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A community-based delivery system of intermittent preventive treatment of malaria in pregnancy and its effect on use of essential maternity care at health units in Uganda
Transactions of the Royal Society of Tropical Medicine and Hygiene (2007) 101, 1088—1095
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/trst
A community-based delivery system of intermittent preventive treatment of malaria in pregnancy and its effect on use of essential maternity care at health units in Uganda Anthony K. Mbonye a,∗, I.C. Bygbjerg b, Pascal Magnussen c a
Department of Community Health, Ministry of Health, Box 7272, Kampala, Uganda Department of International Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark c Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark b
Received 22 January 2007; received in revised form 26 June 2007; accepted 26 June 2007 Available online 5 September 2007
KEYWORDS Malaria; Pregnancy; Intermittent preventive treatment; Antenatal care; Health systems; Uganda
Summary Community delivery of intermittent preventive treatment of malaria in pregnancy (IPTp) is one potential option that could mitigate malaria in pregnancy. However, there is concern that this approach may lead to complacency among women with low access to essential care at health units. A non-randomised community trial assessed a new delivery system of IPTp through traditional birth attendants, drug shop vendors, community reproductive health workers and adolescent peer mobilisers (the intervention) compared with IPTp at health units (control). The study enrolled a total of 2081 pregnant women with the new approaches. Data on care-seeking practices before and after the intervention were collected. The majority of women with the new approaches accessed IPTp in the second trimester and adhered to two doses of sulfadoxine/pyrimethamine (SP) (1404/2081; 67.5%). Antenatal care (four recommended visits) increased from 3.4% (27/805) to 56.8% (558/983) (P < 0.001). The proportion of women delivering at health units increased from 34.3% (276/805) to 41.5% (434/1045) (P = 0.02), whilst the proportion of women seeking care for malaria at health units increased from 16.7% (128/767) to 36.0% (146/405) (P < 0.001). Similarly, use of insecticide-treated nets increased from 7.7% (160/2081) to 22.4% (236/1055) (P < 0.001). In conclusion, the community-based system was effective in delivering IPTp, whilst women still accessed and benefited from essential care at health units. © 2007 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
1. Introduction ∗ Corresponding author. Tel.: +256 772 411 668; fax: +256 41 321 572. E-mail address: [email protected] (A.K. Mbonye).
Current priorities for health care in developing countries include identifying cost-effective interventions for diseases
0035-9203/$ — see front matter © 2007 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.trstmh.2007.06.017
Community delivery of IPTp and use of health interventions that impose the greatest burden as well as determining how to deliver these interventions effectively, efficiently and equitably (World Bank, 2006). The challenge faced by policy-makers and programme managers in malaria-endemic countries is to increase access to malaria treatment and prevention interventions, as malaria is a leading cause of mortality among children and pregnant women (Brabin, 1983; Garner and Gulmezoglu, 2000; Greenwood et al., 1989; McGregor et al., 1983) yet access and use of these interventions is poor (Amooti-Kaguna and Nuwaha, 2000; Guyatt et al., 2004; Menendez, 1999; Ndyomugyenyi et al., 1998; Shulman, 1999; van Eijk et al., 2004). In Uganda, only 42% of pregnant women attend antenatal care (ANC) services four times as recommended (Uganda Bureau of Statistics, 1988, 2001) and only 34% use malaria chemoprophylaxis and intermittent preventive treatment of malaria in pregnancy (IPTp). Uganda initiated a homebased management (HBM) of fever strategy in 2002 (Ugandan Ministry of Health, 2002). Assessment of the impact of the HBM strategy in southwestern Uganda has concluded that HBM improves drug access (Nsungwa-Sabiti et al., 2004), leads to high referral compliance and extends primary health care to the communities by maintaining linkages with the formal health services (Kallander et al., 2006a, 2006b). One of the concerns when considering community distribution of malaria treatment and prevention interventions is whether it may lead to complacency among women with decreased use of essential health services. However, health-based interventions such as ANC provide one of the opportunities to promote maternal and infant health (Schultz et al., 1995). ANC services provide assessment and management of maternal risk factors, testing for syphilis, management of anaemia and routine antimalarial drugs for treatment and prevention of malaria (Rooney, 1992; Stanfied and Galazka, 1984). In Uganda, low utilisation of ANC limits access to malaria treatment and prevention in pregnancy and has been attributed to cost of services and long distances to health units (Amooti-Kaguna and Nuwaha, 2000; Mbonye et al., 2006a; Ndyomugyenyi et al., 1998). This situation prevails even though women in malaria-endemic countries recognise malaria as a serious illness (Guyatt et al., 2004; HelitzerAllen et al., 1993; Holtz et al., 2004; Kengeya-Kayondo et al., 1994; Mbonye et al., 2006a; Ndyomugyenyi et al., 1998). Poor utilisation of ANC and other interventions has also been attributed to deficiencies in the health system (Guyatt et al., 2004; Holtz et al., 2004; van Eijk et al., 2004). It has been concluded that malaria control programmes that rely only on ANC as a delivery system are likely to have poor coverage and compliance to IPTp (Menendez, 1999; Schultz et al., 1995). Given this scenario, alternative delivery approaches need to be identified (Helitzer-Allen et al., 1993; Menendez, 1999). This study tested new approaches of delivering IPTp through traditional birth attendants (TBA), drug shop vendors (DSV), community reproductive health workers (CRHW) and adolescent peer mobilisers (APM). The acceptability and sustainability of the new approaches have been published elsewhere (Mbonye et al., 2007). This article presents data on the effect of the new community-based delivery of IPTp on access and use of health services and the implications for malaria prevention in Uganda.
