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BACKGROUND: Malaria in pregnancy remains a significant cause of morbidity and mortality, affecting the highly endemic countries of sub-Saharan Africa (SSA). Insecticide-treated nets (ITNs) are effective for malaria prevention. However, poor adherence in SSA remains a challenge. METHODS: We conducted a standard questionnaire survey among 710 pregnant women from 37 primary care clinics in the Upper West Region of Ghana from January through May 2019. Using a sequential explanatory design, we integrated the survey data from six focus group discussions with pregnant women. RESULTS: While 67% of women had some general knowledge about malaria prevention, only 19% knew the specific risks in pregnancy. Determinants of ITN use included ITN ownership (odds ratio [OR] 2.4 [95% confidence interval {CI} 1.3 to 4.4]), good maternal knowledge of the risks of malaria in pregnancy (OR 2.4 [95% CI 1.3 to 4.3]) and more antenatal care (ANC) contacts (OR 1.3 [95% CI 1.0 to 1.5)]. Focus group discussions showed that non-use of ITNs resulted from inappropriate hanging infrastructure, a preference for other malaria prevention alternatives, allergy and heat. CONCLUSIONS: Specific maternal knowledge of malaria risks in pregnancy was low and influenced the regular use of ITNs. Community and ANC-based malaria interventions should prioritize increasing knowledge of the specific risks of malaria.
The study was conducted in the Upper West Region (UWR) of Ghana (population 868 484 in 2020), an area that is highly endemic for malaria (Figure 1).14 Map of the study area (Upper West Region), showing the two districts selected. ITN use was defined as a pregnant woman having slept under an ITN the night previous to the study interview. A pregnant woman was considered to have good general knowledge regarding the transmission and prevention of malaria if her average score for the knowledge-based questions was at least 50%. A pregnant woman was considered to have good specific knowledge regarding the risks that can result from malaria infection during pregnancy if she listed at least two-thirds of these specific risks correctly. A comparative sequential explanatory mixed-methods model was used.15 First, a survey was conducted among third-trimester pregnant women attending antenatal care (ANC) services in two districts of the UWR. The study focused on third-trimester pregnant women because, per Ghana’s free maternal healthcare policy, ITNs are freely issued to pregnant women upon registration of their pregnancies at the health facility (HF). We presumed that third-trimester women may have had the optimum number of ANC contacts (≥4) and would have been exposed to regular facility-based ANC education on malaria. In addition, focus group discussions (FGDs) were conducted with pregnant women in the area. The study took place from January to May 2019. Quantitative data were collected by administering a standard questionnaire, review of respondents’ ANC records and direct observations. These data included respondents’ sociodemographic and obstetric characteristics and their use or non-use of ITNs. We also assessed the pregnant women’s knowledge of malaria transmission, the risk to pregnancy and malaria prevention. A mean score was calculated for general knowledge using only correct responses, while the specific knowledge of malaria risks in pregnancy was used in the logistic regression model. With an α level of 5% (two-sided t-test) and a power of 80%, the total estimated sample size (N=n1+n2) needed to detect any variations by comparing the two study districts was 710 (n1=355) third-trimester pregnant women, considering the proportions of ITN use in the rural and urban districts to be 70% and 60%, respectively, as described in similar populations.16,17 A multistage sampling approach was used (Figure 2).15 Two of 11 administrative districts in the UWR (1 urban [purposive] and 1 rural [simple random]) were selected for comparison (Figure 1).18 The oldest, most populated and comparatively more resourced of the four urban districts was purposefully selected and compared with one of seven rural districts that was randomly selected. Unlike the urban district, the rural district is underresourced, with dispersed population density and often lacking the requisite health staff. There were 27 HFs offering ANC services in the selected rural district of Lambussie and 27 in the selected urban district of Wa. Through a mix of purposive and simple random sampling, we selected 20 of 27 HFs in Lambussie and 17 of 27 HFs in Wa, for a total of 37 of 54 HFs from both districts. The main HF in each subdistrict, usually the highest referral centre, was automatically included in the sampled HFs; all other HFs were selected through simple random sampling (Table 5, Appendix 1). Prior to the random selection of the HFs, we adopted the simple majority rule of sampling 50%+1 of all eligible HFs in each subdistrict, as used elsewhere.17,19 Thus we sampled at least 50% of the total eligible HFs in each subdistrict. The 50%+1 rule was used because it was not feasible, due to time and other resource requirements, to cover all HFs in all selected subdistricts.17 Based on the total number of eligible HFs in each of the six subdistricts, the sum of 50%+1 of all eligible HFs added up to 20 and 17 HFs for the rural and urban districts, respectively (Table 6, Appendix 1).17 Study design and sampling procedure for ITN ownership and use. The pregnant women were selected from the chosen ANC facilities if they met the inclusion criteria (Figure 2). The pregnant women were recruited first by sequential sampling and then by purposive sampling (at least 25 weeks pregnant). The number of participants sampled from each health facility was based on the rule of proportionality (Table 7, Appendix 1). A semi-structured questionnaire was used by 12 study nurses. The series of questions asked about respondents’ knowledge of malaria and its prevention, the risks of malaria in pregnancy, history of ANC contacts, ownership and use of ITNs, current gestational age and at first ANC visit, parity and sociodemographic characteristics. The FGDs used an interactive question-and-answer format. The sample frame for the FGDs comprised 130 (60 urban and 70 rural) ‘ITN defaulters’ identified through the survey. An ITN defaulter was defined as any pregnant woman who had not slept under an ITN during the previous night (Figure 2). Six FGDs with eight participants each were conducted.20,21 The participants for the FGDs in each district were drawn through a purposive mixed method (only defaulters) and a simple random (lottery) technique (if there were more than eight).22 All women were contacted via phone calls in collaboration with the responsible health workers and invited to participate voluntarily. The main language of communication throughout all FGDs was Dagaare, the primary traditional language spoken in the study area. Data were collected through an FGD guide, an audio recorder and note pads. The FGD guide was developed based on recommended scientific standards.22–24 The guide consisted of questions sectioned into four main themes: participants’ basic understanding of malaria and its associated risks on pregnancy, challenges in accessing or using an ITN, if spouses or other family members posed any hindrance to their use of an ITN and if they felt that the service providers should consider facilitating their access to and use of ITNs. Quantitative data were compiled, cleaned and analysed using Stata (version 14.0; StataCorp, College Station, TX, USA). After descriptive statistics, binary logistic regression was used to analyse the determinants of ITN use. The outcome variable was sleeping under an ITN, measured as categorical (yes/no). The independent variables measured as categorical included marital status, family type, occupation, monthly income, religion, formal education, level of education, gestation at first ANC, parity, ITN ownership, knowledge of risks of malaria in pregnancy and study district. Other variables measured as continuous included the number of ANC contacts, household size and maternal age. Thematic content analysis was used to analyse the qualitative data, considering both inductive and deductive approaches using the QDA Miner Lite and MS Word (Microsoft, Redmond, WA, USA). The recordings of the FGD were translated into English shortly after each group session. The audio recordings were translated independently by the two moderators of the FGDs and compared for validation and analysis. The recordings were played repeatedly and typed verbatim into MS Word according to the flow of the questioning and answering format. The text was validated by repeated reading alongside playing the recordings to ensure that no information was skipped. The responses and discussions for each question were tabulated into similar themes and synthesized according to inductive codes. The emerging expressions were identified and used as inductive codes for the respective themes.
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