Perceptions of malaria in pregnancy and acceptability of preventive interventions among Mozambican pregnant women: Implications for effectiveness of malaria control in pregnancy

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Study Justification:
– The study aimed to understand the perceptions of pregnant women regarding malaria and the recommended prevention interventions in order to identify barriers to uptake and improve their effectiveness.
– The study focused on the low uptake of Intermittent Preventive Treatment (IPTp) and insecticide treated nets (ITNs) in sub-Saharan Africa, despite their cost-effectiveness and straightforward delivery mechanism.
Highlights:
– Malaria was not viewed as a threat to pregnancy by the participants.
– Participants were not fully aware of the adverse maternal and birth outcomes associated with malaria.
– ITNs were the most preferred and used malaria preventive intervention, while IPTp fell between second and third.
– Indoor Residual Spraying (IRS) was the least preferred intervention.
– Perceived convenience, delivery approach, and type of provider were key factors influencing acceptability and uptake of interventions.
Recommendations:
– Improve knowledge about the risks and adverse consequences of malaria in pregnancy to increase acceptability and uptake of preventive interventions.
– Utilize pregnant women, through antenatal care (ANC) services, as vehicles for ITN distribution in communities to maximize overall coverage.
– Enhance knowledge about neonatal health and malaria to improve uptake of interventions delivered through channels other than health facilities.
Key Role Players:
– Pregnant women
– Antenatal care (ANC) providers
– Community health workers
– Health facility staff
– Local government authorities
– Non-governmental organizations (NGOs) working in malaria control
Cost Items for Planning Recommendations:
– Training and capacity building for ANC providers and community health workers
– Procurement and distribution of insecticide treated nets (ITNs)
– Education and awareness campaigns targeting pregnant women and communities
– Monitoring and evaluation activities to assess the effectiveness of interventions
– Coordination and collaboration between stakeholders involved in malaria control efforts

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mixed methods study that collected data from 85 pregnant women in a rural area of Mozambique. The study used observations, in-depth interviews, and focused ethnographic exercises to explore perceptions of malaria in pregnancy and acceptability of preventive interventions. Thematic analysis was performed on qualitative data, and quantitative data from focused ethnographic exercises were summarized into frequency distribution tables and matrices. The study provides valuable insights into the barriers to uptake of malaria preventive interventions among pregnant women. However, the sample size is relatively small, and the study was conducted in a specific geographic area, which may limit the generalizability of the findings. To improve the strength of the evidence, future studies could consider increasing the sample size and including participants from diverse geographic locations to enhance the external validity of the findings.

Background: Intermittent Preventive Treatment (IPTp) and insecticide treated nets (ITNs) are recommended malaria in pregnancy preventive interventions in sub-Saharan Africa. Despite their cost-effectiveness and seemingly straight-forward delivery mechanism, their uptake remains low. We aimed at describing perceptions of pregnant women regarding malaria and the recommended prevention interventions to understand barriers to uptake and help to improve their effectiveness. Methods and findings: We used mixed methods to collect data among 85 pregnant women from a rural area of Southern Mozambique. Information was obtained through observations, in-depth interviews, and focused ethnographic exercises (Free-listing and Pairwise comparisons). Thematic analysis was performed on qualitative data. Data from focused ethnographic exercises were summarized into frequency distribution tables and matrices. Malaria was not viewed as a threat to pregnancy. Participants were not fully aware of malaria- associated adverse maternal and birth outcomes. ITNs were the most preferred and used malaria preventive intervention, while IPTp fell between second and third. Indoor Residual Spraying (IRS) was the least preferred intervention. Conclusions: Low awareness of the risks and adverse consequences of malaria in pregnancy did not seem to affect acceptability or uptake to the different malaria preventive interventions in the same manner. Perceived convenience, the delivery approach, and type of provider were the key factors. Pregnant women, through antenatal care (ANC) services, can be the vehicles of ITN distribution in the communities to maximise overall ITN coverage. There is a need to improve knowledge about neonatal health and malaria to improve uptake of interventions delivered through channels other than the health facility. © 2014 Boene et al.