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2. Materials and methods 2.1. Study area and population The study was carried out in nine subcounties near the lakeshore region of Mukono district, central Uganda. The background characteristics of the study area have been published elsewhere (Mbonye et al., 2006a, 2006b). Briefly, the district has a population size of 850 900, a population density of 179 people per km2 , an annual population growth rate of 2.3% and a total fertility rate of 7.2 (Uganda Bureau of Statistics, 2002). The district has a rural population of 88.0% and is mainly inhabited by Baganda people, the largest tribe in Uganda. The district experiences high temperatures and heavy rainfall during the months of March—May and October—November. This district was selected because most areas are hyperendemic for malaria, whilst those on the shores of Lake Victoria are holoendemic and experience perennial transmission levels.
2.2. The intervention study A study was designed to assess the new approaches to delivering IPTp with sulfadoxine/pyrimethamine (SP) compared with the practice of delivery at health units. In Uganda, IPTp consists of two therapeutic doses of SP (three tablets of 500 mg sulfadoxine + 25 mg pyrimethamine) (Ugandan Ministry of Health, 2001). Nine rural subcounties from the district, which were homogeneous in terms of geography and cultural attributes, were selected. Within each subcounty, at least two parishes were randomly selected. The parishes with health units providing IPTp were selected among the health units in the study area. Three health centres III (Seeta-Namuganga, Kattogo and Seeta-Nazigo) and Kawolo District Hospital participated in the study. In Uganda, a health centre III is the lowest health facility with a maternity unit and provides ANC, delivery services and routine IPTp. In total, 25 parishes were selected: 4 tested IPTp at health units (control) while 21 tested IPTp administered by the new approaches (the intervention). The number of parishes selected for each cluster was determined by the sample size required and the expected rate at which pregnant women would be recruited. The study was not randomised because clusters were not uniform in the distribution of health units providing IPTp and the availability of community resource persons. However, the populations in the clusters were comparable in terms of socioeconomic status and other background characteristics. The study targeted all pregnant women who lived in the study area. One of the key components of the intervention study was a community mobilisation and sensitisation campaign to ensure that all women received information on the intervention and where to get SP. In total, the study area had an estimated population of 54 000. The expected number of pregnancies during the study period was 3596 (Uganda Bureau of Statistics, 2002). Because there was no register of people in this area, the number of pregnant women who accepted the first dose of SP served as the denominator for calculating the proportion of women who received the second dose of SP and other outcome variables (Figure 1).
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A.K. Mbonye et al.
Figure 1 Study profile. IPTp: intermittent preventive treatment of malaria in pregnancy; SP: sulfadoxine/pyrimethamine; DSV: drug shop vendor; TBA: traditional birth attendant; CRHW: community reproductive health worker; APM: adolescent peer mobiliser.
Fifty-one community resource persons were identified by the research team and the district and community leaders. The resource persons were composed as follows: 13 APMs, 14 CRHWs, 14 TBAs and 10 DSVs. Currently, APMs are trained to provide information on health issues, especially prevention of HIV/AIDS and prevention of unwanted pregnancies, among adolescents and young people. TBAs are trained to provide clean deliveries and to refer complications to health units. CRHWs are trained to promote safe motherhood and other health promotion activities. All the resource persons, including DSVs, are involved in the HBM of fevers. The DSVs are licensed and sell class C drugs to all clients within their locality. They sell medicines from shops but do not provide home visits, although they are usually qualified health workers who offer medical consultations. IPTp was offered free at all the approaches since all services are free at public health units in Uganda. DSVs usually offer services to the community such as immunisation and storing supplies and drugs as part of a public—private partnership encouraged by the policy in Uganda. The community resource persons were distributed in all 21 clusters. All the resource persons were trained for a period of 1 week. The following areas were covered: dangers of malaria in pregnancy; malaria prevention in pregnancy; the benefits and side effects of SP; taking blood samples for parasite count/haemoglobin analysis; taking the baby’s weight; and estimating gestational age. Birth weight was taken using a baby weighing scale (UNICEF-Super Samson Salter) measuring to the nearest 50 g, whilst gestational age was estimated using the date of the last menstrual period. After training, each resource person was given a month’s supply of SP, mebendazole, iron, folic acid and basic supplies
such as gloves, disposable syringes, disinfectant, cotton, gauze, laboratory slides/lancets, stationery and a bicycle to assist in community mobilisation and follow-up of pregnant women. The resource persons were not paid a salary. Recruitment of pregnant women was undertaken in May 2003 to February 2005. Women who consented to participate in the study were given SP as directly observed therapy (DOT) during the second and third trimester as recommended by the policy in Uganda. The procedure for enrolling pregnant women was through creating awareness and home visits by resource persons as well as those who visited DSVs for care; whilst at health units women attended routine services. Pregnant women also received iron and folic acid supplementation, deworming and information on proper nutrition. As part of the intervention, women received an explanation on the benefits of accessing ANC and other services at health units. Exclusion criteria were women who refused to give consent to the study and those who gave a history of allergy to sulphonamide-containing drugs. A structured questionnaire (in Luganda, the local language) was administered by the resource persons to each pregnant woman at (i) recruitment, (ii) before receiving the second dose of SP and (iii) at 36 weeks gestation or at delivery to collect data on sociodemographic characteristics, obstetric history, reported malaria illnesses, care-seeking practices, use of insecticide-treated nets (ITN) and use of IPTp. These data were also collected at health units. The primary outcome measures for the intervention study were the proportion of pregnant adolescents and primigravidae reached by the new approach, the gestational age at recruitment and the proportion of pregnant women who completed the two scheduled doses of SP.
