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Background: Malaria in pregnancy is a major cause of adverse maternal and fetal outcomes. Intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is one of the control strategies promoted by WHO. In response to mounting resistance to SP, intermittent screening and treatment (ISTp) has been proposed as an alternative. The objective of this study was to explore the acceptability of ISTp for health workers and pregnant women. Methods: Semi-structured interviews of ten health workers and five focus group discussions of 38 women enrolled in an ongoing trial comparing IPTp-SP and ISTp with dihydroartemisinin-piperaquine (DP) were conducted at two antenatal clinics in rural Malawi. All transcripts were coded and themes were identified using a content analysis approach. Results: Amongst health workers, there were contrasting opinions on the preference of blood sampling methods, and the influence of method on reliability of diagnosis. The perceived greater effectiveness of DP compared to SP was appreciated, however concerns of user compliance with the full dose of DP in non-trial settings were raised. Despite the discomfort of repeated finger pricks, pregnant women were generally accepting of ISTp, particularly the chance for regular blood tests to check for infections and the perceived greater effectiveness with fewer side effects of DP compared to SP. Conclusion: In the trial context, pregnant women tended to prefer ISTp-DP over IPTp-SP. Health workers were also accepting of ISTp-DP as an alternative to IPTp-SP in light of increasing SP resistance. However, reliability of stock, adherence to malaria test results and user adherence to the full course of DP may present barriers to successful routine implementation. Effective communication with health workers and between health workers, pregnant women and their communities will be essential for the acceptability of focused antenatal care, including the best malaria control measures available.
Malaria is endemic to Malawi with an estimated four million episodes of clinical malaria annually [24]. Malaria infection during pregnancy remains largely asymptomatic with evidence of placental malaria in an estimated one in four deliveries [25]. According to the Malawi Malaria Indicator Survey (MIS) of 2014, 52% of the population had access to long-lasting, insecticide-treated nets (LLINs), with 70% of households owning at least one net. Within the same survey, 62% of pregnant women were reported to use a LLIN and 63% reported receiving two or more doses of IPTp-SP [24]. This acceptability study was conducted between June and July 2012 in Mpemba and Madziabango health centres in the Southern Region of Malawi, nested within a larger clinical trial of the efficacy of ISTp-DP compared to IPTp-SP. Methods of the main trial have been described elsewhere [22]. Briefly, HIV sero-negative women of all gravidae, between 16 and 28 weeks of gestation presenting for their first antenatal visit were enrolled and randomized to either the ISTp-SP or ISTp-DP arm. Women randomized to the control arm received SP by direct observation (DOT) at each antenatal visit, whilst those randomized to the ISTp-DP arm were first screened with a commercial RDT, and RDT-positive women were treated with a standard 3-day course of DP. The dose of DP was adjusted for the woman’s weight and all doses of DP were supervised. At enrolment, all women had blood samples taken by finger prick for HIV and haemoglobin assessment. At each antenatal visit, all women had a 5 ml venous blood sample drawn for assessment of study malaria endpoints and malaria screening in the ISTp arm, and routine care including screening for anaemia (at the last antenatal visit). RDT results were used to determine care. Malaria smears and PCR were used to assess the trial outcome of plasmodium infection during pregnancy; malaria smears were not used for point of care and read several weeks after they were taken. Live fetal endpoints were collected at delivery to assess babies born with a small weight for gestational age, low birth weight (<2500 g) or preterm (<37 weeks). Postpartum women and newborns were followed-up at 1 and 6 weeks after delivery. A LLIN was provided to each woman upon enrolment and all participation costs were met by the study. Both trial staff and facility health workers involved in providing antenatal services at participating health facilities were interviewed. Only women enrolled in the trial who had completed the 6-week postnatal visit were recruited for the client focus group discussions (FGDs). Health workers from Mpemba and Madziabango health centres involved in the delivery of antenatal services, and trial staff involved in the clinical trial were purposively selected to take part in the study. Trial research nurses were responsible for the majority of the trial duties. Health workers who were interviewed conducted ‘health talks’ to educate pregnant women about ANC and the trial. All eligible health workers (facility or trial staff) available on the days that the field team visited the health facility were interviewed. Women who received either ISTp or IPTp-SP as part of the trial and were attending the clinic for their 6-week postpartum follow-up visit on the day of data collection were purposively selected to take part in the study [26]. As the recruitment for the FGDs depended on who was attending clinic for their postpartum follow-up on the day that the fieldworkers were at the facility, they were heterogeneous for trial arm to ensure they included enough people for discussion. This meant that some women in the same discussion group may have experienced IPTp-SP, while others may have experienced IST-DP; amongst those in the ISTp-DP arm, some women may never have had a positive RDT and so would not have received DP. This observational study, embedded within an RCT, involved primary collection of qualitative data in the form of SSIs and FGDs. SSIs were administered to ANC health workers and trial staff and lasted between 45 min and 1.5 h. Interview topic guides included: health worker perceptions of malaria in pregnancy; experiences of the risk and consequences of malaria for pregnant women under their care; knowledge, experience and opinions of implementing ISTp as part of the trial; prior experience of conducting blood tests; and, opinions on the ISTp strategy if it were to be introduced as policy. SSIs were conducted in either English or Chichewa, or both in accordance to the preference of the interviewee. SSIs conducted in English were facilitated by DA; those conducted in Chichewa were facilitated by one of two trained fieldworkers fluent in both Chichewa and English. FGDs were structured around a discussion topic guide to understand the experience and perceptions of women with respect to their recent pregnancy during the trial. Topics included: expectations of ANC visits; reasons for repeat visits; and experience with drugs, blood tests and, other services received during ANC visits. A key focus was to determine women’s opinions of repeated finger pricks and blood tests. Respondents were also asked to consider, based on their experiences, the potential acceptability of ISTp under operational conditions were it to become policy. Each FGD was carried out in Chichewa and moderated by two trained local facilitators. Each SSI and FGD was digitally recorded with informed consent, transcribed into Word and kept securely until analysis was completed. Those conducted in Chichewa were translated directly into English during transcription by the two local fieldworkers. All field notes were coded to maintain the confidentiality of participants. Translation and transcription was verified by a local social scientist for quality assurance. All transcripts were coded and themes were identified using a content analysis approach [26]. Information was coded using NVivo v9.2 and content analysis was based on inductive coding [26]. Themes were identified using a combination of a priori issues included in the discussion and interview guides that were informed by the research question, as well as emergent issues raised by the participants. Each participant and FGD was assigned a number, which is used in the presenting of quotes.
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