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Background: Improving maternal health remains a priority to the Ghanaian government. Consequently, it has implemented the World Health Organization recommendation of distributing free long-lasting insecticidal nets (LLINs) to pregnant women-one of the effective strategies to combating malaria in pregnancy. However, the burden of negative outcomes of malaria in pregnancy such as low birth weight and miscarriages is still high. This may be related to the health system, socio-cultural and economic dynamics that influence LLIN use, but their role is not well understood. This ethnographic study sought to understand health system, socio-cultural, economic and environmental dynamics in utilization of LLINs among pregnant women in two Ghanaian regions. Methods: An ethnographic study design was used. In-depth interviews and conversations were conducted among health workers, pregnant women and opinion leaders. Observations were conducted in 12 communities and eight health facilities. Ethical clearance was obtained from the University of Health and Allied Sciences’ Research Ethics Committee. Nvivo 11 was used to support data coding. Data were triangulated and analysed using a thematic approach. Results: Findings suggest health system, socio-cultural, economic, environmental and individual factors influenced LLIN use. Health facility readiness in stocking LLINs influenced ownership and use. Receiving appropriate information from health providers and encouragement from public officials improved LLIN use. Women with a history of LLIN use prior to becoming pregnant and women who had young children remained consistent users. Experiencing irritating effects of LLINs and preference for traditional methods to wade off mosquitoes, reduced LLIN use. Pregnant women whose household and family members used LLINs were influenced positively to use them. Gender power relations between husbands and wives influenced women’s use of LLINs. The type of housing and weather conditions contributed to inconsistent use. Staying out late for business purposes and to converse, exposed pregnant women to mosquito bites. Conclusion: Giving out LLINs at facility level should be accompanied with comprehensive information, which is relevant to the socio-cultural context that women live in. Mass distribution should factor in individual and public information to promote community acceptance and proper use of ITNs. Facilities should be encouraged to constantly maintain LLINs stock in order to ensure that ANC registrants receive LLINs for use.
The study was conducted in five districts, three in the Ashanti and two in the Volta regions of Ghana. Eight health facilities: (five government and three faith-based) and twelve communities were chosen for the study. A three-stage selection process was used: (i) Five districts were selected; (ii) the district hospitals in the five districts automatically qualified to participate in the study; (iii) the study team visited the hospitals and went through antenatal care (ANC) case records. The total number of malaria in pregnancy cases from January, 2015 to March, 2018 in the different communities was recorded and the community with the highest recorded number of malaria in pregnancy cases in each facility was chosen to participate in the study. Information on communities that each facility served was obtained from the offices of the study districts’ health directorate. Most of the communities had an average population of 10,000 inhabitants. However, one of the districts in the Volta region had communities with an average of 2000 inhabitants, so six communities with the highest number of malaria in pregnancy cases were combined to form two study units (Table 1). The study team then conducted community entry activities such as paying courtesy calls on the assembly members and chiefs and holding meetings with a cross section of opinion leaders to inform and to seek their permission to conduct the study in their communities. Interactions and interviews with pregnant women revealed that in some of the chosen communities specific health facilities were preferred for ANC services. Three of such facilities, which are faith-based health facilities comprising of two Christian and one Moslem health facility were included in the study (Table 1). Study health facilities and study communities with pseudonyms in the Ashanti and Volta Regions aStudy facilities in the Ashanti region have been given the pseudonyms: ASFacility01, ASFacility02, ASFacility03 and ASFacility04. Study communities in the Ashanti region have been given pseudonyms: ASCommunity01, ASCommunity02, ASCommunity03, ASCommunity04 bStudy facilities in the Volta region have been given the pseudonyms VRFacility01, VRFacility02, VRFacility03, VRFacility04. Study communities in the Volta Region have been given pseudonyms: VRCommunity01, VRCommunity02, VRCommunity03, VRCommunity04 This ethnographic study used non-participant observations, transect walks, conversations, in depth interviews (IDIs) and case studies to obtain data from health workers, pregnant women and community members, from April, 2018 to March, 2019. The research team comprised of eight research assistants and each was assigned to a facility and at least one community, to spend long and active periods to learn, experience and represent the lives of study subjects in their natural setting [17–19]. To prevent a Hawthorn effect, observations were conducted intermittently in the eight facilities and 12 communities [20]. MD participated in data collection and also supervised the implementation of the study. The Ewe and Twi languages were used for IDIs with pregnant women and community members in the Volta and Ashanti regions, respectively. Transect walks were carried out in the study communities to afford the team a visual picture of environmental issues such as mosquito breeding sites, hygiene conditions, type of housing, nearness and access to health facilities and other important areas in the communities. A research assistant carried out observations in a health facility and interacted with the pregnant women who attended ANC. The study was explained to them and those who were interested were taken through a consenting process and recruited to participate in IDIs, after a written consent had been obtained. Pregnant women were also recruited from the communities, using the snowball method. The first pregnant woman to be identified helped the research assistant to identify others. Opinion leaders such as assembly members, linguists, traditional birth attendants were also invited to participate in IDIs. Case studies were purposively selected from women who regularly attended ANC on a monthly basis and those who were irregular or skipped their ANC appointments. Pregnant women who were clinically diagnosed with malaria and were willing to participate in the study were included as case studies. They were visited several times at home for observations and conversations with research assistants. Health workers who provided ANC service and had been working in a facility for more than 1 year, majority of whom were midwives, were selected to participate in the study. Follow up conversations and interviews were conducted with procurement officers, laboratory personnel and officials at the district health directorate, to clarify some of the issues raised in IDIs with health providers and health managers. ANC unit managers commonly referred to as in-charge, facility managers such as senior medical officers, physician assistants and administrators, were also interviewed to help understand managerial and administrative issues. Details of the different category of study participants and the methods used for data collection have been presented in Table 2. Data collection methods and categories of respondents aObservations were carried out intermittently in 4 health facilities and 4 large communities from May, 2018 to March, 2019 in the Ashanti Region bObservations were carried out in four health facilities, 6 small and 2 large communities from April, 2018 to March, 2019 in the Volta Region Interviews were tape recorded and transcribed verbatim to preserve interviewees’ original messages and experiences. Interviews in Ewe and Twi were transcribed into English to enable easy analysis and comparison. Qualitative analysis software, Nvivo Version 11 was used to generate a coding list on common themes that arose from the data (interviews, observation notes and conversations). Two coders, independently coded the data thematically. The analysis aimed at identifying similarities, patterns, differences, and contradictions in the information presented by interviewees [21]. Main themes that were identified from the analysis formed the basis for interpreting and reporting on study findings. Ethical clearance was obtained from the University of Health and Allied Sciences’ Research Ethics Committee [UHAS-REC/A.I Ul 17−18]. Written consent was obtained from all interview participants, while oral consent was obtained from study participants that conversations were held with and for observations. Permission was sought from district directors of health and facility managers. Besides actual country and region names, pseudonyms have been used for individuals and facilities’ names, to protect informants’ identity.
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