Community delivery of IPTp and use of health interventions
2.3. Definitions Malaria was defined as a febrile illness characterised by feeling hot with headache, joint pains and general weakness. The local term omusujja gw’ensiri, translated as ‘fever caused by mosquitoes’, was used to refer to malaria. This term is also widely used in this region to refer to malaria (Kengeya-Kayondo et al., 1994; Mbonye et al., 2006a). The reference period for reported malaria episodes was 2 weeks prior to the assessment. In the intervention study, access was defined as the proportion of women who received the first dose of SP in the second trimester as recommended by the policy. Compliance with IPTp was defined as the proportion of women who completed two doses of SP and the denominator was the number of women recruited for the first dose at each approach. The term self-treatment used in this study refers to anything from a cool bath to a course of antimalarial of home-stocked drugs. This is distinguished from seeking care at drug shops since this is usually accompanied by consultation and purchase of appropriate medicines.
2.4. The post-intervention study A semistructured questionnaire containing closed and openended questions was administered to 1321 (47.4%) randomly selected women out of 2785 who participated in the intervention study immediately after the intervention study was completed. Two hundred and fifty-three (19.2%) had received SP at health units, whilst 1068 (80.8%) had received IPTp at the new approaches. The structured questionnaire covered the following areas: sociodemographic characteristics; and access and use of IPTp and other health services. For comparison purposes, the tools collected data on the same thematic areas as for the intervention study. Sixty key informant interviews were conducted after the intervention among the resource persons, health workers, women who had participated in the intervention and opinion leaders, since they were regarded to be more knowledgeable on health-related matters in their community. All respondents spoke Luganda, the local dialect, and questions were asked and responses recorded in the local dialect. These were later translated into English. Responses were initially coded separately for the Luganda and English versions and thematic areas were obtained. Data were manually analysed along the defined themes.
2.5. Statistical analyses Data were entered into Epi Info version 6.0 (CDC, Atlanta, GA, USA), cleaned and transferred to Stata version 8.2 (Stata Corp., College Station, TX, USA) for analysis. Univariate and bivariate analyses were performed to calculate frequency distributions and factors related to malaria morbidity, care-seeking practices and access and compliance rates to IPTp. For quantitative variables, Student’s t-test and one-way ANOVA were used for normally distributed variables (age and gestation period). The effect of the intervention on use of health services was assessed using a two-sample proportion test. A probit regression model
1091 was used to assess factors associated with use of ANC at health units. The dependent variable was ANC attendance. The model used a dummy variable with 0 as the value for ANC visits <4 and 1 as the value for ≥4 ANC visits. The model was constructed using the enter method and only significant variables at P < 0.05 were retained. The model fit was assessed for robustness using the loglikelihood ratio test and considered sufficient if the P-value was <0.05. Because of the cluster sampling technique for the intervention study, the design effect at analysis was computed by taking the parish as the primary sampling unit. The design effect for all outcome variables was >1.0, indicating that cluster sampling was an appropriate design. The new approaches (DSVs, TBAs, CRHWs and APMs) were analysed as one cluster since there were no statistically significant differences on all outcome variables between the groups, with the health units as another cluster. The sample size calculation for the intervention study was based on the current uptake of malaria chemoprophylaxis in Uganda, estimated at 34% (Uganda Bureau of Statistics, 2001), and to detect a 12% difference between health units and the new approaches. All the calculations assumed a power of 80% and 5% level of significance. The sample size for the post-intervention study was calculated to detect a 10% difference in ANC attendance between the groups of women who accessed IPTp at health units and the new approaches, assuming the current ANC attendance rate of 42% (Uganda Bureau of Statistics, 2001). To achieve comparable groups, the pregnant women who exclusively accessed IPTp (both the first and second dose of SP) at the health units constituted the control group, whilst pregnant women who exclusively accessed IPTp at the new approaches constituted the intervention group. Careseeking practices related to the current pregnancy before the intervention and care-seeking practices during and after the intervention were compared.
3. Results 3.1. Study population A total of 2081 women who accessed IPTp at the new approaches were interviewed on care-seeking practices related to the current pregnancy. The mean age was 23.9 years (range 14—43 years); the majority (69.0%) were aged 20—34 years and adolescents (age 10—19 years) comprised 25.0% (521/2081). Similarly, the majority of these women (76.0%) were dependent on peasant agriculture. The majority of respondents and their spouses (in both delivery approaches) had attained primary education, whilst few had attained secondary education and a small proportion had no education (Table 1). A total of 1055 women were sampled for the post-intervention study. The majority (73.7%) were aged 20—34 years, 59.2% were dependent on peasant agriculture and the majority (60.7%) had attained primary education. The background characteristics that determine care-seeking practices, such as education of respondent, education of spouse and occupational status, were comparable among women in the intervention and post-intervention surveys (Table 1).
1092 Table 1
A.K. Mbonye et al. Background characteristics of pregnant women who participated in the study
Background characteristic
Women utilising the new approaches (baseline) (N = 2081) n (%)
Women utilising the new approaches (post intervention) (N = 1055) n (%)
Age (years) 10—19 20—34 35—50
521 (25.0) 1435 (69.0) 125 (6.0)
177 (16.8) 778 (73.7) 100 (9.5)
0.03 0.02 0.32
Marital status Single Married Widowed/separated
337 (16.2) 1203 (57.8) 541 (26.0)
49 (4.6) 944 (89.5) 62 (5.9)
0.03 <0.001 0.004
Occupation of respondents Peasant agriculture Small-scale business Household work Salaried
1582 (76.0) 92 (4.4) 92 (4.4) 315 (15.1)
625 (59.2) 236 (22.4) 236 (22.4) 67 (6.4)
<0.001 <0.001 <0.001 0.06
Education of respondents No education Primary education Secondary education Tertiary institution
294 (14.1) 1352 (65.0) 383 (18.4) 52 (2.5)
176 (16.7) 640 (60.7) 218 (20.7) 21 (2.0)
0.5 0.06 0.51 0.89
Education of spouses No education Primary education Secondary education Tertiary institution
92 (4.4) 1241 (59.6) 670 (32.2) 78 (3.7)
164 (15.5) 556 (52.7) 296 (28.1) 39 (3.7)
0.008 0.006 0.12 —
3.2. The intervention study
P-value
accessed SP both from health units and from the community approaches.
