Adherence to intermittent preventive treatment for malaria in pregnancy in urban kano, northern Nigeria

  • Pathogens and Global Health, Volume 106, No. 6, Year 2012

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Study Justification:
– Malaria in pregnancy is a significant health issue, leading to maternal and fetal morbidity and mortality.
– The uptake of preventive antimalarials, specifically intermittent preventive treatment for malaria in pregnancy (IPTp), is low in Nigeria.
– Understanding the factors associated with uptake and adherence to IPTp is crucial for improving malaria prevention strategies.
Study Highlights:
– The study was conducted in Kano Municipal local government area, an urban area with a high prevalence of malaria.
– A cross-sectional study design was used, and data was collected from antenatal attendees in primary health centers.
– Factors associated with adherence to IPTp included advanced maternal age, higher educational attainment, higher parity, lower gestational age at booking, and use of insecticide-treated nets.
– Strengthening health systems and addressing cultural factors are necessary to expand coverage of malaria prevention strategies in Nigeria.
Study Recommendations:
– Improve access to and availability of preventive antimalarials, particularly in primary health centers.
– Increase awareness and education about the importance of IPTp among pregnant women and healthcare providers.
– Strengthen health systems to ensure proper supervision and monitoring of IPTp administration.
– Address cultural factors that may hinder the uptake and adherence to IPTp, such as misconceptions and beliefs.
Key Role Players:
– Ministry of Health: Responsible for policy development, coordination, and implementation of malaria prevention strategies.
– Primary Health Centers: Provide antenatal care services and administer IPTp.
– Community Health Officers and Community Health Extension Workers: Staff primary health centers and play a role in delivering antenatal care services.
– Nurses/Midwives: Provide healthcare services and supervise the administration of IPTp.
– Research Assistants: Collect data and assist in the study process.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers on IPTp administration and monitoring.
– Procurement and distribution of preventive antimalarials to primary health centers.
– Awareness and education campaigns targeting pregnant women and the general population.
– Monitoring and evaluation activities to assess the effectiveness of the implemented recommendations.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is cross-sectional, which limits the ability to establish causality. However, the study includes a relatively large sample size and adjusts for potential confounding factors. To improve the strength of the evidence, a randomized controlled trial or a longitudinal study design could be considered. Additionally, including a control group and conducting follow-up assessments would provide more robust evidence.

Malaria in pregnancy is associated with substantial risk of maternal and fetal morbidity and mortality. The uptake of preventive antimalarials is low in malaria endemic countries, including Nigeria. Using a crosssectional study design, we assessed factors associated with uptake and adherence to intermittent preventive treatment for malaria in pregnancy (IPTp) among antenatal attendees in primary health centers in Kano, northern Nigeria (n5239). A total of 137 respondents (57.3%) reported receiving preventive antimalarials, but only 88 respondents (36.8%) [95% confidence interval (CI): 30.7-43.3%] reported ingesting pills in the clinic under supervision. Factors associated with adherence to IPTp after adjustment for potential confounding included: advanced maternal age [adjusted odds ratio (AOR) (95%CI)52.1 (1.3- 6.37)], higher educational attainment [AOR (95%CI)53.2 (1.32-6.72)], higher parity [AOR (95%CI)51.6 (1.07-3.94)], lower gestational age at booking [AOR (95% CI)51.72 (1.24-3.91)], and use of insecticidetreated nets [AOR (95%CI)52.03 (1.13-3.26)]. There is a need for strengthening health systems and addressing cultural factors that impede efforts at expanding coverage of malaria prevention strategies in Nigeria. © W. S. Maney & Son Ltd 2012.

