Reaching the unreached: effectiveness and satisfaction with community-directed distribution of sulfadoxine-pyrimethamine for preventing malaria in pregnancy in rural South-East, Nigeria

  • Malaria Journal, Volume 19, No. 1, Year 2020

listen audio

Study Justification:
– The study aimed to assess the effectiveness and satisfaction with community-directed distribution of sulfadoxine-pyrimethamine (IPTp-SP) for preventing malaria in pregnancy in rural South-East Nigeria.
– Innovative community strategies were advocated to increase IPTp-SP coverage, especially in areas with weak health infrastructure and high malaria transmission.
– The study aimed to provide evidence on the impact of community-directed distribution of IPTp-SP on uptake among pregnant women in Ebonyi State, Nigeria.
Study Highlights:
– The intervention involved advocacy visits, community-wide sensitizations on malaria prevention, house-to-house directly observed IPTp-SP administration, and follow-up visits by trained community-selected community-directed distributors (CDDs).
– Monthly IPTp-SP coverage increased significantly from 31.4% to 71.6% after the community-directed distribution of IPTp-SP.
– Sleeping under insecticide-treated nets (ITNs) increased from 62.4% to 84.3%.
– Reporting of fever during pregnancy decreased from 64.9% to 17.0%.
– Traditional birth attendants and patent medicine vendors remained more patronized than the primary health center.
– Mothers rated CDD services well (93.6%), were satisfied (97.6%), and preferred community IPTp administration to facility administration (92.3%).
Recommendations:
– The authors recommend sustained large-scale implementation of community-directed distribution of IPTp-SP with active community engagement.
– The findings suggest that community-directed distribution of IPTp-SP can improve uptake of IPTp-SP and ITN use, leading to better malaria prevention in pregnancy.
– Efforts should be made to strengthen the role of primary health centers and reduce reliance on traditional birth attendants and patent medicine vendors.
– Community engagement and involvement should be prioritized to ensure the success and sustainability of the intervention.
Key Role Players:
– Community-selected community-directed distributors (CDDs): Trained individuals responsible for house-to-house IPTp-SP administration and follow-up visits.
– Primary health centers (PHCs): Health facilities providing maternal health services and support for the community-directed distribution of IPTp-SP.
– Traditional birth attendants and patent medicine vendors: Existing healthcare providers in the community who need to be engaged and integrated into the intervention.
Cost Items for Planning Recommendations:
– Training and capacity building for community-selected CDDs.
– Advocacy and community sensitization activities.
– Procurement and distribution of IPTp-SP drugs.
– Monitoring and evaluation activities.
– Supportive supervision and mentorship for CDDs.
– Communication and information materials for community engagement.
– Strengthening of primary health centers and infrastructure.
– Integration and coordination efforts with traditional birth attendants and patent medicine vendors.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it presents clear findings from a before-and-after study conducted in a rural community in Nigeria. The study shows a significant increase in the uptake of IPTp-SP and ITN use after the implementation of community-directed distribution. The satisfaction of mothers with the services is also highlighted. To improve the evidence, it would be beneficial to include information on the sample size, demographic characteristics of the participants, and any potential limitations of the study.

Background: Innovative community strategies to increase intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) coverage is advocated particularly in rural areas, where health infrastructure is weakest and malaria transmission highest. This study involved proof-of-concept implementation research to determine satisfaction with and effectiveness of community-directed distribution of IPTp-SP on uptake among pregnant women in Ebonyi State, Nigeria. Methods: This before-and-after study was carried out in 2019 in a rural community in Ebonyi State Nigeria. The intervention involved advocacy visits, community-wide sensitizations on malaria prevention, house-to-house directly observed IPTp-SP administration, and follow-up visits by trained community-selected community-directed distributors (CDDs). Monthly IPTp-SP coverage was assessed over 5 months and data analysed using SPSS version 20. Results: During the study, 229 women received the first dose of IPTp while 60 pregnant women received 5 or more doses of IPTp. The uptake of ≥ 3 IPTp doses increased from 31.4% before the community-directed distribution of IPTp to 71.6% (P < 0.001) by the fourth month post-initiation of the community-directed distribution of IPTp. Sleeping under insecticide-treated net (ITN) the night before the survey increased from 62.4 to 84.3% (P < 0.001) while reporting of fever during pregnancy decreased from 64.9 to 17.0% (P < 0.001). Although antenatal clinic utilization increased in the primary health centre serving the community, traditional birth attendants and patent medicine vendors in the community remained more patronized. Post-intervention, most mothers rated CDD services well (93.6%), were satisfied (97.6%), and preferred community IPTp administration to facility administration (92.3%). Conclusion: Community-directed distribution of IPTp-SP improved uptake of IPTp-SP and ITN use. Mothers were satisfied with the services. The authors recommend sustained large-scale implementation of community-directed distribution of IPTp with active community engagement.