With regard to access, the majority of women with the new delivery system (1905/2062; 92.4%) received the first dose of SP in the second trimester compared with 76.1% (523/687) with health units (P < 0.001). The mean gestational age for all women was 21.4 weeks (range 16—36 weeks). Mean gestational age was 23.1 weeks among women utilising IPTp at health units compared with 20.8 weeks with the new delivery system (P < 0.001). Adherence to two doses of SP was 39.9% (281/704) with health units and 67.5% (1404/2081) with the new delivery system (P < 0.001) (Table 2). Few women (286/1685; 17.0%)
3.3. Effect of the new approaches on access and use of health services Access to ANC and other services at health units was assessed among women who had received IPTp with the new approaches (community level). Before the intervention, only 27/805 (3.4%) of the women reported having attended ANC at least four times as recommended by the policy. After the intervention, the majority of women (558/983; 56.8%) had attended the four or more ANC visits. Similarly,
Table 2 Effect of community-based delivery of intermittent preventive treatment of malaria in pregnancy (IPTp) on access and adherence rates Access and adherence to IPTp
Pregnant women who utilised SP with health units
Pregnant women who utilised SP with the new approaches
P-value
Timing of first dose of SP (weeks of gestation) First dose of SP in second trimester First dose of SP in third trimester Proportion 10—19 years at first dose Proportion primigravidae at first dose Proportion of women adhering to two doses of SP Proportion of women using ITNs
(N = 704) 23.1 weeks 523/687 (76.1%) 164/687 (23.9%) 200/704 (28.4%) 166/704 (23.6%) 281/704 (39.9%) 64/259 (24.7%)
(N = 2081) 20.8 weeks 1905/2062 (92.4%) 157/2065 (7.6%) 521/2081 (25.0%) 435/2081 (20.9%) 1404/2081 (67.5%) 211/1416 (14.9%)
<0.001 <0.001
SP: sulfadoxine/pyrimethamine; ITN: insecticide-treated net.
0.03 0.04 <0.001 <0.001
Community delivery of IPTp and use of health interventions
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Table 3 Effect of community-based delivery of intermittent preventive treatment of malaria in pregnancy (IPTp) on access and use of health services Type of service ANC attendance ≥1 ANC visit 1 ANC visit 2 ANC visits 3 ANC visits ≥4 ANC visits Place where last child was delivered Home TBA Health unit Morbidity since delivery of last child Had malaria Sought treatment when got malaria Source of care Self-treatment at home Health units Drug shops Private clinics
Care-seeking practices before the intervention
Care-seeking practices post intervention
P-value
839/2081 (40.3%) 529 (65.7%) 198 (24.6%) 51 (6.3%) 27 (3.4%) N = 805
1011/1055 (95.8%) 35 (3.6%) 133 (13.5%) 257 (26.1%) 558 (56.8%) N = 983
<0.001 <0.001 0.01 0.002 <0.001
108 (13.4%) 421 (52.3%) 276 (34.3%) N = 805
146 (14.0%) 465 (44.5%) 434 (41.5%) N = 1045
906/1830 (49.5%) 767/1861 (41.2%)
443/1045 (42.4%) 405/436 (92.9%)
0.01 <0.001
371 (48.4%) 128 (16.7%) 125 (16.3%) 143 (18.6%) N = 767
31 (7.7%) 146 (36.0%) 116 (28.6%) 112 (27.7%) N = 405
<0.001 <0.001 0.02 0.03
0.89 0.02 0.02
ANC: antenatal care; TBA: traditional birth attendant.
pre-intervention the proportion of women who delivered their last child at health units was 34.3% (276/805) and this increased to 41.5% (434/1045) among women who had accessed IPTp at the new approaches (Table 3). Morbidity and care-seeking practices were assessed for the current pregnancy. The proportion of women reporting a malaria illness pre intervention was 49.5% (906/1830), whilst the proportion of women who sought care when they had malaria was 41.2% (767/1861). At the end of the intervention, the proportion of women who reported malaria illnesses decreased to 42.4% (443/1045) and the proportion of those who sought care increased to 92.9% (405/436). The source of care for malaria before and after the intervention varied. Whereas a large proportion of pregnant women at baseline (371/767; 48.4%) had resorted to self-treatment, only 7.7% (31/405) of women resorted to self-treatment after the intervention. The proportion of women seeking care at health units increased from 16.7% (128/767) to 36.0% (146/405). Similarly, seeking care at drug shops increased from 16.3% (125/767) to 28.6% (116/405) (Table 3). ANC use (four visits) was assessed among women who utilised IPTp with the new approaches (Table 4). The following factors were associated with increased use of ANC: women who utilised IPTp with health units and with APMs were likely to attend the four visits of ANC as recommended by the policy in Uganda. Similarly, adolescents aged 10—19 years, women with secondary education, women who delivered at health units and distance <2 km to a health unit were associated with increased ANC attendance. Use of services for women who accessed IPTp at health units was compared with those who accessed IPTp in the
community. A higher proportion of women who accessed IPTp at health units attended the four recommended ANC visits (76.1% vs. 56.8%; P < 0.001); similarly, deliveries at health units were higher (65.5% vs. 41.5%; P < 0.001) as well as care-seeking at health units (47.8% vs. 36.1%; P = 0.03) (data not shown).
