Perceptions and practices for preventing malaria in pregnancy in a peri-urban setting in south-western Uganda

Malaria Journal, Volume 15, No. 1, Year 2016

Interpretation

Background: Malaria in pregnancy contributes greatly to maternal morbidity and mortality in Uganda. Thus it is urgent to identify possible barriers that limit access to existing interventions. The aim of this study was to assess perceptions and practices regarding malaria prevention during pregnancy in a peri-urban area and explore ways to scale-up malaria prevention interventions, since little is known about malaria in peri-urban settings. Methods: A survey was conducted in Kabale municipality south-western Uganda from April-June, 2015. Data was collected using a structured questionnaire targeting pregnant women, who delivered in the study area 1 year prior to the survey. Univariate analyses were performed at assess the level of knowledge and practices on malaria prevention during pregnancy. Results: A total of 800 women was interviewed. The majority of women, 96.1 % knew that malaria was a dangerous disease in pregnancy; 60.3 % knew that it caused anaemia, and 71.3 % associated malaria with general weakness. However, fewer women (44.9 %) knew that malaria in pregnancy caused abortions, while 14.9 % thought it caused stillbirths. Similarly, few women (19 %) attended the recommend four antenatal care visits; less than a half (48.8 %) accessed two doses of sulfadoxine-pyrimethamine (SP) for malaria prevention in pregnancy while 16.3 % received at least three doses of SP, as recommended by the current policy. The main reasons for poor antenatal care attendance were: women felt healthy and did not see a need to go for antenatal care, long distances and long waiting hours at clinics. The reasons given for not taking SP for malaria prevention were: women were not feeling sick; they were not aware of the benefits of SP in pregnancy, they were sleeping under insecticide-treated nets; fear of side effects of SP; and the antenatal care clinics were far. Conclusion: Despite a good knowledge that malaria is a dangerous disease in pregnancy, there was poor access to antenatal care and use of SP for malaria prevention in pregnancy. There is urgent to address existing health system constraints in order to increases access to malaria prevention in pregnancy in this setting. A survey was conducted in Kabale municipality, south-west Uganda, from April to June, 2015. This area was selected because little is known about malaria in peri-urban areas. All the three divisions in Kabale municipality participated in the study. A division has a population of approximately 50,000 people and a ward 5000 people. Data collection targeted pregnant who delivered 1 year prior to the survey. The Local Council III offices provided data on divisions, wards and the number of households in each ward. In each ward, a list of households was obtained and all women aged 15–49 years, who had delivered 1 year preceding the survey and consented to participate in the study were interviewed. The study was conducted in Kabale District, in south-western Uganda. The district experiences low malaria transmission and occasionally gets malaria outbreaks with severe signs and symptoms of the disease. It is situated 560 km from the capital city, Kampala and has temperatures ranging from 11 to 24 °C; with a mean annual rainfall of 1000–1250 mm. There are two rainy seasons, the heavy one between March and May, and the lesser one between September and November. Kabale municipality has a total of 32 health facilities including eight government health centres and one referral hospital. All the health facilities offer antenatal care (ANC), distribution of insecticide-treated nets (ITNs), malaria treatment and information on prevention of malaria. Data was collected on the following variables: socio-demographic characteristics, access to ANC and delivery care, access to malaria prevention services, use of SP for IPTp, and knowledge on adverse effects of malaria and preventions practices. Five research scientists experienced in malaria research conducted the interviews. They underwent refresher training for 3 days on research techniques, and study procedures; and participated in the pretesting and revision of the questionnaire tools before actual field work. The questionnaire was pretested among 43 participants outside the study area. Some questions on perceptions of malaria in pregnancy that had not been framed well and therefore not understood by the participants were revised for clarity. The final questionnaire was administered in the local language (Rukiga). Said Ishak supervised all aspects of data collection. Sample size calculation aimed to detect a difference of 5 % in the proportion of women who completed antenatal care visits in the district estimated at 38 % [21]. In order to estimate the proportion with a ±5 % absolute precision, at a power of 80 and 5 % level of significance (two-sided), a minimum sample of 784 pregnant women with 10 % non-participation was targeted for the study. Data was entered and verified using Microsoft Access 2007 (Microsoft Inc., Redmond, Washington) and analysed using STATA version 11.0 (STATA Corporation, College Station, Texas). Univariate analyses were performed to calculate proportions on perceptions and preventing practices. Responses from open-ended questions were coded and manually analysed. Ethical approval for the research was granted by Makerere University, College of Health Sciences, School of Public health Higher Degrees, Research and Ethics Committee (HDREC). Permission was also granted by the District health office. During field work, an information sheet about the study was given out and written informed consent was sought prior to the interviews.

