Implementation of a malaria prevention education intervention in Southern Ethiopia: a qualitative evaluation

BMC Public Health, Volume 22, No. 1, Year 2022

Interpretation

Background: Though school-aged children (SAC) are at high risk of malaria, they are the ones that benefit the least from malaria prevention measures. A cluster randomized controlled trial was conducted to evaluate the effect of malaria prevention education (MPE) on insecticide-treated bed net (ITN) utilization and prompt diagnosis, reported incidence and treatment (PDAT) of malaria. Qualitative evaluation of the implementation of such interventions is vital to explain its effectiveness and will serve as guidance for future interventions. Therefore, this study aimed to evaluate the implementation of the MPE in southern Ethiopia. Methods: The trial was registered in Pan African Clinical Trials Registry (PACTR202001837195738) on 21/01/2020. A descriptive qualitative study using semi-structured interview with participants of the MPE was conducted in January 2020 and January 2021. The collected data were transcribed verbatim and analyzed thematically. The analysis of the data was supported by NVivo. Results: The four themes identified after evaluation of MPE training were the setup of the training, challenges for the success of the training, anticipated challenges for practice as per the protocol and experienced immediate influences of the training. Participants appreciated the training: content covered, way of delivery and the mix of the participants. The context specific facilitators to bed net use were the collateral benefits of ITN and perceived at high risk of malaria while its barriers were quality and quantity of the bed nets, bed net associated discomforts, malaria health literacy and housing condition. Severeness of malaria symptoms and malaria health literacy were reported as both barriers and facilitators of the PDAT of malaria. The identified facilitators of PDAT of malaria were health professionals’ attitude and exposure to MPE while its barriers were poverty, use of traditional medicine, health facility problems and Coronavirus Disease 2019 (COVID-19) pandemic. Conclusion: Low attendance of parents in the training was the major challenge for the success of MPE. National malaria program should ensure the access to malaria prevention measures; and future studies using increased frequency of the intervention embedded with monitoring adherence to the intervention protocol shall be conducted to improve the gains from existing malaria interventions. This study was conducted in Dara Mallo and Uba Debretsehay Districts in Southern Ethiopia. According to the 2007 national census, a total of 150,145 people were living in the two districts, and of these 76,550 (51%) were males [26]. The updated population in the study area was described in the previous article [27]. An update made by the respective districts in 2020 indicates that there was a total of 94,396 people in Uba Debretsehay district and 110,207 people in the Dara Mallo district. The location map of the study area was indicated in Fig. 1. Location map indicating where the present study was conducted in southern Ethiopia, 2020–2021 The intervention, MPE, was developed after exploring the parents’ perception of cause of malaria and their malaria prevention experience among SAC in kutcha district in southern Ethiopia [19] and existing literature. The intervention is designed to correct misperception of cause of malaria and incorrect malaria prevention practices. The intervention providers (trained science teachers and school headmasters from each school) first explored the perception of cause of malaria and their malaria prevention experiences. Then, the intervention providers discussed the correct causes of malaria and malaria prevention measures from the MPE document. This document included topics on the cause of malaria, consequences of malaria, prevention of malaria, symptoms of malaria and treatment of malaria. In addition, both the children as well as their parents were demonstrated on how to properly fix the bed nets. The intervention is given to the SAC (5–14 years) and their parents in separate groups by the trained science teachers from each school. The trial was registered in Pan African Clinical Trials Registry with the registration number of PACTR202001837195738 on 21/01/2020. This intervention was implemented, in the last week of December 2019, by trained science teachers and school headmasters in the intervention schools. As indicated above, the implementers started the training by exploring the perceived causes of malaria and their lived experiences, and then corrected the misperceptions and incorrect experiences. We hypothesized that improved knowledge on the right cause of malaria and consequences of malaria coupled with increased awareness about malaria prevention strategies could lead to effective and consistent utilization of malaria prevention strategies. Knowledge of the symptoms of malaria and awareness about the consequences of malaria would make parents to seek medical care for their child from the health facility promptly. Prompt diagnosis and treatment would interrupt the onward transmission of malaria parasites to other susceptible individuals and malaria associated morbidities and its complications. A descriptive qualitative evaluation was used to address the research questions. First, we explored how the participants experienced the intervention, immediate influences of the intervention and anticipated challenges for practice as per the protocol of the intervention. In the 2nd time point of data collection, the context specific barriers and facilitators of the ITN utilization and PDAT of malaria were explored. A total of 25 participants (9 intervention implementers and 16 recipients) were included in the study to address how the participants experienced the intervention and anticipated challenges to practice as per the intervention and immediate influences of the intervention. They were sampled based on the maximum variation sampling technique. Those involved in the study were diverse with respect to district, residence place, the quality of the intervention (as described by the setup of the training delivered), gender, and the role in the intervention process (either intervention implementer or parent of the selected SAC). At the end of the trial, we explored the barriers and facilitators for ITN utilization and PDAT (the outcomes we focused on in the intervention) of malaria (implementation during the trail) and looked at how the intervention assisted participants. To explore the barriers and facilitators of ITN use by SAC, all participants involved in the study were eligible; but for PDAT of malaria, only children who had shown symptoms of malaria after the intervention were included. Twelve parents of the SAC and the 9 key informants were involved to address the barriers and facilitators of the ITN utilization and PDAT of malaria. The key informants recruited were the intervention providers, health extension workers (government paid females trained on the health extension program), malaria focal persons in the district health offices and health centers in the study area. These were also sampled by using the maximum variation sampling technique. The data collection, using semi-structured interviews, was done at two time-points. The first one, addressing the evaluation of the training, was conducted about two weeks after the intervention. The topic guides were developed with the main focus of the big themes mentioned above: how the intervention participants experienced the intervention, its immediate experienced influences and the anticipated challenges to practice as per the protocol. The 2nd time point was one year after the intervention when context specific factors affecting ITN utilization and PDAT of malaria were explored. The topic guides were developed with the main focus of the sub-themes mentioned: barriers, facilitators and how the intervention influenced the ITN utilization and PDAT of malaria. The parents were interviewed in their residence homes while the school directors were interviewed in the school compound or their residence area. Interview with the health extension workers, malaria focal persons in the health centers and district health officers were held in their respective working offices. Participation in the intervention was monitored by independent monitors, who were not among the research team to avoid bias. Information from this independent monitoring was used to select the participants of the intervention and its quality. There were three individuals who carried out the interview process. They were health professionals with MSc in maternal and child health, MPH in health education and promotion and MSc in tropical and infectious diseases. All interviewers have experience of qualitative research and conducting interviews. The interviews were audio recorded and notes were taken during the data collection process. The interviews were undertaken in local languages (Gamogna or Gofegna) and Amharic (commonly spoken language all over Ethiopia) depending on the preference of the participant in the study. The interviewers involved in the data collection process were fluent in the local languages and Amharic (commonly spoken language in Ethiopia). After each interview, there was a debriefing session with the interview team in order to adapt the topic guide when necessary to improve data collection. The digital audio material was transcribed by one of the three interviewers in verbatim. The transcribed data were translated to english and read once again and the data analyst listened repeatedly to the audio material in order to deeply immerse into the data. The data were analyzed thematically by ZZ (one of the researchers involved in the interview process and trained in qualitative research methods)-always keeping the main focus of the big themes and subthemes mentioned above. These were used as a guiding frame. First the initial transcripts were coded line by line to unravel the data. After 4 interviews, these open codes were segregated/ordered based on their similarities into subthemes. These subthemes are further grouped and refined to form big themes and discussed among the research team. The analysis of the data was supported by the new QSR NVivo version 1.5.1 (940) [28]. At the different stages of the analysis, the codes, subthemes and themes were discussed with the other two senior experts in qualitative research (HB; SA).