3.4. Reasons for low uptake of IPTp among women attending ANC We investigated the reasons for low uptake of IPTp among women attending ANC. The results observed with the new approaches could be due to the fact that the resource
Table 4 Factors associated with access to antenatal care at health units Covariate
Odds ratio
95% CI
P-value
Using IPTp with the health units Secondary education Age (10—19 years) Using IPTp with APMs Women who delivered at health unit Distance <2 km to health unit
2.6
2.0—4.8
0.001
2.4 2.2 2.1 1.9
2.1—6.5 2.0—5.3 1.3—5.3 1.3—2.9
0.002 0.003 0.005 0.001
1.8
1.2—3.2
0.009
IPTp: intermittent preventive treatment pregnancy; APM: adolescent peer mobiliser.
of
malaria
in
1094 persons encouraged women to attend ANC and to benefit from other services at health units. The following factors were ranked in order of frequency in which they were mentioned: the high costs involved in accessing SP at health units; having to walk long distances; and the burden of household work. Some of the women said they had to convince their husbands in order to get permission to care for the children while the women were away. Some women who got the first dose of SP at health units said that they did not get the second dose because at the time of the ANC visit there was no stock of SP.
4. Discussion These results show that the new approach of delivering IPTp is feasible and effective. Women received IPTp at the community level while they also accessed ANC, delivery care and treatment of malaria and other ailments at health units. One of the key aspects of the intervention was a community mobilisation and awareness of malaria prevention in pregnancy and appropriate treatment of malaria in general. This was possible because the intervention utilised community resource persons who were already engaged in other health promotion activities, thus delivery of IPTp was an additional effort. This did not only lead to effective delivery of IPTp but was important for sustainability of this approach. The results show that there was increased access and compliance to IPTp associated with the new approaches. As previously indicated, access to resource persons and their ability to make frequent home visits, especially CRHWs and APMs, were important factors for reaching pregnant women early with IPTp (Mbonye at al., 2007). The importance of trust varied with the different approaches the women used to access IPTp. Trust in different providers, including health workers, was reflected by women’s choices on the sources of IPTp. The factors that most influenced access to ANC were age, education, source of IPTp, women who delivered at health units and distance to health units. In Uganda, young women and those with higher education are more likely to attend ANC and to deliver at health units compared with women with no education or primary education (Uganda Bureau of Statistics, 1995, 2001). An interesting finding from this study is the influence of the source of IPTp on use of health services. This is possibly related to the explanations given by the resource persons, the trust the pregnant women had in them and the quality of care offered. However, this study did not measure the quality of care at the new delivery approaches and we recommend future studies to take this aspect into consideration. We note that relatively few adolescents and primigravidae were utilising the new approaches, yet these are the most vulnerable to malaria in pregnancy. This finding has implications on the acceptability of the new approaches by this group. Stigmatisation of adolescent pregnancy has previously been documented in the study community, whilst adolescents and primigravidae are not considered at risk of malaria in pregnancy (Mbonye et al., 2006b). We recommend a further study to assess ways of reaching adolescents and primigravidae with IPTp and other malaria prevention interventions.
A.K. Mbonye et al. Considerable variation in access and use of health units for malaria treatment and prevention has been previously documented. Part of this variation is explained by cultural practices, income status, education levels and prevalence of the disease (McCombie, 1996). It has been concluded that the severity of illness and the cost of accessing services are the two most important factors influencing access to health services (Foster, 1991; McCombie, 1996). In this paper, the observed increase in ANC use, delivery care, ITNs and treatment-seeking patterns for malaria may be due to other ongoing interventions such as HBM of fevers, promotion of ITNs and other malaria prevention interventions. Similarly, there could have been overlap among the comparison groups accessing IPTp and use of health services. However, this was overcome by comparing only women who exclusively accessed two doses of SP at each delivery point. In choosing community-based delivery of IPTp, there is fear that women may be complacent and opt not to use health facility-based interventions. In the design of the intervention study, this was considered and women were encouraged to seek specialised care at health units. Community resource persons were trained to identify any complications and to refer them. Similarly, when considering drug distribution at a community level, there are real dangers such as drug overdose and misuse of the drug leading to drug resistance. In this study, resource persons were trained to follow-up on pregnant women and to identify side effects of SP and to refer such women to health units for management. In addition to this, the study provided cards to all women who received the first dose of SP showing that they were involved in the study in order to avoid inappropriate use of SP and, furthermore, resource persons were trained in explaining the appropriate dose for malaria treatment and prevention with IPTp and the timing of the first and second dose of SP. One of the limitations of this study is the use of the case definition for malaria. The local term omusujja gw’ensiri is commonly used interchangeably with another local term omussujja, which is non-specific and refers to any febrile illness (Kengeya-Kayondo et al., 1994; Mbonye et al., 2006a). Thus, use of this could probably lead to an overestimate of reported malaria. Our findings could have policy implications for malaria prevention in pregnancy, especially the feasibility of linking the new approaches with health units. The resource persons will have to be trained, facilitated and linked to the health units to get SP and basic supplies and for effective supervision. The results will further be disseminated at national, district and subcounty levels to advocate for more resources and budget allocation to prevention of malaria in pregnancy and to promote maternal health programmes. Since most resource persons were already trained and involved in other health promotion activities such as home management of fevers, delivery of IPTp was an additional task and this is important for the sustainability of this approach. Similarly, the involvement of community leaders in the selection of resource persons and monitoring the study together with the investigation team was another way of sustaining the new delivery system. In conclusion, community-based delivery of IPTp is an effective and feasible option that can mitigate the negative effects of malaria in pregnancy. Linking the new approaches
Community delivery of IPTp and use of health interventions
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to the health units could yield complementary results, and we recommend future studies to identify programming modalities on this aspect.