This study was conducted in the Ebiriogu community, which is located in the Okuzzu-Ukawu political ward in Ukawu Development Centre in Onicha local government area (LGA) of Ebonyi State, Southeast Nigeria. Ukawu Development Centre has 3 political wards: Okuzzu-Ukawu, Isinkwo and Abomege. Each political ward has a variable number of primary health centres (PHCs). Okuzzu-Ukawu political ward has 6 PHCs (one of which is located in Ebiriogu) and a dispensary. Ebiriogu community has 3 settlements and one PHC, which is the major source of orthodox health care services in the community. People of the community also access health services in the PHCs located in the other political wards, as well as from traditional healers. The people of Ukawu are mostly Ibos, the dominant tribe of South-East geopolitical zone of Nigeria and their major occupations include farming and trading. Ebonyi State is located in South-East Nigeria with Abakaliki as the state capital. There are 3 senatorial zones and 13 LGAs in the state. According to the 2006 population and housing census, the population of Ebonyi State is approximately 2,176,947 with a landmass of 5,935 sq km. Infants (children < 1 year old) make up 4% of the population, children under 5 years 20%, and women of childbearing age 22% of the population [3]. Malaria transmission in Nigeria is perennial, with seasonal peaks in March to September in the south and August to November in north. Temperature and rainfall variations could affect the distribution of mosquitoes and in turn influence the seasonality of malarial episodes and symptoms [2, 7]. This study was conducted during the rainy season (June-October), which represents the seasonal peak period for malaria transmission in southern Nigeria. In Ebonyi State, some PHCs are selected and supported by development partners while others are not. This support is usually in line with development partner’s organizational objectives and could range from capacity building on different aspects of health, monitoring and evaluation, supportive supervision, and community-level activities, among others. Ebiriogu community was selected because the PHC is not supported by any development partner. This is because, for supported facilities, development partners may have maternal health-related activities (inclusive of prevention and care for malaria in pregnancy) in the facility and community, which may confound findings from this study. Additionally, it is hoped that using a community with non-supported facilities will discourage dependence on external partners and promote sustainability, given recent donor fatigue in Nigeria and other developing countries. Eligible women who were in the second trimester of pregnancy, had experienced quickening and had not received a dose of SP in the previous one month. Pregnant women with a history of allergy to sulfur drugs, unexplained recurrent jaundice, or who were already on cotrimoxazole prophylaxis were excluded from receiving IPTp-SP. The study was an intervention study without control or randomization conducted in three phases: baseline, implementation and post-implementation evaluation. At baseline, uptake of IPTp was assessed using interviewer-administered questionnaires among 242 pregnant women and women who had given birth within 6 months before the survey. The questionnaires were administered by trained graduate research assistants. The respondents were recruited from the PHC in Ebiriogu community as well as 4 other PHCs in Ukawu Development Centre offering immunization and antenatal care services. These other PHCs were selected based on high levels of patronage by mothers. Baseline data collection was conducted over a 3-week period. At the PHC facility, registers were used to collect data on IPTp uptake.

N/A

The recommendation from the study is to implement community-directed distribution of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) for preventing malaria in pregnancy. This approach involves engaging and training community members as community-directed distributors (CDDs) who can provide IPTp-SP and educate pregnant women on malaria prevention. The study found that this approach effectively increased the uptake of IPTp-SP and the use of insecticide-treated nets (ITNs) among pregnant women.

To implement this recommendation, it is important to conduct advocacy visits and community-wide sensitizations on malaria prevention to raise awareness and promote the importance of IPTp-SP and ITN use. Trained CDDs can then conduct house-to-house directly observed administration of IPTp-SP to ensure proper adherence to the treatment regimen. Follow-up visits by the CDDs can provide additional support and address any concerns or questions from pregnant women.

It is crucial to sustain and expand this community-directed distribution approach to reach more rural areas with limited access to maternal health services. This can be achieved through collaboration with local health authorities, NGOs, and development partners. By scaling up the community-directed distribution of IPTp-SP, more pregnant women can benefit from this innovative approach and improve their access to maternal health services.