The study was conducted in Manhiça, southern Mozambique, located 80 Km north of Maputo city. The district covers an area of 2,360 Km2 and its population in 2007 was around 160,000 inhabitants, of which 23% comprised women of reproductive age [12]. Malaria transmission is perennial, with moderate seasonality that peaks during the rainy season (from November to March), and mainly due to Plasmodium falciparum [13]. The prevalence of HIV in women attending the ANC clinic was 29.4% in 2010 [14]. The population of Manhiça belongs mainly to the Changana ethnic group. They are mostly subsistence farmers, informal traders, employees of two local sugar estates, and migrant labours in South Africa [15]. Adult illiteracy rate is 71%, being more prevalent among women [15]. Around 92.000 inhabitants are under continuous follow-up through a Demographic Surveillance System (DSS), which covers an area of around 500 Km2 (also known as the Demographic Surveillance Area) and routinely registers pregnancies, births, deaths, and migrations. During 2009, the DSS registered 2,539 new pregnancies (unpublished data, Manhiça DSS 2009), and around 2,000 women attended ANC visits (unpublished data, MDH 2009). The ANC clinic at the Manhiça District Hospital (MDH) offers maternal and child health treatment and preventive services that include screening and treatment of syphilis, anaemia, and urinary tract infections, IPTp with SP (administered 3 times during pregnancy), ITNs distribution, antihelmintic, ferrous sulphate and folate tablets, tetanus toxoid vaccination, and prevention of mother to child transmission (PMTCT) of HIV with administration of antiretrovirals [16]. For malaria prevention, in addition, indoor residual spraying (IRS) is carried out in yearly rounds in the community. This was a mixed method study, generating qualitative and quantitative data. Specifically, standard qualitative data collection approaches namely observation of ANC clinic activities and in-depth interviews (IDIs) with pregnant women were combined with focused ethnographic study (FES) data collection approaches [17], [18]. Focused ethnographic studies address some of the limitations of the classic ethnographic design, by making use of a package of exercises that can be applied during the course of individual or group interviews [18], [19]. The exercises used in this study were Free-listing and Pairwise comparison. The exercises help to swiftly generate, organize and categorize insights regarding local perceptions and behaviours and how these are shaped by cultural norms. Data was collected by a trained female Mozambican social scientist with experience in conducting qualitative studies (HB) assisted by a local female interviewer (RP), who was specifically trained for this study. Both of them are fluent in Portuguese and Changana languages. The majority of interviews and FES exercises were conducted in Changana and very few were conducted in Portuguese. Choice of language was determined by participants’ convenience. Through in-depth interviews (Form S1), perceptions about malaria in pregnancy, and the use and acceptability of conventional and traditional malaria preventive interventions were explored. The interviews targeted both women attending ANC and women who had not attended any ANC visit during their current pregnancy. Participants not attending ANC were involved in a single interview at home, while ANC attendants were expected to be involved in three interviews. The first interview with ANC attendants was conducted at the health facility immediately after the administration of the first IPTp dose. For the second and third interviews women were followed up at home, up to two weeks after administration of the second IPTp dose, and up to 24 weeks after the end of the pregnancy respectively. While the first and second interviews focused on aspects related to pregnant women’s perceptions and experiences with the different interventions offered to them during ANC, the third interview dealt, in addition, with their overall degree of satisfaction with regards to such interventions in the light of the pregnancy outcome, and any other issues that the interviewer had not managed to address during the previous interviews. Interviewing the participants several times and outside the health facility environment allowed rapport building between the interviewer and the participant. During the IDIs with ANC attendants, Free-listing and Pairwise comparison exercises were conducted as part of the Focused Ethnographic Study component. Through the Free-listing exercise (Form S2), a list of perceived and experienced health problems and complaints during pregnancy was generated, through an open-ended question, at the start of each IDI. The interviewer then probed about perceived causes and consequences of each of the identified health problems both for the mother and the foetus. The exercise ended by the interviewer revisiting each of the mentioned complaints and discussing the perceived severity and the perceived risk of contracting the illness. Pairwise comparison consisted in the use of pictorial vignettes representing malaria preventive interventions and other interventions delivered through ANC. First, the vignettes were presented to the participants all at once, and an agreement was