Kallander, K., Tomson, G., Nsabagasani, X., Nsungwa-Sabiti, J., Senyonjo, Y., Pariyo, G., Peterson, S., 2006b. Can community health workers and caretakers recognise pneumonia in children? Experiences from western Uganda. Trans. R. Soc. Trop. Med. Hyg. 100, 956—963. Kengeya-Kayondo, J.F., Seeley, J.A., Kajura-Bajenja, E., Kabunga, E., Mubiru, E., Sembajja, F., Mulder, D.W., 1994. Recognition, treatment seeking behaviour and perception of cause of malaria among rural women in Uganda. Acta Trop. 58, 267—273. Mbonye, A.K., Neema, S., Magnussen, P., 2006a. Treatment-seeking practices for malaria in pregnancy among rural women in Mukono district, Uganda. J. Biosoc. Sci. 38, 221—237. Mbonye, A.K., Neema, S., Magnussen, P., 2006b. Malaria in pregnancy, risk perceptions and care seeking practices among adolescents in Mukono district Uganda. Int. J. Adolesc. Med. Health 18, 561—573. Mbonye, A.K., Magnussen, P., Bygbjerg, I.B., 2007. Intermittent preventive treatment of malaria in pregnancy: the effect of new delivery approaches on access and compliance rates in Uganda. Trop. Med. Int. Health 12, 519—531. McCombie, S.C., 1996. Treatment seeking for malaria: a review of recent research. Soc. Sci. Med. 43, 933—945. McGregor, I.A., Wilson, M.E., Billewicz, W.Z., 1983. Malaria infection of the placenta in The Gambia, West Africa; its incidence and relationship to still birth, birthweight and placental weight. Trans. R. Soc. Trop. Med. Hyg. 77, 232—244. Menendez, C., 1999. Priority areas for current research on malaria during pregnancy. Ann. Trop. Med. Parasitol. 93 (Suppl. 1), S71—S74. Ndyomugyenyi, R., Neema, S., Magnussen, P., 1998. The use of formal and informal services for antenatal care and malaria treatment in rural Uganda. Health Policy Plan. 13, 94—102. Nsungwa-Sabiti, J., K¨ allander, K., Nsabagasani, X., Namusisi, K., Pariyo, G., Johansson, A., Tomson, G., Peterson, S., 2004. Local fever illness classifications: implications for home management of malaria strategies. Trop. Med. Int. Health 9, 1191—1199. Rooney, C., 1992. Antenatal care and maternal health: how effective is it? A review of the evidence. World Health Organization, Geneva, pp. 10—37. Schultz, L.J., Steketee, R.W., Chitsulo, L., Wirima, J.J., 1995. Antimalarials during pregnancy: a cost-effectiveness analysis. Bull. World Health Org. 73, 207—214. Shulman, C.E., 1999. Malaria in pregnancy: its relevance to safemotherhood programmes. Ann. Trop. Med. Parasitol. 93 (Suppl. 1), S59—S66. Stanfied, J.P., Galazka, A., 1984. Neonatal tetanus in the world today. Bull. World Health Org. 62, 647—669. Uganda Bureau of Statistics, 1988. The Uganda Demographic and Health Survey. Uganda Bureau of Statistics, Entebbe, Uganda. Uganda Bureau of Statistics, 1995. The Uganda Demographic and Health Survey. Uganda Bureau of Statistics, Entebbe, Uganda. Uganda Bureau of Statistics, 2001. The Uganda Demographic and Health Survey. Uganda Bureau of Statistics, Entebbe, Uganda. Uganda Bureau of Statistics, 2002. The Statistical Abstract. Uganda Bureau of Statistics, Entebbe, Uganda. Ugandan Ministry of Health, 2001. The Malaria in Pregnancy Control Policy. Ministry of Health, Kampala, Uganda. Ugandan Ministry of Health, 2002. Implementing Guidelines for the National Home Based Management of Fever Strategy. Ministry of Health, Kampala, Uganda. van Eijk, A.M., Ayisi, J.G., ter Kuile, F.O., Slutsker, L., Otieno, J.A., Misore, J.O., Odondi, J.O., Rosen, D.H., Kager, P.A., Steketee, R.W., Nahlen, B.L., 2004. Implementation of intermittent preventive treatment with sulphadoxine—pyrimethamine for control of malaria in pregnancy in Kisumu, western Kenya. Trop. Med. Int. Health 9, 630—637. World Bank, 2006. Diseases Control Priorities Project: priorities in health. The World Bank Group.
Authors’ contributions: AKM and PM developed the research proposal, protocol and study design, and participated in data collection and supervision, data analysis and preparation of the manuscript; ICB participated in development of the research proposal, protocol and study design and participated in preparation of the manuscript. All authors read and approved the manuscript. PM and ICB are guarantors of the paper. Acknowledgements: We would like to thank Mr Steven Kalake, Ms Jolly Namuddu, Ms Charity Wamala, all the resource persons, all respondents and study participants, and the local leaders for their support during field work. We wish to thank Ms Olivia Kiconco for data entry. Funding: The Gates Malaria Partnership, London School of Hygiene and Tropical Medicine, with contributions from DBLInstitute of Health Research and Development, Denmark, and the Ministry of Health, Uganda. Conflicts of interest: None declared. Ethical approval: Danish National Committee for Biomedical Research Ethics; Uganda National Council of Science and Technology.
