Determinants of uptake of malaria preventive interventions among pregnant women in eastern Uganda

Malaria Journal, Volume 20, No. 1, Year 2021

Interprétation

Background: Consistent use of insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp) have been recommended as cost-effective interventions for malaria prevention during pregnancy in endemic areas. However, the coverage and utilization of these interventions during pregnancy in sub-Saharan Africa is still suboptimal. This study aimed to determine the uptake of IPTp and ITNs and associated factors among women during their recent pregnancy in Eastern Uganda. Methods: This was a cross-sectional study conducted among 2062 women who had delivered within the last 12 months prior to the start of the study in three districts of Eastern Uganda. The primary outcomes were consistent ITN use and optimal uptake (at least 3 doses) of IPTp. A modified Poisson regression was used to examine the association between consistent ITN use and the uptake of optimal doses of IPTp with independent variables. Data were analysed using Stata 14 software. Results: The level of uptake of IPTp3 (at least three doses) was 14.7%, while IPTp2 (at least two doses) was 60.0%. The majority (86.4%) of mothers reported regularly sleeping under mosquito nets for the full duration of pregnancy. Uptake of IPTp3 was associated with engaging in farming (adjusted PR = 1.71, 95% CI [1.28–2.28]) or business (adjusted PR = 1.60, 95% CI [1.05–2.44]), and attending at least 4 antenatal care (ANC) visits (adjusted PR = 1.72, 95% CI [1.34–2.22]). On the other hand, consistent ITN use was associated with belonging to the fourth wealth quintile (adjusted PR = 1.08, 95% CI [1.02–1.14]) or fifth wealth quintile (adjusted PR = 1.08, 95% CI [1.02–1.15]), and attending at least 4 ANC visits (adjusted PR = 1.07, 95% CI [1.03–1.11]). Conclusion: Uptake of IPTp3 and consistent ITN use during pregnancy were lower and higher than the current Ugandan national targets, respectively. Study findings highlight the need for more efforts to enhance utilization of ANC services, which is likely to increase the uptake of these two key malaria preventive measures during pregnancy. This was a cross-sectional study conducted in the districts of Iganga, Luuka and Buyende in eastern Uganda. This region is predominantly rural, cover an area of 3549.8 km2, and have an estimated population of 1,065,284 inhabitants living in 208,030 households [13]. These districts are served by at least 75 government-run health facilities and several private not for profit (PNFP) health centres [14]. Malaria, which is mostly attributable to Plasmodium falciparum, is endemic in this area. The main economic activity in these districts is subsistence farming, but other occupations include small-scale businesses, such as fishing, grain milling, market vending, motorcycle transport and formal employment. The Basoga, a Bantu-speaking group, are the predominant ethnic group, which make up to 9% of Uganda’s population [14]. The study units were households, and the study domain included women who had delivered in the last 12 months prior to the start of the study and were resident in the area. Mothers were included in the study whether the child was delivered preterm or full-term, and irrespective of the birth outcome (whether the baby was alive or dead). Those who had not lived in the community for at least 1 year were excluded from the study. Data were collected from 2062 mothers in three health sub-districts (HSDs): Buyende, Luuka, and Iganga. Sixteen (16) sub-counties (6 in Buyende, 6 in Luuka, and 4 in Iganga) were proportionately selected from the HSDs. The sub-counties in each HSD were randomly selected and within each sub-county, one parish was randomly selected. Two villages were randomly selected from each parish, and a list of households with mothers who met the criteria were listed. Participants were sampled at the village level using simple random sampling from the village listing made with the aid of local council 1 (village) leader. From each selected village, at least 50 households were visited by the enumerators from which one eligible respondent was selected per household. This study utilized secondary data from a broader study entitled “Innovations for increasing access to integrated safe delivery, PMTCT and newborn care in Rural Uganda”. An interviewer-administered structured questionnaire developed based on the literature on the uptake of IPTp-SP and ITNs among pregnant women was used to collect quantitative data. The original English questionnaire was translated to Lusoga, the local language spoken by the study participants. Data were collected on socio-demographic characteristics, uptake of IPTp-SP, ITNs, and frequency of ANC visits. Research assistants were trained on appropriate methods of data collection, and the tool appropriately piloted. The primary outcome variables of the study were consistent ITN use and optimal uptake of IPTp-SP which were self-reported. Consistent ITN use was defined as sleeping under an ITN every night for the full duration of the last pregnancy, while optimal uptake of IPTp-SP was defined as 3 or more doses received during pregnancy. The covariates (independent variables) included the timing of first ANC, number of ANC visits, sociodemographic characteristics (such as maternal age, marital status, level of education of women, occupation, household size, parity, and wealth (measured using a wealth asset index). The wealth quintiles were generated using principal component analysis based on the information collected on assets owned and household structure. The covariates used for this study were selected from critical review of related published literature [11, 12]. Data were analysed using Stata Version 14.0 (StataCorp, Texas, US). Descriptive statistics such as frequencies and percentages were used to present categorical data, while means and standard deviations were used where data were continuous. The associations between the outcome variables (consistent ITN use and uptake of 3 or more IPTp-SP doses) and explanatory variables were explored using modified Poisson regression. Initially, unadjusted prevalence ratios (PRs) were obtained for the association between each outcome and each predictor variable. Prevalence ratios were preferred over odds ratios since odds ratios would overestimate the effect size when outcomes are common (prevalence > 10%) [15, 16], as was the case in the current study. All epidemiologically meaningful independent variables were considered for a fully saturated model. Interactions between predictor variables and the primary outcomes were as well examined. A stepwise backward elimination method was then applied, removing variables with the largest non-significant p values, systematically until only significant variables and those that improved the fit of the model were retained. The prevalence ratios (PR) and 95% confidence intervals are presented. A p-value of less than 0.05 was considered statistically significant.

