider such realities. Our results suggest improving community-level knowledge about malaria using culturally-appropriate health education materials; making traditional healers partners in malaria control; promoting within-village rapid diagnosis and treatment; increasing ITN distribution and promoting their use as potential strategies to decrease infection rates in these communities. These insights may be used to shape malaria control programs among marginalized populations. Introduction Malaria infection is a major public health concern, thought to cause more than one million deaths in the world every year.

India has the highest number of malaria deaths outside of the African continent with an estimated 200,000 deaths annually. Approximately 50% of all malaria deaths in India occur among members of tribal groups.

As tribal persons constitute less than 10% of India's total population, these communities bear a disproportionately heavy burden of disease. Malaria control activities in India are carried out through the direction of the World Bank-funded National Vector Borne Disease Control Programme (NVBDCP). Strategies for malaria control employed by NVBDCP include: 1) early detection and prompt treatment of malaria cases 2) vector control using methods such as insecticide treated nets (ITN) and indoor residual spray (IRS) with Deltamethrin, 3) reducing breeding of mosquitoes by environmental management and source reduction and 4) community participation to control mosquito breeding. While mortality and infection rates show declining trends in many regions of India as a result of this program, tribal regions of India continue to have high prevalence and mortality due to malaria. In order to address the heavy burden of malaria in tribal regions, the NVBDCP has developed a vulnerable communities' plan (VCP), acknowledging that service delivery, vector management and community mobilization needs to be improved in these regions. The action plan proposed under the VCP stresses early case detection and management, and arranging referrals to healthcare providers to avert morbidity and mortality.