References Amooti-Kaguna, B., Nuwaha, F., 2000. Factors influencing choice of delivery sites in Rakai district of Uganda. Soc. Sci. Med. 50, 203—213. Brabin, B.J., 1983. An analysis of malaria in pregnancy in Africa. Bull. World Health Org. 61, 1005—1016. Foster, S.D., 1991. Pricing, distribution, and use of antimalarial drugs. Bull. World Health Org. 69, 349—363. Garner, P., Gulmezoglu, A.M., 2000. Prevention versus treatment for malaria in pregnant women. Cochrane Database Syst. Rev. (2):CD000169. Greenwood, B.M., Greenwood, A.M., Snow, R.W., Byass, P., Bennett, S., Hatib-N’Jie, A.B., 1989. The effect of malaria chemoprophylaxis given by traditional birth attendants on the course and outcome of pregnancy. Trans. R. Soc. Trop. Med. Hyg. 83, 589—594. Guyatt, H.L., Noor, A.M., Ochola, S.A., Snow, R.W., 2004. Use of intermittent presumptive treatment and insecticide treated bed nets by pregnant women in four Kenyan districts. Trop. Med. Int. Health 9, 255—261. Helitzer-Allen, D.L., McFarland, D.A., Wirima, J.J., Macheso, A.P., 1993. Malaria chemoprophylaxis compliance in pregnant women: a cost-effectiveness analysis of alternative interventions. Soc. Sci. Med. 36, 403—407. Holtz, T.H., Kachur, S.P., Roberts, J.M., Marum, L.H., Mkandala, C., Chizani, N., Macheso, A., Parise, M.E., 2004. Use of antenatal care services and intermittent preventive treatment for malaria among pregnant women in Blantyre District, Malawi. Trop. Med. Int. Health 9, 77—82. Kallander, K., Tomson, G., Nsungwa-Sabiiti, J., Senyonjo, Y., Pariyo, G., Peterson, S., 2006a. Community referral in home management of malaria in western Uganda: a case series study. BMC Int. Health Hum. Rights 6, 2.
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A community-based delivery system of intermittent preventive treatment of malaria in pregnancy and its effect on use of essential maternity care at health units in Uganda Anthony K. Mbonye a,∗, I.C. Bygbjerg b, Pascal Magnussen c a
Department of Community Health, Ministry of Health, Box 7272, Kampala, Uganda Department of International Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark c Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark b
Received 22 January 2007; received in revised form 26 June 2007; accepted 26 June 2007 Available online 5 September 2007
KEYWORDS Malaria; Pregnancy; Intermittent preventive treatment; Antenatal care; Health systems; Uganda
Summary Community delivery of intermittent preventive treatment of malaria in pregnancy (IPTp) is one potential option that could mitigate malaria in pregnancy. However, there is concern that this approach may lead to complacency among women with low access to essential care at health units. A non-randomised community trial assessed a new delivery system of IPTp through traditional birth attendants, drug shop vendors, community reproductive health workers and adolescent peer mobilisers (the intervention) compared with IPTp at health units (control). The study enrolled a total of 2081 pregnant women with the new approaches. Data on care-seeking practices before and after the intervention were collected. The majority of women with the new approaches accessed IPTp in the second trimester and adhered to two doses of sulfadoxine/pyrimethamine (SP) (1404/2081; 67.5%). Antenatal care (four recommended visits) increased from 3.4% (27/805) to 56.8% (558/983) (P < 0.001). The proportion of women delivering at health units increased from 34.3% (276/805) to 41.5% (434/1045) (P = 0.02), whilst the proportion of women seeking care for malaria at health units increased from 16.7% (128/767) to 36.0% (146/405) (P < 0.001). Similarly, use of insecticide-treated nets increased from 7.7% (160/2081) to 22.4% (236/1055) (P < 0.001). In conclusion, the community-based system was effective in delivering IPTp, whilst women still accessed and benefited from essential care at health units. © 2007 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
1. Introduction ∗ Corresponding author. Tel.: +256 772 411 668; fax: +256 41 321 572. E-mail address: [email protected] (A.K. Mbonye).