AI Digest

Study Justification:

– School-aged children (SAC) are at high risk of malaria but benefit the least from prevention measures.
– This study aimed to evaluate the implementation of malaria prevention education (MPE) in southern Ethiopia.
– Qualitative evaluation is vital to understand the effectiveness of interventions and guide future interventions.

Highlights:

– The MPE training was appreciated by participants, who found the content and delivery effective.
– Context-specific facilitators of bed net use included collateral benefits of ITN and perceived high risk of malaria.
– Barriers to bed net use included quality and quantity of bed nets, discomfort, malaria health literacy, and housing conditions.
– Severeness of malaria symptoms and health literacy were reported as both barriers and facilitators of prompt diagnosis and treatment.
– Facilitators of prompt diagnosis and treatment included health professionals’ attitude and exposure to MPE.
– Barriers to prompt diagnosis and treatment included poverty, use of traditional medicine, health facility problems, and the COVID-19 pandemic.
– Low attendance of parents in the training was a major challenge for the success of MPE.

Recommendations:

– National malaria programs should ensure access to malaria prevention measures.
– Future studies should increase the frequency of interventions and monitor adherence to the intervention protocol.

Key Role Players:

– Trained science teachers and school headmasters for intervention delivery.
– Health extension workers, malaria focal persons, and health center staff for support and coordination.