The study was conducted in Kano Municipal local government area (LGA), one of the 44 LGAs of Kano State, Nigeria (estimated population: 365 525).20 Most of the women are fulltime homemakers, of Hausa–Fulani ethnicity. Malaria is endemic in this LGA with perennial transmission. The LGA is urban and is divided into 10 wards. There are 12 primary health care centers (PHCs) and four general hospitals. The PHCs are staffed by community health officers, community health extension workers, and a few nurses/midwives. Antenatal care services are conducted on Tuesdays and Thursdays in the PHCs. Other activities at PHCs include distribution of free ITNs supplied by the Federal Ministry of Health. Five frequency modulation (FM) radio stations (Freedom Radio, Rahama Radio, Cool FM, Radio Kano 2 FM, and Wazobia radio) serve residents of urban Kano and neighboring states. In addition, women in the study area are ardent listeners of foreign radio stations like the Hausa language service of the BBC, VOA, and Radio Deutsche Welle Hausa Service. These stations air health programs including those targeted at preventing malaria during pregnancy. Local, national, and global satellite television stations occasionally broadcast health programs that are viewed in the study area. Mobile telephone services are nearly universal, but access to internet services is very limited. The study population comprised all consenting pregnant women attending antenatal care at all the primary health centers rendering antenatal services in Kano Municipal LGA between June 2011 and July 2011. A cross-sectional descriptive design was used. We applied Fisher formula21 to compute the required sample size for the survey, using estimates of reported IPTp use among pregnant women in a previous study.22 In order to detect IPTp use with an error rate of 5% and 95% confidence interval (CI), the minimum sample size was inflated by 10% and rounded up to 250 to account for non-response. Respondents were selected using probability proportionate to size (of average annual attendance) from three randomly selected antenatal clinics from the six PHCs rendering antenatal services. In each sampled PHC, systematic sampling technique was used to recruit respondents. Using the estimate of the average clinic attendance, a sampling interval was determined for each PHC and applied accordingly, with balloting employed to determine the first enrollee. Information was collected using an interviewer-administered questionnaire adapted from a previous study.18 The questionnaire was structured with a combination of close and open-ended questions. Questions eliciting attitude and perceptions were on a five-point Likert scale or open ended. The questionnaire comprised questions on socio-demographic characteristics, obstetric history, and knowledge of malaria and IPTp, including attitudes to IPTp and antenatal clinic attendance. In the participating clinics, gestational age was routinely estimated by the last menstrual period and symphisio-fundal height measurement. Ultrasound scan was utilized for dating in cases of unsure date, first trimester cases, or when there was discrepancy between last menstrual period and symphisio-fundal height. Information on perception of attitude and activities of antenatal clinic staff toward IPTp was also assessed. The questionnaire was translated into Hausa language and administered by four trained female research assistants. Ethical approval for this study was obtained from the Aminu Kano Teaching Hospital Institutional Review Board. Data entry and analysis were performed using Statistical Package for Social Sciences (SPSS) version 16.0 (SPSS Inc., Chicago, IL, USA). Data were summarized using frequency tables, graphs, means, and standard deviations (SDs). Correct responses to knowledge questions were awarded one mark and wrong responses scored zero. The total scores were converted to percentages and graded as poor (0–39%), fair (40–69%), and good (70–100%). A woman was considered adherent if she swallowed the prescribed dose under the supervision of health workers at the clinic. To identify factors associated with adherence, bivariate analysis was employed using Chi-squared test or Chi-squared test for trend, as appropriate. Adjustment for confounding among factors was effected using logistic regression analysis. The crude odds ratio (OR) provides a measure of the strength of relationship between adherence to IPT (dependent variable) and each independent variable at the bivariate level. Adjusted odds ratios (AORs) were obtained by including variables found to be significantly associated with adherence at bivariate level en bloc in a logistic regression model. This was to determine the independent effects of various levels of these independent variables while controlling for the effect of the others. The corresponding 95% confidence intervals were also reported. All tests of significance were considered significant if P<0.05.

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

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women with information about maternal health, including preventive measures for malaria. These apps can also send reminders for antenatal care appointments and medication adherence.

2. Community Health Workers: Train and deploy community health workers to provide education and support to pregnant women in their communities. These workers can conduct home visits, distribute preventive antimalarials, and provide counseling on the importance of adherence to intermittent preventive treatment for malaria in pregnancy (IPTp).

3. Radio and Television Campaigns: Collaborate with local radio and television stations to broadcast health programs that focus on preventing malaria during pregnancy. These programs can provide information on the benefits of IPTp and encourage pregnant women to seek antenatal care services.

4. Partnerships with Mobile Network Operators: Collaborate with mobile network operators to provide free or subsidized mobile data packages for pregnant women, enabling them to access health information and resources online. This can help overcome the limited access to internet services in the study area.

5. Integration of Services: Integrate malaria prevention services, such as distribution of insecticide-treated nets, with antenatal care services. This can ensure that pregnant women have access to both preventive antimalarials and bed nets during their antenatal visits.

6. Health Education Campaigns: Conduct targeted health education campaigns in the community, focusing on the importance of IPTp and dispelling myths and misconceptions surrounding its use. These campaigns can be conducted through community meetings, posters, and pamphlets.

