Treatment-seeking and uptake of malaria prevention strategies among pregnant women and caregivers of children under-five years during COVID-19 pandemic in rural communities in South West Uganda: a qualitative study

Background: Despite efforts to avert the negative effects of malaria, there remain barriers to the uptake of prevention measures, and these have hindered its eradication. This study explored the factors that influence uptake of malaria prevention strategies among pregnant women and children under-five years and the impact of COVID-19 in a malaria endemic rural district in Uganda. Methods: This was a qualitative case study that used focus group discussions, in-depth interviews, and key informant interviews involving pregnant women, caregivers of children under-five years, traditional birth attendants, village health teams, local leaders, and healthcare providers to explore malaria prevention uptake among pregnant women and children under-five years. The interviews were audio-recorded, transcribed and data were analyzed using thematic content approach. Results: Seventy-two participants were enrolled in the Focus Group Discussions, 12 in the in-depth interviews, and 2 as key informants. Pregnant women and caregivers of children under-five years were able to recognize causes of malaria, transmission, and symptoms. All participants viewed malaria prevention as a high priority, and the use of insecticide-treated mosquito bed nets (ITNs) was upheld. Participants’ own experiences indicated adverse effects of malaria to both pregnant women and children under-five. Home medication and the use of local herbs were a common practice. Some participants didn’t use any of the malaria prevention methods due to deliberate refusal, perceived negative effects of the ITNs, and family disparity. The Corona Virus Disease-2019 (COVID-19) control measures did not abate the risk of malaria infection but these were deleterious to healthcare access and the focus of malaria prevention. Conclusions: Although pregnant women and caregivers of children under-five years recognized symptoms of malaria infection, healthcare-seeking was not apt as some respondents used alternative approaches and delayed seeking formal healthcare. It is imperative to focus on the promotion of malaria prevention strategies and address drawbacks associated with misconceptions about these interventions, and promotion of health-seeking behaviors. As COVID-19 exacerbated the effect of malaria prevention uptake and healthcare seeking, it’s critical to recommit and integrate COVID-19 prevention measures in normative living and restrict future barriers to healthcare access. This was a qualitative, explanatory single case study using focus group discussions, in-depth interviews and key informant interviews as the main sources of evidence. The case was defined as the common case conducted in Birere sub-county located in Isingiro district, southwestern Uganda between August to November 2020, to garner insights into the factors that influence the uptake of malaria prevention strategies among pregnant women and children under-five years [20]. Birere sub-county comprises 9 parishes and 76 villages, with a population of 26,000 people [2]. The study period overlapped with the second annual peak of the rainy season (September to November), and by this time, some of the instituted COVID-19 restrictions including in-country means of transport had been partially uplifted as of July 21st 2020. Study activities were conducted in compliance with the COVID-19 guidelines. The study purposively enrolled participants aged 18 years or above who were pregnant and/or provided care for pregnant women and newborns and had lived in Birere sub-county in Isingiro district for at least 6 months. These included pregnant women, caregivers of children under-five years, community health workers (village health teams) and tradition birth attendants and local leaders. For example, although the antenatal care (ANC)-based healthcare providers (HCPs) offer ANC services including malaria prevention and treatment; traditional birth attendants (TBAs) remain pivotal in the communities, partly due to persistent gaps in rural HCP availability and continued preferences for home-based deliveries. The auxiliary nurse midwives (ANMs) provide primary healthcare in community-level clinics and they support maternal-child health care provision. The village health teams (VHTs) act as community liaisons for the promotion of primary health care services, while the local council (LC) leaders supported community mobilization. Informed by previous qualitative studies, in which saturation is typically reached after interviewing 6–12 individuals with similar backgrounds [18], this study conducted 8 focus group discussions (FGDs), 13 in-depth interviews (IDIs), and 2 key informant interviews (KIIs)0.3. The details of the respondents are summarized in Table ​Table11. Showing the data collection methods and the different respondents – 4 FGDs with caregivers of children under-five years – 4 FGDs with pregnant women -2 IDIs with caregivers of children under-five years, – 2 with pregnant women, -2 with local leaders, -3 with health care providers, – 2 with VHTs, -1TBA -1 community social worker -1 for the sub-county VHT coordinator -1 for the