Cost Items for Planning Recommendations:

– Training materials and resources for science teachers and school headmasters.
– Communication and coordination costs for health extension workers and health center staff.
– Monitoring and evaluation expenses to ensure intervention adherence.
– Awareness campaigns and educational materials for parents and the community.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative evaluation of the implementation of a malaria prevention education intervention in Southern Ethiopia. The study provides insights into the participants’ experiences, challenges, and facilitators of the intervention. However, the evidence is limited to a specific geographic area and does not include quantitative data or a control group for comparison. To improve the strength of the evidence, future studies could consider conducting a randomized controlled trial with a larger sample size and including a control group to assess the effectiveness of the intervention. Additionally, incorporating quantitative measures of ITN utilization and PDAT of malaria would provide more objective data for evaluation.

Abstract

This study was conducted in Dara Mallo and Uba Debretsehay Districts in Southern Ethiopia. According to the 2007 national census, a total of 150,145 people were living in the two districts, and of these 76,550 (51%) were males [26]. The updated population in the study area was described in the previous article [27]. An update made by the respective districts in 2020 indicates that there was a total of 94,396 people in Uba Debretsehay district and 110,207 people in the Dara Mallo district. The location map of the study area was indicated in Fig. 1. Location map indicating where the present study was conducted in southern Ethiopia, 2020–2021 The intervention, MPE, was developed after exploring the parents’ perception of cause of malaria and their malaria prevention experience among SAC in kutcha district in southern Ethiopia [19] and existing literature. The intervention is designed to correct misperception of cause of malaria and incorrect malaria prevention practices. The intervention providers (trained science teachers and school headmasters from each school) first explored the perception of cause of malaria and their malaria prevention experiences. Then, the intervention providers discussed the correct causes of malaria and malaria prevention measures from the MPE document. This document included topics on the cause of malaria, consequences of malaria, prevention of malaria, symptoms of malaria and treatment of malaria. In addition, both the children as well as their parents were demonstrated on how to properly fix the bed nets. The intervention is given to the SAC (5–14 years) and their parents in separate groups by the trained science teachers from each school. The trial was registered in Pan African Clinical Trials Registry with the registration number of PACTR202001837195738 on 21/01/2020. This intervention was implemented, in the last week of December 2019, by trained science teachers and school headmasters in the intervention schools. As indicated above, the implementers started the training by exploring the perceived causes of malaria and their lived experiences, and then corrected the misperceptions and incorrect experiences. We hypothesized that improved knowledge on the right cause of malaria and consequences of malaria coupled with increased awareness about malaria prevention strategies could lead to effective and consistent utilization of malaria prevention strategies. Knowledge of the symptoms of malaria and awareness about the consequences of malaria would make parents to seek medical care for their child from the health facility promptly. Prompt diagnosis and treatment would interrupt the onward transmission of malaria parasites to other susceptible individuals and malaria associated morbidities and its complications. A descriptive qualitative evaluation was used to address the research questions. First, we explored how the participants experienced the intervention, immediate influences of the intervention and anticipated challenges for practice as per the protocol of the intervention. In the 2nd time point of data collection, the context specific barriers and facilitators of the ITN utilization and PDAT of malaria were explored. A total of 25 participants (9 intervention implementers and 16 recipients) were included in the study to address how the participants experienced the intervention and anticipated challenges to practice as per the intervention and immediate influences of the intervention. They were sampled based on the maximum variation sampling technique. Those involved in the study were diverse with respect to district, residence place, the quality of the intervention (as described by the setup of the training delivered), gender, and the role in the intervention process (either intervention implementer or parent of the selected SAC). At the end of the trial, we explored the barriers and facilitators for ITN utilization and PDAT (the outcomes we focused on in the intervention) of malaria (implementation during the trail) and looked at how the intervention assisted participants. To explore the barriers and facilitators of ITN use by SAC, all participants involved in the study were eligible; but for PDAT of malaria, only children who had shown symptoms of malaria after the intervention were included. Twelve parents of the SAC and the 9 key informants were involved to address the barriers and facilitators of the ITN utilization and PDAT of malaria. The key informants recruited were the intervention providers, health extension workers (government paid females trained on the health extension program), malaria focal persons in the district health offices and health centers in the study area. These were also sampled by using the maximum variation sampling technique. The data collection, using semi-structured interviews, was done at two time-points. The first one, addressing the evaluation of the training, was conducted about two weeks after the intervention. The topic guides were developed with the main focus of the big themes mentioned above: how the intervention participants experienced the intervention, its immediate experienced influences and the anticipated challenges to practice as per the protocol. The 2nd time point was one year after the intervention when context specific factors affecting ITN utilization and PDAT of malaria were explored. The topic guides were developed with the main focus of the sub-themes mentioned: barriers, facilitators and how the intervention influenced the ITN utilization and PDAT of malaria. The parents were interviewed in their residence homes while the school directors were interviewed in the school compound or their residence area. Interview with the health extension workers, malaria focal persons in the health centers and district health officers were held in their respective working offices. Participation in the intervention was monitored by independent monitors, who were not among the research team to avoid bias. Information from this independent monitoring was used to select the participants of the intervention and its quality. There were three individuals who carried out the interview process. They were health professionals with MSc in maternal and child health, MPH in health education and promotion and MSc in tropical and infectious diseases. All interviewers have experience of qualitative research and conducting interviews. The interviews were audio recorded and notes were taken during the data collection process. The interviews were undertaken in local languages (Gamogna or Gofegna) and Amharic (commonly spoken language all over Ethiopia) depending on the preference of the participant in the study. The interviewers involved in the data collection process were fluent in the local languages and Amharic (commonly spoken language in Ethiopia). After each interview, there was a debriefing session with the interview team in order to adapt the topic guide when necessary to improve data collection. The digital audio material was transcribed by one of the three interviewers in verbatim. The transcribed data were translated to english and read once again and the data analyst listened repeatedly to the audio material in order to deeply immerse into the data. The data were analyzed thematically by ZZ (one of the researchers involved in the interview process and trained in qualitative research methods)-always keeping the main focus of the big themes and subthemes mentioned above. These were used as a guiding frame. First the initial transcripts were coded line by line to unravel the data. After 4 interviews, these open codes were segregated/ordered based on their similarities into subthemes. These subthemes are further grouped and refined to form big themes and discussed among the research team. The analysis of the data was supported by the new QSR NVivo version 1.5.1 (940) [28]. At the different stages of the analysis, the codes, subthemes and themes were discussed with the other two senior experts in qualitative research (HB; SA).