reached between the participant and the interviewer as to which intervention each vignette represented. The participant was asked to organize the vignettes from the most preferred to the least preferred intervention. The interviewer used a data extraction form to register the preferences (Form S3). Secondly, the vignettes were presented to the participant in pairs, i.e., each vignette was matched one-on-one with another vignette at a time, encouraging the participant to think about the relative advantages and disadvantages of each of the presented interventions. For each pair, the participant was asked to elect the favourite one, and a discussion followed regarding the reasons for the choice. Lastly, observations were carried out at the ANC clinics, both in the waiting and consultation rooms. The latter generated information about the participants’ interaction with health care providers, as well as on their reactions to the procedures offered to them. It also provided insights about the possible contextual factors impeding or facilitating the implementation and acceptability of the interventions. This study took place from September 2010 to November 2011. Two groups of participants were recruited. One group comprised pregnant women attending the first ANC visit and willing to participate in the qualitative study. Every day, the ANC nurse recruited the first two patients who fulfilled the inclusion criteria. The social scientist then asked for consent and arranged for the appropriate time and place for an initial interview. To capture the views and opinions of those who had not had access to ANC services, a second group of participants was recruited, consisting of randomly selected pregnant women identified through the DSS. Every day, two women were recruited by the DSS fieldworker who annotated the directions of the household and possible dates for an initial interview. A minimum sample size of 20 per group was foreseen in order to fulfil the study objectives. A final sample size of 85 women was obtained based on the saturation point, which is reached when the inclusion of new participants is suspended due to redundancy in the data being generated [20]. The number of observations was also determined by saturation, giving a total of 30 observations conducted at the ANC clinic over a period of six months. Ethical approval for this study was granted by the National Health Bioethics Committee in Mozambique (IRB nr. 00002657). Written informed consent was sought from all participants. Among the participants of this study we included a subgroup of 11 pregnant women between the ages of 15 and 18, reflecting the range of ages of pregnant women at risk of malaria in the study area. Regarding participation of these women in the study, a waiver for parental consent was given by the IRB because they are considered to be mature minors who make autonomous decisions regarding their pregnancy and foetus. In fact, the majority of them were either married or not living with their parents. Moreover, culturally, the likelihood of an undisclosed pregnancy in the first trimester is high, therefore parental permission, which implied disclosure of pregnancy status, would pose more social harm to the participants than the participation in the study without parental permission. Participation of this group of women was crucial because they are the group most at risk of malaria-related pregnancy adverse consequences. Exclusion of this group from studies like this may deny benefits to this group on the long run. All data analysis was performed using MS Excel [21] and Paired Comparison Worksheet [22]. For the data generated through the Free-listing exercise, all the illnesses that were identified by the participants were sorted in decreasing order of frequency of being mentioned. Further, for each illness, the perceived symptoms, preventive measures, and known treatment options were tabulated according to the frequency of being mentioned [17], [18], [23]. Analysis of Pairwise comparisons was performed in two steps. First, for the component of the Pairwise comparison whereby each participant was asked to rank their preference among the seven interventions presented to them all at once, the interventions were tabulated according to the frequency in which these interventions were elected as 1st, 2nd, …nth choice (n = 7). Secondly, for the component of the Pairwise comparison whereby participants were asked to choose their preference between interventions that were presented in pairs, each intervention obtained one to three points according to the difference in the frequency mentioned compared to the alternative, and zero points for a tie. Interventions were then ranked according to the total number of points obtained after the scores of all possible comparison pairs were added [24]. The in-depth interviews and the discussions held during the FES exercises were digitally recorded and transcribed verbatim and field notes were taken during observations. Transcriptions and field notes were read and data were extracted and tabulated according to three key themes: (i) perceptions and knowledge of malaria in pregnancy; (ii) knowledge and acceptability of ANC services; (iii) acceptability and use of malaria preventive interventions in general and IPTp in particular.