Résumé de l’IA

Study Justification:

– The study aimed to determine the uptake of malaria preventive interventions, specifically insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp), among pregnant women in eastern Uganda.
– The study addressed the suboptimal coverage and utilization of these interventions in sub-Saharan Africa.
– The findings of the study would provide valuable insights into the factors associated with the uptake of ITNs and IPTp, which could inform strategies to improve malaria prevention during pregnancy.

Study Highlights:

– The study found that the uptake of IPTp3 (at least three doses) was 14.7%, while IPTp2 (at least two doses) was 60.0%.
– The majority (86.4%) of mothers reported regularly sleeping under mosquito nets for the full duration of pregnancy.
– Factors associated with the uptake of IPTp3 included engaging in farming or business and attending at least 4 antenatal care (ANC) visits.
– Factors associated with consistent ITN use included belonging to the fourth or fifth wealth quintile and attending at least 4 ANC visits.
– The study highlighted the need for more efforts to enhance the utilization of ANC services, which is likely to increase the uptake of ITNs and IPTp during pregnancy.

Recommendations for Lay Reader and Policy Maker:

– Increase awareness and education about the importance of ITN use and IPTp during pregnancy.
– Strengthen ANC services and promote early and regular attendance.
– Target interventions towards women engaged in farming or business to improve IPTp uptake.
– Focus on improving access to ITNs for women in lower wealth quintiles.
– Collaborate with local communities and stakeholders to develop and implement effective malaria prevention strategies during pregnancy.

Key Role Players:

– Ministry of Health: Responsible for policy development and implementation of malaria prevention programs.
– District Health Offices: Responsible for coordinating and implementing malaria prevention activities at the district level.
– Health Facilities: Provide ANC services and distribute ITNs and IPTp.
– Community Health Workers: Educate and raise awareness among pregnant women about ITN use and IPTp.
– Non-Governmental Organizations: Support implementation of malaria prevention interventions and provide resources.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers and community health workers.
– Procurement and distribution of ITNs and IPTp.
– Development and dissemination of educational materials.
– Monitoring and evaluation of program implementation.
– Community engagement and mobilization activities.
– Research and data collection for monitoring and evaluation purposes.

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are areas for improvement.