Materials

Innovations

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

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide educational resources and information on maternal health, including prenatal care, nutrition, and postnatal care. These apps can be easily accessible to pregnant women and new mothers, providing them with important information and reminders.

2. Telemedicine: Establish telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals and receive prenatal care remotely. This can help overcome geographical barriers and ensure that women receive the necessary care and guidance throughout their pregnancy.

3. Community Health Workers: Train and deploy community health workers who can provide education and support to pregnant women in their communities. These workers can conduct home visits, provide basic prenatal care, and refer women to healthcare facilities when necessary.

4. Maternal Health Vouchers: Implement voucher programs that provide pregnant women with access to essential maternal health services, such as prenatal check-ups, delivery, and postnatal care. These vouchers can be distributed to women in need, ensuring that they can access quality care regardless of their financial situation.

5. Transportation Solutions: Develop innovative transportation solutions, such as mobile clinics or ambulances, to improve access to healthcare facilities for pregnant women in remote areas. This can help overcome transportation barriers and ensure timely access to emergency obstetric care.

6. Health Education Campaigns: Conduct targeted health education campaigns to raise awareness about the importance of maternal health and encourage women to seek prenatal care. These campaigns can use various mediums, such as radio, television, and community outreach programs, to reach a wide audience.

7. Maternal Health Information Systems: Implement digital information systems that track and monitor maternal health indicators, such as antenatal care visits, deliveries, and postnatal care. These systems can help identify gaps in care and enable healthcare providers to intervene and provide appropriate support.

8. Public-Private Partnerships: Foster collaborations between public and private sectors to improve access to maternal health services. This can involve partnering with private healthcare providers to expand service delivery, leveraging private sector expertise in technology and innovation, and mobilizing resources for maternal health programs.

It is important to note that the specific context and needs of the target population should be considered when implementing these innovations. Additionally, continuous evaluation and monitoring of these interventions are crucial to ensure their effectiveness and impact on improving access to maternal health.

AI Innovations Description

The study described in the provided text evaluated the implementation of a malaria prevention education (MPE) intervention in southern Ethiopia. The MPE intervention aimed to improve insecticide-treated bed net (ITN) utilization, prompt diagnosis and treatment (PDAT) of malaria, and overall knowledge about malaria prevention among school-aged children (SAC) and their parents.

The study found several key findings and recommendations:

1. Training Setup: The participants appreciated the content covered in the training, the delivery method, and the mix of participants. However, low attendance of parents in the training was identified as a major challenge for the success of the MPE intervention.

Recommendation: To improve the success of future interventions, it is recommended to address the challenge of low parent attendance by implementing strategies to increase parent engagement, such as scheduling training sessions at convenient times and actively involving parents in the planning and implementation process.