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

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based systems to provide pregnant women with information about malaria prevention, ANC services, and the importance of IPTp and ITNs. These tools can also be used to send reminders for ANC visits and medication adherence.

2. Community Health Workers (CHWs): Train and deploy CHWs to educate pregnant women in rural areas about the risks of malaria in pregnancy and the benefits of preventive interventions. CHWs can also distribute ITNs and provide IPTp medication directly to pregnant women in their communities.

3. Peer Support Groups: Establish peer support groups for pregnant women to share their experiences, knowledge, and concerns about malaria prevention and ANC services. These groups can provide emotional support and help address barriers to accessing maternal health services.

4. Integration of Services: Integrate malaria prevention interventions, such as ITN distribution and IRS, with ANC services. This can ensure that pregnant women receive comprehensive care and have easy access to both malaria prevention and maternal health services in one location.

5. Health Education Campaigns: Conduct targeted health education campaigns to raise awareness about the risks of malaria in pregnancy and the importance of preventive interventions. These campaigns can use various communication channels, such as radio, posters, and community meetings, to reach a wide audience.

6. Public-Private Partnerships: Collaborate with private sector organizations, such as pharmaceutical companies and technology companies, to improve access to maternal health services. This can involve providing discounted or subsidized IPTp medication and ITNs, as well as leveraging technology for innovative solutions.

7. Strengthening Health Systems: Invest in strengthening health systems in rural areas, including improving infrastructure, training healthcare providers, and ensuring the availability of essential supplies and medications for maternal health services.

It’s important to note that these are just potential recommendations based on the information provided. The feasibility and effectiveness of these innovations would need to be further assessed and tailored to the specific context of maternal health in Mozambique.
AI Innovations Description
The study mentioned in the description aimed to understand the barriers to uptake and improve the effectiveness of malaria prevention interventions for pregnant women in Mozambique. Based on the findings, the following recommendations can be developed into innovations to improve access to maternal health:

1. Increase awareness: Develop targeted educational campaigns to raise awareness among pregnant women about the risks and adverse consequences of malaria in pregnancy. Emphasize the importance of preventive interventions and the potential benefits for both the mother and the baby.

2. Improve knowledge dissemination: Strengthen the knowledge dissemination process by providing accurate and easily understandable information about malaria prevention interventions during antenatal care visits. Ensure that healthcare providers have the necessary training and resources to effectively communicate this information to pregnant women.

3. Enhance acceptability of interventions: Address the factors influencing the acceptability of malaria prevention interventions. Focus on improving the convenience, delivery approach, and type of provider associated with these interventions. For example, explore innovative ways to distribute insecticide-treated nets (ITNs) through antenatal care services, involving pregnant women as vehicles for distribution in their communities.

4. Tailor interventions to local context: Take into account the local cultural norms and beliefs when designing and implementing maternal health interventions. Consider the preferences and perceptions of pregnant women regarding different preventive interventions, such as ITNs, intermittent preventive treatment (IPTp), and indoor residual spraying (IRS). Adapt interventions to align with the preferences of the target population.

5. Strengthen healthcare infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas where access to maternal health services may be limited. Ensure that ANC clinics are well-equipped to provide a comprehensive range of services, including screening and treatment for malaria, as well as other common health problems during pregnancy.

By implementing these recommendations, it is possible to develop innovative approaches to improve access to maternal health and enhance the effectiveness of malaria prevention interventions for pregnant women in Mozambique.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Increase awareness: Develop targeted education campaigns to raise awareness about the risks and adverse consequences of malaria in pregnancy. This can include community outreach programs, educational materials, and workshops for pregnant women and their families.

2. Improve knowledge dissemination: Strengthen the dissemination of information about maternal health interventions, such as Intermittent Preventive Treatment (IPTp) and insecticide-treated nets (ITNs). This can be done through antenatal care (ANC) services, community health workers, and other channels.

3. Enhance convenience and accessibility: Ensure that maternal health interventions are easily accessible and convenient for pregnant women. This can involve improving the availability and distribution of ITNs, as well as streamlining the delivery of IPTp through ANC services.

4. Address cultural norms and preferences: Take into account the cultural norms and preferences of the target population when designing and implementing maternal health interventions. This can involve conducting community consultations and engaging with local leaders and influencers to promote acceptance and uptake of the interventions.

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

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the percentage of pregnant women receiving ANC services, the percentage of pregnant women using ITNs, and the percentage of pregnant women receiving IPTp.

2. Collect baseline data: Gather data on the current status of these indicators in the target population. This can be done through surveys, interviews, and data from health facilities and ANC clinics.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the indicators. This model should consider factors such as population size, geographical distribution, and existing healthcare infrastructure.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. This can involve adjusting parameters such as the coverage and effectiveness of interventions, as well as the implementation strategies.

5. Analyze results: Analyze the results of the simulations to determine the projected changes in the indicators. This can include comparing the baseline data with the simulated data to assess the potential improvements in access to maternal health.

6. Validate and refine the model: Validate the simulation model by comparing the simulated results with real-world data, if available. Refine the model based on feedback and additional data to improve its accuracy and reliability.

7. Communicate findings: Present the findings of the simulation study to stakeholders, policymakers, and healthcare providers. Use the results to advocate for the implementation of the recommended interventions and to inform decision-making processes.

By following this methodology, it is possible to simulate the impact of recommendations on improving access to maternal health and provide evidence-based insights for decision-making and resource allocation.

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