Abstrait

This was a cross-sectional study conducted in the districts of Iganga, Luuka and Buyende in eastern Uganda. This region is predominantly rural, cover an area of 3549.8 km2, and have an estimated population of 1,065,284 inhabitants living in 208,030 households [13]. These districts are served by at least 75 government-run health facilities and several private not for profit (PNFP) health centres [14]. Malaria, which is mostly attributable to Plasmodium falciparum, is endemic in this area. The main economic activity in these districts is subsistence farming, but other occupations include small-scale businesses, such as fishing, grain milling, market vending, motorcycle transport and formal employment. The Basoga, a Bantu-speaking group, are the predominant ethnic group, which make up to 9% of Uganda’s population [14]. The study units were households, and the study domain included women who had delivered in the last 12 months prior to the start of the study and were resident in the area. Mothers were included in the study whether the child was delivered preterm or full-term, and irrespective of the birth outcome (whether the baby was alive or dead). Those who had not lived in the community for at least 1 year were excluded from the study. Data were collected from 2062 mothers in three health sub-districts (HSDs): Buyende, Luuka, and Iganga. Sixteen (16) sub-counties (6 in Buyende, 6 in Luuka, and 4 in Iganga) were proportionately selected from the HSDs. The sub-counties in each HSD were randomly selected and within each sub-county, one parish was randomly selected. Two villages were randomly selected from each parish, and a list of households with mothers who met the criteria were listed. Participants were sampled at the village level using simple random sampling from the village listing made with the aid of local council 1 (village) leader. From each selected village, at least 50 households were visited by the enumerators from which one eligible respondent was selected per household. This study utilized secondary data from a broader study entitled “Innovations for increasing access to integrated safe delivery, PMTCT and newborn care in Rural Uganda”. An interviewer-administered structured questionnaire developed based on the literature on the uptake of IPTp-SP and ITNs among pregnant women was used to collect quantitative data. The original English questionnaire was translated to Lusoga, the local language spoken by the study participants. Data were collected on socio-demographic characteristics, uptake of IPTp-SP, ITNs, and frequency of ANC visits. Research assistants were trained on appropriate methods of data collection, and the tool appropriately piloted. The primary outcome variables of the study were consistent ITN use and optimal uptake of IPTp-SP which were self-reported. Consistent ITN use was defined as sleeping under an ITN every night for the full duration of the last pregnancy, while optimal uptake of IPTp-SP was defined as 3 or more doses received during pregnancy. The covariates (independent variables) included the timing of first ANC, number of ANC visits, sociodemographic characteristics (such as maternal age, marital status, level of education of women, occupation, household size, parity, and wealth (measured using a wealth asset index). The wealth quintiles were generated using principal component analysis based on the information collected on assets owned and household structure. The covariates used for this study were selected from critical review of related published literature [11, 12]. Data were analysed using Stata Version 14.0 (StataCorp, Texas, US). Descriptive statistics such as frequencies and percentages were used to present categorical data, while means and standard deviations were used where data were continuous. The associations between the outcome variables (consistent ITN use and uptake of 3 or more IPTp-SP doses) and explanatory variables were explored using modified Poisson regression. Initially, unadjusted prevalence ratios (PRs) were obtained for the association between each outcome and each predictor variable. Prevalence ratios were preferred over odds ratios since odds ratios would overestimate the effect size when outcomes are common (prevalence > 10%) [15, 16], as was the case in the current study. All epidemiologically meaningful independent variables were considered for a fully saturated model. Interactions between predictor variables and the primary outcomes were as well examined. A stepwise backward elimination method was then applied, removing variables with the largest non-significant p values, systematically until only significant variables and those that improved the fit of the model were retained. The prevalence ratios (PR) and 95% confidence intervals are presented. A p-value of less than 0.05 was considered statistically significant.

Matériaux

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Interventions: Develop and implement mobile phone-based interventions to provide pregnant women with reminders and information about the importance of consistent ITN use and optimal uptake of IPTp. This could include sending text messages or using mobile apps to educate and motivate women to adhere to these preventive measures.

2. Community Health Worker (CHW) Training and Support: Strengthen the capacity of community health workers to provide education and counseling on the importance of consistent ITN use and optimal uptake of IPTp. This could involve training CHWs on malaria prevention during pregnancy and providing them with the necessary resources and support to effectively deliver these messages to pregnant women in their communities.

3. Integration of Services: Integrate malaria prevention interventions with other maternal health services, such as antenatal care (ANC) visits. This could involve ensuring that pregnant women receive information and services related to ITN use and IPTp during their ANC visits, and that healthcare providers are trained to deliver these interventions as part of routine care.

4. Targeted Outreach and Education: Conduct targeted outreach and education campaigns to raise awareness about the importance of consistent ITN use and optimal uptake of IPTp among pregnant women and their communities. This could involve using various communication channels, such as radio, television, community meetings, and social media, to disseminate information and promote behavior change.

5. Addressing Socioeconomic Barriers: Implement strategies to address socioeconomic barriers that may hinder access to ITNs and IPTp, such as poverty and limited resources. This could involve providing subsidies or vouchers for ITNs, improving access to ANC services, and addressing transportation challenges to ensure that pregnant women can access and afford these preventive measures.

6. Quality Improvement Initiatives: Implement quality improvement initiatives in healthcare facilities to ensure that pregnant women receive high-quality and comprehensive care, including consistent ITN use and optimal uptake of IPTp. This could involve training healthcare providers on best practices, improving supply chain management for ITNs and IPTp, and monitoring and evaluating the delivery of these interventions.

