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Objectives: To evaluate barriers preventing pregnant women from using insecticide-treated nets (ITN) and intermittent presumptive treatment (IPT) with sulphadoxine-pyrimethamine (SP) 5 years after the launch of the national malaria strategy promoting these measures in Kenya. Methods: All women aged 15-49 years were interviewed during a community survey in four districts between December 2006 and January 2007. Women pregnant in the last 12 months were asked about their age, parity, education, use of nets, ITN, antenatal care (ANC) services and sulphadoxine-pyrimethamine (SP) (overall and for IPT) during pregnancy. Homestead assets were recorded and used to develop a wealth index. Travel time to ANC clinics was computed using a geographic information system algorithm. Predictors of net and IPT use were defined using multivariate logistic regression. Results: Overall 68% of pregnant women used a net; 52% used an ITN; 84% attended an ANC clinic at least once and 74% at least twice. Fifty-three percent of women took at least one dose of IPT-SP, however only 22% took two or more doses. Women from the least poor homesteads (OR = 2.53, 1.36-4.68) and those who used IPT services (OR = 1.73, 1.24-2.42) were more likely to sleep under any net. Women who used IPT were more likely to use ITNs (OR = 1.35, 1.03-1.77), while those who lived more than an hour from an ANC clinic were less likely (OR = 0.61, 0.46-0.81) to use ITN. Women with formal education (1.47, 1.01-2.17) and those who used ITN (OR: 1.68, 1.20-2.36) were more likely to have received at least one dose of IPT-SP. Conclusion: Although the use of ITN had increased 10-fold and the use of IPT fourfold since last measured in 2001, coverage remains low. Provider practices in the delivery of protective measures against malaria must change, supported by community awareness campaigns on the importance of mothers’ use of IPT. © 2008 Blackwell Publishing Ltd.
Much of the scientific evidence generated to support the policy position on the use of IPT and ITN during pregnancy in Africa was developed in Kenya (Parise et al. 1998; Shulman et al. 1999; Van Eijk et al. 2002, 2004a,b; Njagi et al. 2003; Ter Kuile et al. 2003). In April 2001 the Kenyan National Malaria Strategy was launched with the management and prevention of malaria in pregnancy as a major component with a stated aim to ensure that 60% of pregnant women were using an ITN or effective IPT by 2006 (MOH 2001). The Division of Reproductive Health (DRH) of the Kenyan Ministry of Health (MOH) developed an implementation strategy to ensure effective clinical management of anaemia and delivery of IPT among ANC attendees with the support of the John Hopkins Program for International Education in Reproductive Health (JHPIEGO) and financial support from the UK’s Department for International Development (DFID). The programme began in July 2000 in the two districts of Kilifi and Busia, as a pilot project and was expanded to four districts (Kwale, Taita-Taveta, Homa Bay and Bondo) in 2002. The fundamentals of the Focussed Antenatal Care programme included the provision of cascade in-service training through decentralized training centres that aimed to reach all cadres of nursing and clinical staff involved in seeing ANC clients. For malaria these in-service training initiatives were supported with laminated visual aids covering the basics of diagnosis and management of anaemia and the timing and dosing of presumptive SP provision during the second and third trimesters of pregnancy. Within the framework of the national malaria strategy, IPT is provided at no charge in public health services. The provision of ITN to pregnant women formed part of a separate implementation strategy managed by the Division of Malaria Control (DOMC) and other service delivery partners described in detail elsewhere (Noor et al. 2007). Briefly, between 2001 and 2004 the predominant source of ITN was the commercial retail sector as part of a DFID-funded programme of social marketing. In 2005 this programme changed to include the delivery of heavily subsidized ITN through maternal and child health and ANC clinics for children aged less than 5 years and pregnant women. In 2006 the DOMC launched a combined programme of ITN distribution with the Kenya Expanded Programme for Immunisation’s (KEPI) catch-up mass measles vaccination initiative, providing free ITN to children in 21 districts and free distribution in a further 24 districts not linked to vaccination. The study was conducted in four districts purposively sampled in collaboration with the MOH to provide detailed longitudinal data on changing access to interventions between 2001 and 2006. The study districts represent the range of malaria epidemiological situations that prevail across Kenya: Kwale on the coast with seasonal, high intensity malaria transmission; Bondo on the shores of Lake Victoria with high intensity perennial transmission, Greater Kisii district (combining the new districts of Kisii Central and Gucha) with low, seasonal transmission conditions of the Western highlands, and Makueni district, a semi-arid area with acutely