Menu
Menu
Menu
Menu
Background: Despite declining prevalence of malaria in The Gambia, non-adherence to anti-malarial treatment still remains a challenge to control efforts. There is limited evidence on the socio-cultural factors that influence adherence to anti-malarial treatment in pregnancy. This study explored perceptions of malaria in pregnancy and their influence on adherence to anti-malarial treatment in a rural area of The Gambia. Methods: An exploratory ethnographic study was conducted ancillary to a cluster-randomized trial on scheduled screening and treatment of malaria in pregnancy at village level in the Upper River Region of The Gambia from June to August 2014. Qualitative data were collected through interviewing and participant observation. Analysis was concurrent to data collection and carried out using NVivo 10. Results: Although women had good bio-medical knowledge of malaria in pregnancy, adherence to anti-malarial treatment was generally perceived to be low. Pregnant women were perceived to discontinue the provided anti-malarial treatment after one or 2 days mainly due to non-recognition of symptoms, perceived ineffectiveness of the anti-malarial treatment, the perceived risks of medication and advice received from mothers-in-law. Conclusion: Improving women’s knowledge of malaria in pregnancy is not sufficient to assure adherence to anti-malarial treatment. Addressing structural barriers such as unclear health workers’ messages about medication dosage, illness recognition, side effects of the medication and the integration of relatives, especially the mothers-in-law, in community-based programmes are additionally required.
The study consisted of exploratory ethnographic research ancillary to the cluster randomized trial “Community Based Scheduled Screening and Treatment of Malaria in Pregnancy for Improved Maternal and Infant Health” (referred to hereafter as the ‘COSMIC’ study) (Trial Registration: Current Controlled Trials ISRCTN37259296) [22]. The study focused on exploring general perceptions of adherence to treatment for MiP irrespective of diagnosis by RDTs given the low prevalence in the study area at the time of the study. Data were collected through qualitative research techniques, i.e., participant observation, informal conversations and semi-structured interviews. Data were triangulated in order to limit response bias and to form an in-depth understanding of pregnant women’s perceptions related to anti-malarial medication. The study was conducted between June and August 2014 in the eastern part of The Gambia (i.e., Upper River Region). The study villages were Demba Kunta Koto, Kuta and Mandinka, selected based on previously collected epidemiological data within the COSMIC study (i.e., malaria incidence, indicators of access to antenatal care (ANC) and uptake of the intervention). Malaria transmission in The Gambia has decreased substantially over the last 10 years [19, 20], revealing increasing heterogeneity, with the eastern part of the country having the highest prevalence [21]. Plasmodium falciparum is the main malaria species and transmission in the area is seasonal, occurring primarily between July and December. The population was mainly Serahule and Mandinka, and predominantly Muslim. The area is rural with most inhabitants practicing subsistence farming of groundnut and maize and small-scale informal trade. Remittances received from relatives that have migrated to urban parts of the country, elsewhere in Africa, Europe or USA contributed to the livelihoods of some families. Anti-malarial treatment in the area was provided at satellite health posts operated by community health nurses (CHNs) and at a major health centre situated 10 km away in Basse Sante Su (a regional level health centre). National guidelines for uncomplicated MiP is oral quinine, but artemisinin-based combination therapy (artemether-lumefantrine) may be used in the second and third trimesters. As this study was ancillary to the COSMIC study [22], in the intervention villages, village health workers (VHWs) followed a training programme in which the burden of MiP and its consequences, and the need for pregnant women to take IPTp-SP as early as possible in the second trimester were highlighted. VHWs were trained to use rapid diagnostic test (RDTs) and to treat positive cases with artemether-lumefantrine. Participant observation consisted of participating in everyday activities in the communities and observing ANC services and activities at the heath posts. These observations offered the opportunity for numerous reiterated conversations with community members. This facilitated trust between the researcher and study participants. Additionally, the observations were important to overcome the bias that is often inherent to self-reporting techniques. Interviews were recorded and fully transcribed. When not possible and/or inappropriate, the conversation was not recorded but its content was written down in a field diary. Sampling was theoretical, meaning participants were chosen purposively based on emerging results. Participants identified from the health posts and home visits were selected on criteria such as gender, age, parity, and social position. Furthermore, “snowball” sampling—sampling using participants to identify additional respondents—was utilized to facilitate participant’s confidence in the researcher and hence reduce response bias. The inclusion of other community members, such as health workers and traditional birth attendants, allowed a more holistic understanding of pregnant women’s adherence and reduced the effects of self-reporting bias when only including accounts of pregnant women (Table 1). Overview of collected data Data analysis was an iterative process. All observational findings were noted, compiled and analysed at the end of each day. Whilst still in the field, the researcher translated initial recorded interviews from the local language (Mandinka and Serahuli) into English. These transcripts and observational notes were sequentially analysed in order to inform the interview guide; participant observation and interviews were then conducted to confirm or refute temporary results until saturation was reached. Data were systemized and analysed with NVivo 10 Qualitative Analysis Software (QSR International Pty Ltd. Cardigan UK). The PASS Malaria in Pregnancy Treatment model [12] and the PASS Health Seeking Behaviour model [23] were used to guide the analytic process. Quotations are presented in this paper to illustrate the range of perceptions within each theme illustrating the respondent’s perspectives [24]. Ethical clearance for this study was obtained from the Department of Geography Research Ethics Committee, The University of Sheffield, Sheffield (UK), the Institutional Review Board of the Institute of Tropical Medicine, Antwerp (Belgium) and the of The Gambia Government/MRCG Joint Ethics Committee. The interviewers followed the Code of Ethics of the American Anthropological Association (AAA). The village leaders (Alkalos) and all interviewees were informed before the start of the interview about project goals, the topic and type of questions as well as their right to decline participation, to interrupt or withdraw from the conversation at any time. Oral informed consent was obtained before each interview, which was documented by the researcher. Oral consent was favoured since participants were not at any particular risk and moreover, within the local communities, the act of signing one’s name on a piece of paper was expected to bring about mistrust towards the research team [25, 26] as this is not customary practice. Anonymity and confidentiality were guaranteed by using only descriptive identifiers and assigning a unique code number to each informant.
N/A