The study was conducted in the Ebiriogu community in Ebonyi State, Southeast Nigeria. The community has 3 settlements and one primary health center (PHC) which is the major source of orthodox health care services. The people of the community also access health services from PHCs in other political wards and traditional healers. The population of Ebonyi State is approximately 2,176,947, with a significant proportion being women of childbearing age.

The study was conducted during the rainy season, which represents the seasonal peak period for malaria transmission in southern Nigeria. The selection of Ebiriogu community was based on the PHC not being supported by any development partner, to discourage dependence on external partners and promote sustainability.

The study was conducted in three phases: baseline, implementation, and post-implementation evaluation. Baseline data on IPTp uptake was collected using questionnaires administered by trained research assistants. The study found that the community-directed distribution of IPTp-SP improved the uptake of IPTp-SP and ITN use, and mothers were satisfied with the services provided by the CDDs.
AI Innovations Description
The recommendation from the study to improve access to maternal health is the sustained large-scale implementation of community-directed distribution of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) for preventing malaria in pregnancy. The study found that community-directed distribution of IPTp-SP effectively increased the uptake of IPTp-SP and the use of insecticide-treated nets (ITNs) among pregnant women. The community engagement and involvement of trained community-selected community-directed distributors (CDDs) were key factors in the success of the intervention.

The study also revealed that mothers were satisfied with the services provided by the CDDs and preferred community IPTp administration over facility administration. This suggests that involving the community in the distribution of maternal health interventions can improve access and acceptability among pregnant women.

To implement this recommendation, it is important to engage and train community members as CDDs who can provide IPTp-SP and educate pregnant women on malaria prevention. Advocacy visits and community-wide sensitizations on malaria prevention should be conducted to raise awareness and promote the importance of IPTp-SP and ITN use. House-to-house directly observed administration of IPTp-SP by the CDDs can ensure proper adherence to the treatment regimen. Follow-up visits by the CDDs can also provide additional support and address any concerns or questions from pregnant women.

It is crucial to sustain and expand this community-directed distribution approach to reach more rural areas with limited access to maternal health services. This can be achieved through collaboration with local health authorities, NGOs, and development partners. By scaling up the community-directed distribution of IPTp-SP, more pregnant women can benefit from this innovative approach and improve their access to maternal health services.
AI Innovations Methodology
The methodology used in the study involved a before-and-after design to assess the impact of community-directed distribution of sulfadoxine-pyrimethamine (IPTp-SP) on improving access to maternal health. The study was conducted in a rural community in Ebonyi State, Nigeria.

The intervention included several components: advocacy visits, community-wide sensitizations on malaria prevention, house-to-house directly observed administration of IPTp-SP, and follow-up visits by trained community-selected community-directed distributors (CDDs). The CDDs were responsible for providing IPTp-SP and educating pregnant women on malaria prevention.

Data was collected over a 5-month period using interviewer-administered questionnaires. The questionnaires were administered to pregnant women and women who had given birth within 6 months before the survey. Baseline data on IPTp uptake was collected using registers at the primary health centers (PHCs) in the community and other PHCs in the Ukawu Development Centre.

The study assessed the uptake of IPTp-SP, use of insecticide-treated nets (ITNs), and reported fever during pregnancy before and after the implementation of the community-directed distribution of IPTp-SP. The data was analyzed using SPSS version 20.

The results showed that the uptake of ≥ 3 IPTp doses significantly increased from 31.4% before the intervention to 71.6% after the intervention. The use of ITNs also increased, and the reported fever during pregnancy decreased significantly. The satisfaction of mothers with the services provided by the CDDs was high, and they preferred community IPTp administration over facility administration.

Based on these findings, the study recommends the sustained large-scale implementation of community-directed distribution of IPTp-SP to improve access to maternal health. The study suggests engaging and training community members as CDDs, conducting advocacy visits and community-wide sensitizations, and implementing house-to-house directly observed administration of IPTp-SP. Collaboration with local health authorities, NGOs, and development partners is also important to scale up the intervention and reach more rural areas with limited access to maternal health services.

The study provides valuable evidence on the effectiveness and satisfaction with community-directed distribution of IPTp-SP in improving access to maternal health. By implementing the recommendations from this study, more pregnant women can benefit from this innovative approach and have improved access to maternal health services.


Statistics:
Citations: 3
Identifiers:
DOI: 10.1186/s12936-020-03468-2
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:
Nigeria
Study Design:
Cohort Study, Cross Sectional Study, Grounded Theory, randomised-control-trial
Study Approach:
Quantitative
Participants Gender:
Female
Partilhar isto:
Facebook
Twitter
LinkedIn
WhatsApp
Email