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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.
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