seasonal, low malaria transmission. The use of ANC services, including measures to prevent malaria during pregnancy, at the launch of the KNMS were described by Guyatt et al. (2004). Across the four districts in 2001, 11% of rural women pregnant in the last 12 months had slept under a net during the pregnancy and only 4.6% had slept under an ITN, 23% had taken any treatment course of SP during the pregnancy and less than 5.1% of women had had two presumptive treatment courses of SP in their second and third trimesters (Guyatt et al. 2004). Of the 230 rural and urban national census enumeration area (EA) communities sampled during 2001, 72 rural EAs were re-sampled in 2003 to form the basis of a more detailed homestead longitudinal surveillance. Following community sensitization, all homesteads within an EA were mapped using GPS (Garmin etrex; Garmin Ltd, Kansas, USA). We explained the purpose of the longitudinal study to heads of homesteads and asked them to participate. In November 2003 all consenting homesteads were recruited into the homestead cohort, de jure resident homestead members enumerated including details of date of birth and sex and each homestead member issued a unique identifier linked to their district, EA and household location. Annual censuses were undertaken between December and January 2004/2005 2005/2006 and 2006/2007. All women aged 15–49 years at the time of the 2006/2007 census were selected from the previous annual census to participate in a detailed interview on their pregnancy histories. Women who provided individual consent for interview and those agreeing to participate were questioned on their birth histories and highest levels of formal education attained. For women reporting a pregnancy that had resulted in a delivery in the last 12 months or who reported being currently pregnant further questions were asked on their use of named ANC services, SP (overall or when they were not sick), net use and whether these were treated in last 6 months or were long-lasting treated nets during the last or current pregnancy. Details were recorded on each homestead related to key asset indicators including: homestead head education level and occupation, housing characteristics (type of wall, roof and floor), source of drinking water, type of sanitation facility, homestead size and persons per sleeping room. Principal components were used to construct a wealth index (Filmer & Pritchett 2001). Wealth asset indices were developed separately for each district to allow for innate differences in the meaning of different assets between districts. Each homestead was then classified into a district-specific wealth quintile. Transport routes and topography; government mission and private health services; and physical barriers to travel (hills, rivers and protected areas) were mapped within each district and assembled in arcgis 9.0 (ESRI Inc., USA) (Noor et al. 2003). Because most people in the study districts walk to health facilities (Noor et al. 2006), walking times were computed using data from the digitized footpaths and roads between the nearest ANC provider and woman’s homestead. A travel time algorithm developed in C++ code was used to define speed differentials along the various footpath and road surfaces (Noor et al. 2006). Barriers such as rivers, forests and parks were masked as impassable. Where a path traversed a river or other water features, however, travel speed remained unchanged from that of the intersecting road. Data entry and storage was undertaken using MS Access (Microsoft, Redmond, USA), analysis was undertaken using STATA version 9.2 (Statacorp 2003, College Station, USA) and arcgis 9.0 (ESRI Inc., USA). A cluster-adjusted chi-squared test was performed to construct precision estimates around proportions and compare them across districts. Regression analyses were undertaken on combined data to examine factors that explained the use of nets; ITN; any IPT and two doses of IPT by pregnant women. Univariate regression analyses were first performed to identify which of the predictor variables were significant to the four outcome measures. In the univariate analyses any predictor with a P-value < 0.15 was considered to be a potentially important covariate of the outcome measure. All predictors meeting the entrance criteria were used to estimate a multivariable logistic regression model to identify their combined effect on a given outcome measure. The multivariate models were fitted using the STATA xtgee command with an exchangeable working correlation matrix. This procedure uses generalized estimating equations (GEE) to account for the potential correlation of observations on pregnant women seen in the same EA while accounting for the variability between clusters. All results were weighted for unequal probability of selection of EA within each district (weight = 1/probability of selecting an EA). Both the cluster-adjusted chi-squared test and the multivariate regression were adjusted for the effect of the variation between districts. Odds ratio (OR), 95% confidence interval (CI) and P-values were recorded for each predictor.
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