An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context

Background Intermittent preventive treatment of malaria among pregnant women with sulfadoxine-pyrimethamine (IPTp-SP), is one of the three recommended interventions for the prevention of malaria in pregnancy (MiP) in sub-Sahara Africa. The World Health Organisation recommended in 2012 that SP be given at each scheduled ANC visit except during the first trimester and can be given a dose every month until the time of delivery, to ensure that a high proportion of women receive at least three doses of SP during pregnancy. Despite implementation of this policy, Ghana did not attain the target of 100% access to IPTp-SP by 2015. Additionally, negative outcomes of malaria infection in pregnancy are still recurring. This ethnographic study explored how health system, individual and socio-cultural factors influence IPTp-SP uptake in two Ghanaian regions. Methods The study design was ethnographic, employing non-participant observation, case studies and in depth interviews in 8 health facilities and 8 communities, from April 2018 to March 2019, in two Ghanaian regions. Recommended ethical procedures were observed. Results Health system factors such as organization of antenatal care (ANC) services and strategies employed by health workers to administer SP contributed to initial uptake. Women’s trust in the health care system contributed to continued uptake. Inadequate information provided to women accessing ANC, stock-outs and fees charged for ANC services reduced access to IPTp-SP. Socio-cultural factor such as encouragement from social networks influenced utilization of ANC services and IPTp-SP uptake. Individual factors such as refusing to take SP, skipping ANC appointments and initiating ANC attendance late affected uptake. Conclusion Health system, socio-cultural and individual factors influence uptake of optimum doses of IPTp-SP. Consequently, interventions that aim at addressing IPTp-SP uptake should focus on regular and sufficient supply of SP to health facilities, effective implementation of free ANC, provision of appropriate and adequate information to women and community outreach programmes to encourage early and regular ANC visits. The study design was ethnographic. It included non-participant observations, case studies, informal conversations and in depth interviews (IDIs) (semi-structured interview guides were used to conduct IDIs), to obtain data from healthcare providers, healthcare managers, pregnant women and community members. Informal conversation in this study is defined as: “An unplanned and unanticipated interaction between an interviewer and a respondent that occurs naturally during the course of fieldwork observation. It is the most open-ended form of interviewing” [40]. IDIs were more formal compared to informal conversations, as research assistants used semi-structured interview guides written with probes, transitions and follow-up questions, which provided more data, direction and control than the informal conversations [41:224]. Data were collected from April 2018 to March 2019. The research team comprised of a female medical anthropologist (MA) and 9 graduate research assistants (RAs). Three of the RAs were females and six were males, who could also speak the indigenous language of their assigned study areas: the Twi language for RAs who were recruited in the Ashanti Region and the Ewe language for those who were recruited in the Volta Region. RAs observed and documented ANC care provision in the 8 study facilities and 8 communities. To prevent a Hawthorne effect, observations were conducted intermittently in the eight facilities and 8 communities [42]. MA trained RAs on observations and writing observation notes in accordance with Emerson, Fretz [43]. They were also trained to carry out community entry, to conduct informal conversations and IDIs prior to data collection and during the data collection process. The study was conducted in five districts, three in the Ashanti region (the third district was included in the study, because the district was a new district that had been separated from one of the selected districts, so some of the pregnant women from the chosen district preferred to visit that health facility located in the new district) and two in the Volta region of Ghana. Eight health facilities (Table 1) and 8 communities were chosen for the study. Ashanti region was selected to represent the middle belt of the country, while Volta region was selected to represent the southernmost belt of Ghana. The two regions are linguistically different, Twi is spoken in the Ashanti region and Ewe is spoken in the Volta region. Ashanti Region reported the second highest percentage (98.8%) of women receiving ANC care from skilled providers in 2014, while the Volta region reported the second lowest percentage (93.9%) of women receiving ANC from skilled providers [29]. The district hospitals in the five districts qualified automatically to participate in the study. Also, interactions and interviews with pregnant women in some of the study communities revealed that they preferred to visit particular health facilities for ANC services. Three of such facilities, which are faith-based were included in the study. Thus, a total of 8 health facilities were selected for the study. Some women preferred the three facilities (2 in the Ashanti region and 1 in the Volta region), because they were closer to their communities than the district hospitals. The women’s assertion of nearness to facilities was further confirmed when the study team conducted transect walk in all the study communities, to confirm the location of health facilities [38]. The study team visited the 8 health facilities and went through ANC records and maternity admission records for malaria in pregnancy (MiP) cases. The total number of MiP cases from January 2015 to March 2018 for the different communities that access the services of each facility were tallied. The community with the highest total number of malaria in pregnancy cases in each facility was chosen to participate in the study. The average population for each study community was 10,000 inhabitants. *Study facilities in the Ashanti region have been given the following pseudonyms: ASF01, ASF02, ASF03 and ASF04. Study communities in the Ashanti region have been given the following pseudonyms: ASC01, ASC02, ASC03 and ASC04. #Study facilities in the Volta region have been given the following pseudonyms VRF01, VRF02, VRF03, and VRF04. Study communities in the Volta Region have been given the following pseudonyms: VRC01, VRC02, VRC03 and VRC04. The study team conducted community entry activities such as visiting assembly members and chiefs and holding meetings with a cross section of opinion leaders to inform and to seek their permission to conduct the study in their communities. A research assistant was assigned to one health facility to carry out non-participant observation and to interact with health providers and pregnant women attending ANC. Convenience sampling was used to select pregnant women for conversations [41:27]. RAs took the phone number of any pregnant woman who was attending ANC and was willing to participate in an IDI. The woman was contacted later on and arrangement was made to meet her at her preferred venue for an in depth interview. The snowball method was also used to recruit pregnant women from the 8 study communities [40:115]. The first pregnant woman who was recruited helped the RA to identify other pregnant women in the community. The study was explained to them and those who