AI Digest

Study Justification:

– Malaria in pregnancy is a significant contributor to maternal morbidity and mortality in Uganda.
– Identifying barriers to accessing malaria prevention interventions is crucial for improving maternal health.
– Little is known about malaria in peri-urban settings, making this study important for filling the knowledge gap.

Study Highlights:

– A survey was conducted in Kabale municipality, south-western Uganda, from April to June, 2015.
– 800 women who had delivered in the study area 1 year prior to the survey were interviewed.
– The majority of women had good knowledge about the dangers of malaria in pregnancy.
– However, there was poor access to antenatal care and use of sulfadoxine-pyrimethamine (SP) for malaria prevention.
– Reasons for poor antenatal care attendance included feeling healthy, long distances, and long waiting hours at clinics.
– Reasons for not taking SP for malaria prevention included not feeling sick, lack of awareness of its benefits, and fear of side effects.

Study Recommendations:

– Address existing health system constraints to increase access to malaria prevention in pregnancy.
– Improve awareness about the benefits of antenatal care and SP for malaria prevention.
– Reduce barriers to accessing antenatal care, such as long distances and waiting times.
– Strengthen health facilities in peri-urban areas to provide adequate antenatal care and malaria prevention services.

Key Role Players:

– Ministry of Health: Responsible for policy development and implementation.
– District Health Office: Oversees health services at the district level.
– Health Facility Staff: Provides antenatal care and malaria prevention services.
– Community Health Workers: Educate and mobilize communities on malaria prevention in pregnancy.

Cost Items for Planning Recommendations:

– Training: Refresher training for research scientists and health facility staff.
– Awareness Campaigns: Materials and activities to raise awareness about the benefits of antenatal care and SP.
– Infrastructure Improvement: Upgrading health facilities in peri-urban areas to provide better services.
– Transportation: Ensuring access to health facilities by addressing transportation challenges.
– Monitoring and Evaluation: Establishing systems to monitor the implementation and impact of interventions.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a survey conducted in a specific peri-urban area in Uganda. The study collected data from 800 women who delivered in the study area 1 year prior to the survey. The survey assessed the level of knowledge and practices on malaria prevention during pregnancy. The findings indicate that while the majority of women had good knowledge about the dangers of malaria in pregnancy, there were barriers to accessing antenatal care and using sulfadoxine-pyrimethamine (SP) for malaria prevention. The evidence is based on a relatively large sample size and provides insights into the perceptions and practices in a peri-urban setting. However, the evidence is limited to a specific geographic area and may not be generalizable to other settings. To improve the strength of the evidence, future studies could consider conducting a larger-scale survey in multiple peri-urban areas to assess the generalizability of the findings and identify common barriers to malaria prevention during pregnancy.