2. Barriers and Facilitators of ITN Utilization: The study identified several context-specific barriers and facilitators to ITN utilization. Barriers included the quality and quantity of bed nets, bed net-associated discomforts, low malaria health literacy, and housing conditions. Facilitators included the collateral benefits of ITN and the perception of being at high risk of malaria.

Recommendation: To improve ITN utilization, it is recommended to address the identified barriers by ensuring the availability of high-quality bed nets, providing education on proper bed net usage and maintenance, and increasing malaria health literacy among the community.

3. Barriers and Facilitators of PDAT of Malaria: The study found that the severity of malaria symptoms and malaria health literacy were reported as both barriers and facilitators of PDAT of malaria. Other barriers included poverty, the use of traditional medicine, health facility problems, and the impact of the COVID-19 pandemic. Health professionals’ attitude and exposure to MPE were identified as facilitators of PDAT.

Recommendation: To improve PDAT of malaria, it is recommended to address the identified barriers by strengthening healthcare systems, providing education on the importance of seeking prompt medical care for malaria symptoms, and ensuring access to affordable and effective malaria treatment.

4. Future Studies: The study suggests conducting future studies using increased frequency of the MPE intervention embedded with monitoring adherence to the intervention protocol. This can help improve the gains from existing malaria interventions and provide further insights into the effectiveness of the intervention.

Overall, the study highlights the importance of implementing comprehensive malaria prevention education interventions, addressing barriers to ITN utilization and PDAT, and actively involving parents in the intervention process to improve access to maternal health in southern Ethiopia.

AI Innovations Methodology

Based on the provided description, the study focuses on evaluating the implementation of a malaria prevention education (MPE) intervention in southern Ethiopia. The goal of the intervention is to improve insecticide-treated bed net (ITN) utilization, prompt diagnosis, reported incidence, and treatment (PDAT) of malaria among school-aged children (SAC). The study uses a qualitative evaluation methodology to assess the implementation of the intervention and explore the barriers and facilitators of ITN utilization and PDAT of malaria.

To improve access to maternal health, here are some potential recommendations that can be considered:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide pregnant women with access to information, resources, and support for maternal health. These apps can offer features such as appointment reminders, educational content, nutrition guidance, and emergency helplines.

2. Telemedicine Services: Establish telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video or phone calls. This can help overcome geographical barriers and provide timely advice and guidance for maternal health concerns.

3. Community Health Workers: Train and deploy community health workers who can provide maternal health services and education directly to women in their communities. These workers can conduct regular check-ups, provide prenatal care, and offer guidance on nutrition, hygiene, and safe delivery practices.

4. Transportation Support: Develop transportation systems or programs that provide affordable and accessible transportation for pregnant women to reach healthcare facilities. This can help overcome transportation barriers and ensure timely access to maternal health services.

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

1. Define the target population: Identify the specific group of pregnant women who would benefit from the recommended innovations. Consider factors such as geographical location, socioeconomic status, and existing barriers to access.

2. Collect baseline data: Gather data on the current state of access to maternal health services in the target population. This can include information on healthcare facility availability, transportation options, knowledge and awareness levels, and utilization of maternal health services.

3. Develop a simulation model: Create a simulation model that incorporates the recommended innovations and their potential impact on improving access to maternal health. This model should consider factors such as the number of women reached, the frequency of interaction with the innovations, and the expected outcomes in terms of improved access and health outcomes.

4. Input data and parameters: Input the collected baseline data and relevant parameters into the simulation model. This can include data on population size, geographical distribution, healthcare facility capacity, transportation infrastructure, and the effectiveness of the recommended innovations.

5. Run simulations: Run multiple simulations using the model to simulate different scenarios and assess the potential impact of the recommended innovations on improving access to maternal health. This can involve varying parameters such as the coverage and effectiveness of the innovations, as well as different population scenarios.

6. Analyze results: Analyze the results of the simulations to evaluate the potential impact of the recommended innovations on improving access to maternal health. Assess the changes in key indicators such as the number of women accessing maternal health services, reduction in barriers, and improvements in health outcomes.

7. Refine and iterate: Based on the simulation results, refine the model and recommendations as necessary. Iterate the simulation process to explore different scenarios and optimize the potential impact of the innovations on improving access to maternal health.

By following this methodology, stakeholders can gain insights into the potential benefits and challenges of implementing the recommended innovations and make informed decisions on how to improve access to maternal health.

Author

Dima Health

Identifiers:

DOI: 10.1186/s12889-022-14200-x

Research Areas:

Community Interventions, COVID, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Ethiopia

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory, Phenomenological Study, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female