HC-III in charge Key: FGD Focus Group Discussion, IDI In-depth Interview, VHT Village Health Team, TBA Traditional Birth Attendant, HC Health Centre The study participants were recruited from the 8-parishes in which, four parishes were selected for FGDs among pregnant women, and an equal number were considered for caregivers of children under-five years. Another parish was considered for each KII and IDI. The parishes were selected randomly to eliminate bias. The one parish that was not considered in either FGD for pregnant women or caregivers of children under-five years was prioritized for the in-depth interview respondents. Assisted by the local council-1 leaders, the VHTs compiled a list of households with a pregnant woman or a child under-five years. The list was used to randomly select households that participated in the FGD. Each FGD was clustered at the parish, with each village represented. Participants to the IDIs and KIIs were identified and contacted by the VHT coordinator, and the study team then followed up with those who were willing to participate. Guided by previous studies [21–25], data collection tools (supplementary files 1 and 2) were developed. FGD and KII questions focused on symptom recognition, healthcare seeking, knowledge, and behaviors towards malaria prevention. Also, the study assessed the impact of the COVID-19 pandemic on prevention uptake. The IDIs with pregnant women explored behavior to protect against malaria during pregnancy. On the other hand, IDIs with HCPs assessed the perceived behaviors of pregnant women and caregivers of children under-five towards malaria prevention uptake, and if malaria was emphasized during ANC. The interview guides were reviewed by two independent experts who were knowledgeable in the field of malaria. After the expert review, these were translated by 2-separate proficient persons who knew well both English and Runyankore-Rukiiga languages. Then, one of the research team members (CA) and the principal investigator (IMT) compared the translations, and compiled the final translated tools. These were then cross checked by two members of the team (RK and RN) for accuracy and comprehension in the Runyankore-Rukiiga language. The interview guides were pretested in communities within Mbarara City, Southwestern Uganda, and changes were made accordingly. Further, the interview guides were piloted in the first interview and edited during the data collection process in response to emerging themes. Additionally, participants’ socio-demographic information was captured. Data collection was conducted by at least three members of the team supported by a research assistant who was conversant with the topic on malaria, and qualitative research methods. The research team liaised with the VHTs and LCs on the day of the appointment, and a convenient time as proposed by the participants was considered to convene. Each FGD was comprised of 8–10 participants in light of the COVID-19 guidelines. Individual introductions were done, and the research team sought individual written informed consent after explaining the purpose of the study. An interview guide in the local language (Runyankore-Rukiiga) was shared with the participants and guided the discussion with probing to pursue any emerging inquiry in major trends and cross-cutting themes. A member of the team led the discussion, and clarity to the question(s) was ensured by rephrasing where necessary. Participants were anonymized, and the discussion was guided by agreed rules to warrant appropriate communication. Field notes were recorded to contextualize the data and provide reflections on each interview, and the interviews were audio-recorded. The audio recordings were transcribed and translated into English if conducted in the local language (Runyankore-Rukiiga language). Transcripts were carefully and independently studied by two dedicated members of the team, and reviewed by the lead author to assess translation quality and fidelity. Transcripts were read and re-read to allow familiarization with the text, and brief notes were taken to document the emerging themes. A codebook was developed based on the original and emerging themes. Content analysis was used to conduct the initial data analysis, and NVivo 10 (QRS International) was used to guide data analysis based on the emerging themes and patterns. Data from varied participants and sources (FGDs, IDIs, KIIs, and observations) were extracted and triangulated by three members of the team. The emerging concepts were categorized based on the study objective, coded, and subjected to conventional content analysis using a thematic approach with typical and atypical statements identified for sub-themes to illustrate key findings. Ethical approval was obtained from the Mbarara University of Science and Technology Research and Ethics Committee (UG-REC-005) before the beginning of the study. Administrative permission was obtained from Isingiro district health office. The study obtained written informed consent, and permission to audio record the interviews from all participants. Legally authorized representatives (literate family member) of illiterate participants provided informed consent for the study. The anonymity of participants was ensured at all stages of data collection and analysis.