Community-based delivery of intermittent preventive treatment of malaria in pregnancy in Burkina Faso: a qualitative study

Community-based strategies to increase coverage of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in sub-Saharan Africa: a systematic review, meta-analysis, meta-ethnography, and economic assessment

BACKGROUND

Community-based approaches might increase uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). We assessed the effects of community-based approaches on IPTp-SP and antenatal care coverage, and barriers and facilitators to implementation in sub-Saharan Africa.

METHODS

We did a systematic review, meta-analysis, meta-ethnography, and economic assessment. We searched the WHO International Clinical Trials Registry Platform, PubMed, the Malaria in Pregnancy Library database, Medline, Global Health and Global Health Archives, and the Cochrane Library for trials, mixed-methods, qualitative, and cost-effectiveness studies of community health worker promotion of antenatal care, IPTp-SP delivery, or both, with no language restrictions, published before March 21, 2024. Information on interventions, number of IPTp-SP doses, antenatal care visits, and barriers and facilitators were extracted. We did a meta-analysis (random effects) comparing effects on two or more or three or more IPTp-SP doses and one or more or four or more antenatal care visits. We followed Noblit and Hare's method of meta-ethnography to synthesise qualitative findings, using reciprocal translation and line-of-argument synthesis. We developed a theory for increased community IPTp-SP uptake. We also summarised cost and cost-effectiveness studies. This study is registered with PROSPERO, CRD42022364114.

FINDINGS

Of 4753 records screened, we included 23 (0·5%) reporting on 15 studies. Community health worker involvement was associated with an increase in two or more IPTp-SP doses (pooled risk ratio 1·48, [95% CI 1·24-1·75]; 12 sub-studies; I2 94·7%) and three or more IPTp-SP doses (1·73 [1·19-2·50]; ten sub-studies, I2 97·5%), with no decrease in four or more antenatal care visits (1·17 [1·00-1·36]; 13 sub-studies; I2 90·3%). Cluster-randomised controlled trials showed a lower increase in coverage of three or more IPTp-SP doses (1·08 [1·00-1·16]; I2 0·0%; six studies) compared with before-and-after studies (2·86 [1·29-6·33]; I2 98·9%; four studies; subgroup analysis p=0·019). Barriers to community health worker delivery of IPTp-SP included women's fear of side-effects, lack of knowledge, lack of trust in community health workers, and sociocultural factors. Community sensitisation, engagement of husbands, pre-established community health worker networks, and trained and supported community health workers facilitated IPTp-SP delivery by community health workers. Incremental cost-effectiveness ratios ranged from $1·1 to $543 per disability-adjusted life-year averted.

INTERPRETATION

Community-based approaches increased IPTp-SP coverage and might have a positive effect on the number of antenatal care visits in addition to being cost-effective, although we found high heterogeneity among studies. Community sensitisation and engagement in addition to established, trained, and supported community health workers can facilitate acceptability, delivery, and uptake of IPTp-SP delivered by community health workers.

FUNDING

EDCTP-2 supported by the European Union.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Community engagement approaches for malaria prevention, control and elimination: a scoping review

INTRODUCTION

Globally malaria programmes have adopted approaches to community engagement (ACE) to design and deliver malaria interventions. This scoping review aimed to understand, map, and synthesise intervention activities guided by ACE and implemented by countries worldwide for the prevention, control and elimination of malaria.

METHODS

Three databases (Web of Science, Proquest, and Medline) were searched for peer-reviewed, primary studies, published in English between 1 January 2000 and 31 December 2022. Advanced Google was used to search for grey literature. The five levels of the International Association for Public Participation were used to categorise ACE - (1) Inform, (2) Consult, (3) involve, (4) Collaborate, and (5) Co-lead. Intervention activities were categorised as health education (HE), and/or health services (HS), and/or environmental management (EM). Outcomes were collected as knowledge, attitude, behaviour, help-seeking, health and HS and environment. Enablers and barriers were identified. Malaria intervention phases were categorised as (1) prevention (P), or (2) control (C), or (3) prevention and control (PC) or prevention, control and elimination (PCE).