were interested were recruited to participate in IDIs, after a written consent had been obtained. Opinion leaders such as assembly members, mothers and mothers in-law of pregnant women were invited to participate in IDIs. Case studies were purposively selected from women who regularly attended ANC every month and those who were irregular or skipped ANC appointments. A total of 12 case studies were followed throughout the study period (Table 2). They were visited several times at home, where RAs observed how they took their medications, whether they honoured their ANC appointments, their experiences from their previous ANC visits especially on being offered SP, and whether they were using LLINs. Also, their maternity record booklets were reviewed to confirm the information. *Observations were carried out intermittently in 4 health facilities and 4 communities from May, 2018 to March 2019 in the Ashanti Region. ** District Health Directorate. #Observations were carried out in 4 health facilities and 4 communities from April 2018 to March 2019 in the Volta Region. *# Eighty ANC interactions between health providers and clients were observed: 40 in the Ashanti region and 40 in the Volta region. An average of 10 were observed in each of the four facilities in each region. Health providers, mostly midwives and nurses providing ANC service, who had one year or more work experience in a health facility were selected to participate in the study. ANC unit managers (commonly referred to as in-charge), facility managers such as senior medical officers, physician assistants and administrators were interviewed to help understand managerial and administrative issues. The study team carried out follow-up informal conversations and interviews with procurement officers, laboratory personnel and officials at the district health directorate. The aim was to clarify some of the issues raised in IDIs and conversations with health providers and health managers. Details of the different category of study participants and the methods used for data collection are presented in Table 2. An RA spent several months in a facility observing ANC procedures, interactions between healthcare providers and women who were attending ANC. RAs first observed women and health workers during the following ANC activities: registration of women, checking of women’s blood pressure and protein in their urine, women being attended to in the ANC consulting room, women visiting the laboratory and the pharmacy. In order to understand and experience the various processes that the women went through, RAs also selected ANC attendants at random and accompanied them throughout the ANC process. The RAs obtained permission from the health providers to interact with the women and they also sought verbal consent from such women to accompany them through the ANC procedures. The RAs talked to the women who they chose at random to clarify actions and activities that were observed. RAs wrote down notes on the conversations that they had with the ANC clients and the health workers and later typed them out. Observations and conversations with women focused on women’s knowledge on SP, knowledge on MiP, their intention to take SP among others. Conversations with health providers centred on SP policies, SP availability, information offered to women before and after offering them SP. Conversations and IDIs that were conducted with pregnant women and community members were in the Ewe language for those in the Volta region and the Twi language for those in the Ashanti region. The IDIs centred on knowledge, attitudes, beliefs and practices on malaria in pregnancy (MiP) interventions and socio-cultural practices. RAs conducted IDIs with healthcare providers and healthcare managers in English and they focused on maternal and MiP policies and service provision, challenges and facilitators. IDIs were recorded using digital recorders and they were transcribed verbatim to preserve interviewees’ original messages and experiences. Interviews in Ewe and Twi were transcribed into English to enable easy analysis and comparison. The study used English language to conduct IDIs and conversations with healthcare providers and NHIS officials, because English is the official language of Ghana (see additional files for IDI guides and observation checklists). Also, RAs obtained permission from the women to go through their maternity booklets to confirm IPTp-SP uptake. IDI transcripts, observation notes and notes from conversations were uploaded onto qualitative analysis software NVivo Version 11 to support the analysis. The data was triangulated and a coding list on common themes that arose from the data (IDIs, observation notes and conversations) was generated. MA and ED (ED is a qualitative expert who was hired to support coding of the data in order to enhance validity) independently coded the data thematically. The analysis aimed at identifying similarities, patterns, differences and contradictions in the information observed or presented by study participants [44]. Main themes that were identified from the analysis formed the basis for interpreting and reporting on study findings. This manuscript is part of the larger study mentioned in the introduction, so some of the findings have been reported in the earlier paper [38]. Ethical clearance was obtained from the University of Health and Allied Sciences’ Research Ethics Committee [UHAS-REC/A.I Ul 17, 18]. Written consent was obtained from all interview participants. Verbal consent was obtained from study participants that informal conversations were held with and for observations. While written consent is recommended for study participants, verbal consent can be used in situations where time is of the essence, as was the case with the informal conversations that the study team conducted with some of the clients attending ANC, who did not have time to participate in IDIs [45] In this study women who were attending ANC were invited to participate in conversations and interviews. Those who had ample time for an interview were given time to reflect and their phone numbers were taken by the RAs. They were called at a later date by the RAs and if they consented, the RAs followed up to their homes for interviews, after they had obtained written consent from them. However, RAs conversed with women who were willing to participate in the study, but did not have enough time to participant in IDIs. For such study participants RAs first sought permission from ANC department heads and subsequently from the clients, who granted verbal consent to participate in the study. A few of those who were approached declined to be interviewed. Only one study participant was 16 years old and permission was sought from her mother prior to her inclusion in the study. Permission to conduct the study was sought from district directors of health of participating districts, facility managers of the eight study facilities, department managers and chiefs and assembly members in the study communities. Besides actual country and region names, pseudonyms have been used for districts, individuals and facilities’ names, to protect informants’ identity. Health facility pseudonyms beginning with ASF refer to study facilities in the Ashanti Region and ASC refer to study communities in the Ashanti Region. While the prefix VRF refer to facilities in the Volta region and VRC refer to study communities in the Volta Region. Pseudonyms of respondents are thus predicated by the prefix of the facility or community that the observation, conversation and IDI was conducted respectively.