Abstract

A survey was conducted in Kabale municipality, south-west Uganda, from April to June, 2015. This area was selected because little is known about malaria in peri-urban areas. All the three divisions in Kabale municipality participated in the study. A division has a population of approximately 50,000 people and a ward 5000 people. Data collection targeted pregnant who delivered 1 year prior to the survey. The Local Council III offices provided data on divisions, wards and the number of households in each ward. In each ward, a list of households was obtained and all women aged 15–49 years, who had delivered 1 year preceding the survey and consented to participate in the study were interviewed. The study was conducted in Kabale District, in south-western Uganda. The district experiences low malaria transmission and occasionally gets malaria outbreaks with severe signs and symptoms of the disease. It is situated 560 km from the capital city, Kampala and has temperatures ranging from 11 to 24 °C; with a mean annual rainfall of 1000–1250 mm. There are two rainy seasons, the heavy one between March and May, and the lesser one between September and November. Kabale municipality has a total of 32 health facilities including eight government health centres and one referral hospital. All the health facilities offer antenatal care (ANC), distribution of insecticide-treated nets (ITNs), malaria treatment and information on prevention of malaria. Data was collected on the following variables: socio-demographic characteristics, access to ANC and delivery care, access to malaria prevention services, use of SP for IPTp, and knowledge on adverse effects of malaria and preventions practices. Five research scientists experienced in malaria research conducted the interviews. They underwent refresher training for 3 days on research techniques, and study procedures; and participated in the pretesting and revision of the questionnaire tools before actual field work. The questionnaire was pretested among 43 participants outside the study area. Some questions on perceptions of malaria in pregnancy that had not been framed well and therefore not understood by the participants were revised for clarity. The final questionnaire was administered in the local language (Rukiga). Said Ishak supervised all aspects of data collection. Sample size calculation aimed to detect a difference of 5 % in the proportion of women who completed antenatal care visits in the district estimated at 38 % [21]. In order to estimate the proportion with a ±5 % absolute precision, at a power of 80 and 5 % level of significance (two-sided), a minimum sample of 784 pregnant women with 10 % non-participation was targeted for the study. Data was entered and verified using Microsoft Access 2007 (Microsoft Inc., Redmond, Washington) and analysed using STATA version 11.0 (STATA Corporation, College Station, Texas). Univariate analyses were performed to calculate proportions on perceptions and preventing practices. Responses from open-ended questions were coded and manually analysed. Ethical approval for the research was granted by Makerere University, College of Health Sciences, School of Public health Higher Degrees, Research and Ethics Committee (HDREC). Permission was also granted by the District health office. During field work, an information sheet about the study was given out and written informed consent was sought prior to the interviews.

Materials

N/A

Innovations

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

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging systems to provide pregnant women with information on malaria prevention, antenatal care, and the benefits of SP. This could help address the lack of knowledge and awareness among women.

2. Community health workers: Train and deploy community health workers to visit pregnant women in their homes and provide education on malaria prevention, antenatal care, and the importance of taking SP. This could help overcome barriers such as long distances and waiting hours at clinics.

3. Integrated antenatal care services: Strengthen the existing health facilities in Kabale municipality to provide comprehensive antenatal care services, including malaria prevention interventions. This could improve access to both ANC and malaria prevention services in one location.

4. Public-private partnerships: Collaborate with private sector organizations to increase the availability and accessibility of SP for malaria prevention. This could involve subsidizing the cost of SP or partnering with pharmacies and drug stores to ensure its availability.

5. Behavior change communication campaigns: Conduct targeted campaigns to raise awareness about the dangers of malaria in pregnancy and the importance of ANC and SP. This could involve using various communication channels such as radio, television, and community meetings to reach a wide audience.

6. Improving health system infrastructure: Invest in improving the health system infrastructure in Kabale municipality, including increasing the number of health facilities and improving their capacity to provide quality ANC and malaria prevention services.

These innovations, if implemented effectively, could help improve access to maternal health and reduce the burden of malaria in pregnancy in Kabale municipality, south-western Uganda.