RESULTS

Seventy-five studies were included in the review. Based on ACE levels, most studies were at the inform (n=37) and involve (n=26) level. HE (n=66) and HS (n=43) were the common intervention activities. HE informed communities about malaria, its prevention and vector control. EM activities were effective when complemented by HE. Community-based HS using locally recruited health workers was well-accepted by the community. Involvement of local leaders and collaboration with local stakeholders can be enablers for malaria intervention activities.

CONCLUSION

Involving local leaders and community groups in all stages of malaria prevention programmes is vital for successful interventions. Key elements of successful ACE, that is, consult, collaborate, and co-lead were under-represented in the literature and require attention. National programes must consult and collaborate with community stakeholders to develop ownership of the interventions and eventually co-lead them.

Synthesis of Qualitative Evidence on Malaria in Pregnancy, 2005-2022: A Systematic Review

Qualitative research on malaria in pregnancy (MiP) is incipient, therefore its contextual, experiential and symbolic associated factors are unknown. This study systematizes the qualitative research on MiP, describes knowledge, perceptions and behaviors about MiP, and compiles individual, socioeconomic, cultural and health system determinants of MiP through a meta-synthesis in 10 databases. A total of 48 studies were included with 2600 pregnant women, 1300 healthcare workers, and 2200 relatives or community members. Extensive knowledge was demonstrated on ITN and case management, but it was lacking on SP-IPTp, risks and consequences of MiP. Attitudes were negative towards ANC and MiP prevention. There were high trustfulness scores and preference for traditional medicine and distrust in the safety of drugs. The main determinants of the Health System were rationing, copayments, delay in payment to clinics, high out-of-pocket expenses, shortage, low workforce and work overload, shortcomings in care quality, low knowledges of healthcare workers on MiP and negative attitude in care. The socioeconomic and cultural determinants were poverty and low educational level of pregnant women, distance to the hospital, patriarchal-sexist gender roles, and predominance of local conceptions on maternal-fetal-neonatal health. The meta-synthesis demonstrates the difficulty to detect MiP determinants and the importance of performed qualitative research before implementing MiP strategies to understand the multidimensionality of the disease.

Improving coverage of antenatal iron and folic acid supplementation and malaria prophylaxis through targeted information and home deliveries in Côte d'Ivoire: a cluster randomised controlled trial

INTRODUCTION

Coverage of antenatal iron and folic acid (IFA) supplementation and malaria chemoprophylaxis remains low in many low-income and middle-income settings. We assessed the effectiveness of personal information (INFO) sessions and personal information session plus home deliveries (INFO+DELIV) to increase coverage of IFA supplementation and intermittent preventive treatment in pregnancy (IPTp), and their effectiveness on postpartum anaemia and malaria infection.

METHODS

We included 118 clusters randomised to a control (39), INFO (39) and INFO+DELIV (40) arm, in a trial conducted between 2020 and 2021 with pregnant women (age ≥15 years) in their first or second trimester of pregnancy in Taabo, Côte d'Ivoire. We used generalised linear regression models to assess intervention impact in postpartum anaemia and malaria parasitaemia, and displayed resulting estimates as prevalence ratios.

RESULTS

Overall, 767 pregnant women were enrolled and 716 (93.3%) were followed up after delivery. Neither intervention had an impact on postpartum anaemia, with estimated adjusted prevalence ratios (aPRs) of 0.97 (95% CI 0.79 to 1.19, p=0.770) for INFO and 0.87 (95% CI 0.70 to 1.09, p=0.235) for INFO+DELIV. While INFO had no effect on malaria parasitaemia (aPR=0.95, 95% CI 0.39 to 2.31, p=0.915), INFO+DELIV reduced malaria parasitaemia by 83% (aPR=0.17, 95% CI 0.04 to 0.75, p=0.019). No improvements in antenatal care (ANC) coverage (aPR=1.05, 95% CI 0.81 to 1.36, p=0.692), IFA (aPR=2.00, 95% CI 0.89 to 4.46, p=0.093) and IPTp (aPR=1.03, 95% CI 0.87 to 1.21, p=0.728) compliance were found for INFO. INFO+DELIV increased ANC attendance (aPR=1.35, 95% CI 1.02 to 1.78, p=0.037) and compliance with IPTp (aPR=1.60, 95% CI 1.41 to 1.80, p<0.001) and IFA recommendations (aPR=7.06, 95% CI 3.68 to 13.51, p<0.001).