7. Strengthening Health Systems: Invest in strengthening the health systems in the study area, including improving the availability and accessibility of antenatal care services. This can involve training healthcare providers, ensuring the availability of essential supplies and medications, and improving the overall quality of care.

8. Addressing Cultural Factors: Work with community leaders and influencers to address cultural factors that may impede efforts to expand coverage of malaria prevention strategies. This can involve engaging with religious and traditional leaders to promote the importance of IPTp and antenatal care.

It is important to note that the specific context and needs of the study area should be taken into consideration when implementing these innovations.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health would be to strengthen health systems and address cultural factors that impede efforts at expanding coverage of malaria prevention strategies in Nigeria. This could include:

1. Strengthening healthcare infrastructure: Improve the capacity and resources of primary health centers and general hospitals in urban areas to provide quality antenatal care services, including the provision of preventive antimalarials.

2. Enhancing healthcare education: Increase awareness and knowledge among pregnant women about the importance of preventive antimalarials during pregnancy through targeted health programs on radio and television stations, as well as through community outreach programs.

3. Addressing cultural barriers: Identify and address cultural beliefs and practices that may hinder the uptake and adherence to intermittent preventive treatment for malaria in pregnancy. This could involve engaging community leaders, religious leaders, and traditional birth attendants to promote the importance of preventive antimalarials.

4. Improving access to insecticide-treated nets: Ensure that pregnant women have access to insecticide-treated nets, which have been shown to be associated with higher adherence to intermittent preventive treatment for malaria in pregnancy.

5. Strengthening monitoring and evaluation: Implement a robust monitoring and evaluation system to track the uptake and adherence to intermittent preventive treatment for malaria in pregnancy, and to identify any gaps or challenges that need to be addressed.

By implementing these recommendations, it is expected that access to maternal health, specifically in relation to malaria prevention during pregnancy, will be improved in Nigeria.
AI Innovations Methodology
To improve access to maternal health, here are some potential recommendations based on the information provided:

1. Strengthening Health Systems: Focus on improving the infrastructure, staffing, and resources of primary health centers and general hospitals in the study area. This includes ensuring that these facilities have trained healthcare providers, necessary equipment and supplies, and adequate funding to provide quality maternal health services.

2. Health Education and Awareness: Implement targeted health education programs through various channels such as radio stations, satellite television, and mobile phone services. These programs should provide information on the importance of preventive antimalarials during pregnancy, the benefits of antenatal care, and the risks associated with malaria in pregnancy. Emphasize the use of insecticide-treated nets and other preventive measures.

3. Cultural Sensitivity: Address cultural factors that may impede efforts to expand coverage of malaria prevention strategies. This could involve working closely with community leaders, traditional birth attendants, and religious leaders to promote the importance of maternal health and encourage adherence to preventive measures.

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

1. Baseline Data Collection: Gather data on the current state of access to maternal health services, including the uptake and adherence to intermittent preventive treatment for malaria in pregnancy (IPTp). This could involve conducting surveys, interviews, and reviewing existing data from health facilities.

2. Define Indicators: Identify key indicators to measure the impact of the recommendations. This could include indicators such as the percentage of pregnant women receiving preventive antimalarials, the percentage of women adhering to IPTp, and the percentage of women attending antenatal care.

3. Intervention Implementation: Implement the recommended interventions, such as strengthening health systems and conducting health education programs. Ensure that these interventions are implemented consistently and monitored closely.

4. Data Collection after Intervention: Collect data after the interventions have been implemented to assess the impact. This could involve conducting follow-up surveys, interviews, and reviewing data from health facilities.

5. Data Analysis: Analyze the data collected before and after the interventions to determine the changes in access to maternal health services. Compare the indicators from the baseline data to the post-intervention data to measure the impact of the recommendations.

6. Evaluation and Reporting: Evaluate the results of the analysis and report on the impact of the recommendations. This could involve summarizing the changes in access to maternal health services, identifying any challenges or barriers encountered during the implementation, and making recommendations for further improvements.

By following this methodology, it would be possible to simulate the impact of the recommendations on improving access to maternal health and assess the effectiveness of the interventions implemented.

Statistics:
Citations: 16
Authors: 7
Identifiers:
DOI: 10.1179/2047773212Y.0000000037
ISSN: 20477724
Research Areas:
Community Interventions, Environmental, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce
Study Countries:
Nigeria
Study Design:
Case-Control Study, Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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