AI Innovations Description

The study conducted in Kabale municipality, south-western Uganda aimed to assess perceptions and practices regarding malaria prevention during pregnancy in a peri-urban area and explore ways to scale-up malaria prevention interventions. The study found that while the majority of women knew that malaria was a dangerous disease in pregnancy, there was poor access to antenatal care and use of sulfadoxine-pyrimethamine (SP) for malaria prevention. The main barriers identified were women feeling healthy and not seeing a need to go for antenatal care, long distances and long waiting hours at clinics, lack of awareness of the benefits of SP in pregnancy, fear of side effects of SP, and the clinics being far away.

Based on these findings, a recommendation to improve access to maternal health and prevent malaria during pregnancy could be to implement the following:

1. Increase awareness: Conduct health education campaigns to raise awareness among pregnant women about the dangers of malaria in pregnancy and the importance of antenatal care and SP for prevention.

2. Improve access to antenatal care: Address the barriers of long distances and long waiting hours at clinics by establishing more health facilities or mobile clinics in peri-urban areas. This would make it easier for pregnant women to access antenatal care services.

3. Provide transportation support: Offer transportation support for pregnant women who live far away from health facilities. This could be in the form of subsidized transportation or community-based transportation services.

4. Strengthen health system capacity: Train healthcare providers on the importance of antenatal care and SP for malaria prevention during pregnancy. This would ensure that they have the knowledge and skills to provide appropriate care and counseling to pregnant women.

5. Improve availability and distribution of SP: Ensure that health facilities have an adequate supply of SP for malaria prevention and that it is readily available to pregnant women. This could involve strengthening the supply chain and distribution systems.

6. Address misconceptions and fears: Conduct targeted communication campaigns to address misconceptions and fears related to SP and its side effects. Provide accurate information about the safety and benefits of SP during pregnancy.

By implementing these recommendations, access to maternal health and malaria prevention during pregnancy can be improved in peri-urban areas, ultimately reducing maternal morbidity and mortality associated with malaria.

AI Innovations Methodology

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

1. Increase awareness: Develop and implement targeted awareness campaigns to educate pregnant women and their families about the dangers of malaria in pregnancy and the importance of preventive measures.

2. Improve antenatal care attendance: Address the barriers to antenatal care attendance, such as long distances and long waiting hours at clinics, by establishing satellite clinics or mobile health units in peri-urban areas. Additionally, provide incentives for pregnant women to attend antenatal care visits, such as transportation vouchers or flexible clinic hours.

3. Enhance access to preventive measures: Ensure the availability and accessibility of malaria prevention interventions, such as insecticide-treated nets (ITNs) and sulfadoxine-pyrimethamine (SP), in peri-urban areas. This can be achieved through targeted distribution campaigns and collaboration with local health facilities and community health workers.

4. Strengthen health system capacity: Address existing health system constraints, such as limited resources and staffing, by investing in infrastructure, training healthcare providers, and improving supply chain management for essential maternal health commodities.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of pregnant women attending antenatal care visits, the percentage of pregnant women receiving SP for malaria prevention, and the incidence of malaria in pregnancy.

2. Collect baseline data: Gather baseline data on the selected indicators before implementing the recommendations. This can be done through surveys, interviews, and data collection from health facilities and community health workers.

3. Implement the recommendations: Roll out the recommended interventions, such as awareness campaigns, improved antenatal care services, and enhanced access to preventive measures.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can be done through routine data collection, surveys, and interviews with pregnant women and healthcare providers.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on the selected indicators. Compare the post-intervention data with the baseline data to determine any improvements in access to maternal health.

6. Adjust and refine: Based on the findings from the data analysis, make adjustments and refinements to the interventions as necessary. This could involve scaling up successful interventions, addressing any identified challenges, and ensuring sustainability of the improvements.

7. Repeat the process: Continuously repeat the monitoring, evaluation, and adjustment process to ensure ongoing improvement in access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health in the peri-urban setting in south-western Uganda.

Author

Dima Health

Statistics:

Citations: 4

Identifiers:

DOI: 10.1186/s12936-016-1246-1

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

Study Countries:

Uganda

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female