These are just a few potential innovations that could be considered to improve access to maternal health and increase the uptake of ITNs and IPTp among pregnant women in eastern Uganda. It is important to note that the implementation of these innovations should be context-specific and tailored to the local needs and resources available.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the study is to enhance the utilization of antenatal care (ANC) services. The study found that attending at least 4 ANC visits was associated with increased uptake of optimal doses of intermittent preventive treatment in pregnancy (IPTp) and consistent use of insecticide-treated nets (ITNs). Therefore, efforts should be made to encourage pregnant women to attend ANC visits regularly.

To implement this recommendation, the following strategies can be considered:

1. Awareness campaigns: Conduct community-based awareness campaigns to educate pregnant women and their families about the importance of ANC visits for maternal and child health. Emphasize the benefits of IPTp and ITNs in preventing malaria during pregnancy.

2. Mobile clinics: Establish mobile clinics that can reach remote and underserved areas, providing ANC services and distributing ITNs. This can help overcome geographical barriers and improve access to maternal health services.

3. Community health workers: Train and deploy community health workers to provide education and counseling on ANC services, IPTp, and ITNs. They can also conduct home visits to identify pregnant women who may not be accessing ANC services and provide them with information and support.

4. Incentives: Provide incentives such as free or subsidized transportation, food vouchers, or small cash incentives to encourage pregnant women to attend ANC visits. This can help address financial barriers and increase utilization of ANC services.

5. Collaboration with local leaders and organizations: Engage local leaders, community-based organizations, and women’s groups to promote ANC services and raise awareness about the importance of IPTp and ITNs. This collaboration can help build trust and increase community acceptance of these interventions.

By implementing these strategies, it is expected that the utilization of ANC services will increase, leading to improved access to maternal health interventions such as IPTp and ITNs. This, in turn, can contribute to reducing the burden of malaria during pregnancy and improving maternal and child health outcomes.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen ANC services: Increase the number of ANC visits and promote early initiation of ANC to ensure that pregnant women receive comprehensive care, including education on malaria prevention and access to ITNs and IPTp.

2. Community-based interventions: Implement community-based programs to raise awareness about the importance of consistent ITN use and optimal uptake of IPTp. This can be done through health education sessions, community outreach programs, and involvement of local leaders and community health workers.

3. Improve availability and distribution of ITNs: Ensure that insecticide-treated nets are readily available and accessible to pregnant women in rural areas. This can be achieved through partnerships with NGOs, government agencies, and private sector organizations to distribute ITNs to pregnant women at antenatal care clinics and community health centers.

4. Address socio-economic barriers: Address socio-economic factors that may hinder access to maternal health services, such as poverty, lack of transportation, and limited resources. This can be done by providing financial support for transportation, offering incentives for ANC attendance, and implementing income-generating programs for pregnant women.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population that will be affected by the recommendations, such as pregnant women in rural areas of eastern Uganda.

2. Collect baseline data: Gather data on the current levels of ITN use, uptake of IPTp, and other relevant indicators related to access to maternal health services in the target population.

3. Develop a simulation model: Create a mathematical or statistical model that simulates the impact of the recommendations on the target population. This model should take into account factors such as population size, demographic characteristics, socio-economic factors, and healthcare infrastructure.

4. Input data and parameters: Input the baseline data and parameters into the simulation model, including the current levels of ITN use, uptake of IPTp, and other relevant variables. Also, input the expected changes in these variables based on the implementation of the recommendations.

5. Run the simulation: Run the simulation model to generate projections of the impact of the recommendations on access to maternal health services. This can include estimates of the increase in ITN use, uptake of IPTp, and other relevant indicators.

6. Analyze the results: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health services. This can include evaluating the changes in key indicators, identifying any potential barriers or challenges, and assessing the cost-effectiveness of the recommendations.

7. Refine and validate the model: Refine the simulation model based on feedback and validation from experts in the field of maternal health. Ensure that the model accurately reflects the real-world context and dynamics of the target population.

8. Communicate the findings: Present the findings of the simulation study to relevant stakeholders, such as policymakers, healthcare providers, and community leaders. Use the results to advocate for the implementation of the recommendations and to inform decision-making processes related to improving access to maternal health services.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data. The steps outlined above provide a general framework for conducting such a simulation study.

Auteur

Dima Health

Statistics:

Citations: 6

Identifiers:

DOI: 10.1186/s12936-020-03558-1

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations

Study Countries:

Uganda

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female

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