CONCLUSIONS

INFO+DELIV can substantially increase compliance with IFA supplementation and improve malaria prevention. However, the increases in IFA supplementation are likely insufficient to address the prevalence of often severe anaemia in this population.

TRIAL REGISTRATION NUMBER

NCT04250428.

The social dimensions of community delivery of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria and the Democratic Republic of the Congo

INTRODUCTION

Intermittent preventive treatment in pregnancy with sulphadoxine pyrimethamine (IPTp) is a key malaria prevention strategy in sub-Saharan African countries. We conducted an anthropological study as part of a project aiming to evaluate a community-based approach to the delivery of IPTp (C-IPTp) through community health workers (CHWs) in four countries (the Democratic Republic of Congo, Madagascar, Mozambique and Nigeria), to understand the social context in order to identify key factors that could influence C-IPTp acceptability.

METHODS

A total of 796 in-depth interviews and 265 focus group discussions were undertaken between 2018 and 2021 in the four countries with pregnant women, women of reproductive age, traditional and facility-based healthcare providers, community leaders, and relatives of pregnant women. These were combined with direct observations (388) including both community-based and facility-based IPTp delivery. Grounded theory guided the overall study design and data collection, and data were analysed following a combination of content and thematic analysis.

RESULTS

A series of key factors were found to influence acceptability, delivery and uptake of C-IPTp in project countries. Cross-cutting findings include the alignment of the strategy with existing social norms surrounding pregnancy and maternal health-seeking practices, the active involvement of influential and trusted actors in implementation activities, existing and sustained trust in CHWs, the influence of husbands and other relatives in pregnant women's care-seeking decision-making, the working conditions of CHWs, pregnant women's perceptions of SP for IPTp and persistent barriers to facility-based antenatal care access.

CONCLUSIONS

The findings provide evidence on the reported acceptability of C-IPTp among a wide range of actors, as well as the barriers and facilitators for delivery and uptake of the intervention. Overall, C-IPTp was accepted by the targeted communities, supporting the public health value of community-based interventions, although the barriers identified should be examined if large-scale implementation of the intervention is considered.

Retrospective evaluation of referral by community health workers on the uptake of intermittent preventive treatment of Malaria in pregnancy in Ohaukwu, Ebonyi State, Nigeria

Background

The World Health Organization recommends a minimum of three doses of quality-assured sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy (IPTp), in moderate to high malaria transmission areas in sub-Saharan Africa. Currently, coverage of IPTp lags behind coverage of antenatal care (ANC) visits; in Nigeria, 57% of women attended four or more ANC visits, whereas only 17% received the recommended three or more doses of IPTp. The innovative program aimed to close this gap by providing counseling on the benefits of comprehensive ANC, referral to ANC and community distribution of IPTp (C-IPTp), complementing IPTp at ANC. The study aimed to examine whether CHW referral to ANC improved the likelihood of receiving three or more doses of IPTp.

Methods

The data for this study were extracted from the maternity record books of 1437 pregnant women seen at 25 public health facilities in Ebonyi State, Nigeria. The outcome of interest was defined as the receipt of three or more doses of IPTp (IPTp3) and the independent variable was referral to ANC by a community health worker for any visit. Descriptive statistics were reported and the results from the multi-level regressions are reported as adjusted odds and prevalence ratios with corresponding 95% confidence intervals.

Results

Of the 936 women included in the analysis, 24.47% received the recommended three or more IPTp doses and 61.32% were referred by a community health worker (CHW) for at least one ANC visit. There was no difference in the mean number of ANC visits between women who received C-IPTp and those who received IPTp exclusively at a facility (2.40 vs 2.52; p = 0.374). There were no maternal characteristics associated with CHW referral. Women who were referred by a CHW had 60% greater odds (95% CI, 1.08–2.38) of receiving IPTp3 than those who were never referred.

Conclusion

The results indicate that CHW referrals conducted within a C-IPTp program are associated with higher IPTp uptake but not fewer ANC visits and that CHWs applied the referral process equally. This strengthens the evidence base for C-IPTp scale-up, which could have a large impact in sub-Saharan Africa in mitigating existing health systems issues.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04921-7.