Current priorities for health care in developing countries include identifying cost-effective interventions for diseases
0035-9203/$ — see front matter © 2007 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.trstmh.2007.06.017
Community delivery of IPTp and use of health interventions that impose the greatest burden as well as determining how to deliver these interventions effectively, efficiently and equitably (World Bank, 2006). The challenge faced by policy-makers and programme managers in malaria-endemic countries is to increase access to malaria treatment and prevention interventions, as malaria is a leading cause of mortality among children and pregnant women (Brabin, 1983; Garner and Gulmezoglu, 2000; Greenwood et al., 1989; McGregor et al., 1983) yet access and use of these interventions is poor (Amooti-Kaguna and Nuwaha, 2000; Guyatt et al., 2004; Menendez, 1999; Ndyomugyenyi et al., 1998; Shulman, 1999; van Eijk et al., 2004). In Uganda, only 42% of pregnant women attend antenatal care (ANC) services four times as recommended (Uganda Bureau of Statistics, 1988, 2001) and only 34% use malaria chemoprophylaxis and intermittent preventive treatment of malaria in pregnancy (IPTp). Uganda initiated a homebased management (HBM) of fever strategy in 2002 (Ugandan Ministry of Health, 2002). Assessment of the impact of the HBM strategy in southwestern Uganda has concluded that HBM improves drug access (Nsungwa-Sabiti et al., 2004), leads to high referral compliance and extends primary health care to the communities by maintaining linkages with the formal health services (Kallander et al., 2006a, 2006b). One of the concerns when considering community distribution of malaria treatment and prevention interventions is whether it may lead to complacency among women with decreased use of essential health services. However, health-based interventions such as ANC provide one of the opportunities to promote maternal and infant health (Schultz et al., 1995). ANC services provide assessment and management of maternal risk factors, testing for syphilis, management of anaemia and routine antimalarial drugs for treatment and prevention of malaria (Rooney, 1992; Stanfied and Galazka, 1984). In Uganda, low utilisation of ANC limits access to malaria treatment and prevention in pregnancy and has been attributed to cost of services and long distances to health units (Amooti-Kaguna and Nuwaha, 2000; Mbonye et al., 2006a; Ndyomugyenyi et al., 1998). This situation prevails even though women in malaria-endemic countries recognise malaria as a serious illness (Guyatt et al., 2004; HelitzerAllen et al., 1993; Holtz et al., 2004; Kengeya-Kayondo et al., 1994; Mbonye et al., 2006a; Ndyomugyenyi et al., 1998). Poor utilisation of ANC and other interventions has also been attributed to deficiencies in the health system (Guyatt et al., 2004; Holtz et al., 2004; van Eijk et al., 2004). It has been concluded that malaria control programmes that rely only on ANC as a delivery system are likely to have poor coverage and compliance to IPTp (Menendez, 1999; Schultz et al., 1995). Given this scenario, alternative delivery approaches need to be identified (Helitzer-Allen et al., 1993; Menendez, 1999). This study tested new approaches of delivering IPTp through traditional birth attendants (TBA), drug shop vendors (DSV), community reproductive health workers (CRHW) and adolescent peer mobilisers (APM). The acceptability and sustainability of the new approaches have been published elsewhere (Mbonye et al., 2007). This article presents data on the effect of the new community-based delivery of IPTp on access and use of health services and the implications for malaria prevention in Uganda.
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2. Materials and methods 2.1. Study area and population The study was carried out in nine subcounties near the lakeshore region of Mukono district, central Uganda. The background characteristics of the study area have been published elsewhere (Mbonye et al., 2006a, 2006b). Briefly, the district has a population size of 850 900, a population density of 179 people per km2 , an annual population growth rate of 2.3% and a total fertility rate of 7.2 (Uganda Bureau of Statistics, 2002). The district has a rural population of 88.0% and is mainly inhabited by Baganda people, the largest tribe in Uganda. The district experiences high temperatures and heavy rainfall during the months of March—May and October—November. This district was selected because most areas are hyperendemic for malaria, whilst those on the shores of Lake Victoria are holoendemic and experience perennial transmission levels.
2.2. The intervention study A study was designed to assess the new approaches to delivering IPTp with sulfadoxine/pyrimethamine (SP) compared with the practice of delivery at health units. In Uganda, IPTp consists of two therapeutic doses of SP (three tablets of 500 mg sulfadoxine + 25 mg pyrimethamine) (Ugandan Ministry of Health, 2001). Nine rural subcounties from the district, which were homogeneous in terms of geography and cultural attributes, were selected. Within each subcounty, at least two parishes were randomly selected. The parishes with health units providing IPTp were selected among the health units in the study area. Three health centres III (Seeta-Namuganga, Kattogo and Seeta-Nazigo) and Kawolo District Hospital participated in the study. In Uganda, a health centre III is the lowest health facility with a maternity unit and provides ANC, delivery services and routine IPTp. In total, 25 parishes were selected: 4 tested IPTp at health units (control) while 21 tested IPTp administered by the new approaches (the intervention). The number of parishes selected for each cluster was determined by the sample size required and the expected rate at which pregnant women would be recruited. The study was not randomised because clusters were not uniform in the distribution of health units providing IPTp and the availability of community resource persons. However, the populations in the clusters were comparable in terms of socioeconomic status and other background characteristics. The study targeted all pregnant women who lived in the study area. One of the key components of the intervention study was a community mobilisation and sensitisation campaign to ensure that all women received information on the intervention and where to get SP. In total, the study area had an estimated population of 54 000. The expected number of pregnancies during the study period was 3596 (Uganda Bureau of Statistics, 2002). Because there was no register of people in this area, the number of pregnant women who accepted the first dose of SP served as the denominator for calculating the proportion of women who received the second dose of SP and other outcome variables (Figure 1).
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A.K. Mbonye et al.
Figure 1 Study profile. IPTp: intermittent preventive treatment of malaria in pregnancy; SP: sulfadoxine/pyrimethamine; DSV: drug shop vendor; TBA: traditional birth attendant; CRHW: community reproductive health worker; APM: adolescent peer mobiliser.
Fifty-one community resource persons were identified by the research team and the district and community leaders. The resource persons were composed as follows: 13 APMs, 14 CRHWs, 14 TBAs and 10 DSVs. Currently, APMs are trained to provide information on health issues, especially prevention of HIV/AIDS and prevention of unwanted pregnancies, among adolescents and young people. TBAs are trained to provide clean deliveries and to refer complications to health units. CRHWs are trained to promote safe motherhood and other health promotion activities. All the resource persons, including DSVs, are involved in the HBM of fevers. The DSVs are licensed and sell class C drugs to all clients within their locality. They sell medicines from shops but do not provide home visits, although they are usually qualified health workers who offer medical consultations. IPTp was offered free at all the approaches since all services are free at public health units in Uganda. DSVs usually offer services to the community such as immunisation and storing supplies and drugs as part of a public—private partnership encouraged by the policy in Uganda. The community resource persons were distributed in all 21 clusters. All the resource persons were trained for a period of 1 week. The following areas were covered: dangers of malaria in pregnancy; malaria prevention in pregnancy; the benefits and side effects of SP; taking blood samples for parasite count/haemoglobin analysis; taking the baby’s weight; and estimating gestational age. Birth weight was taken using a baby weighing scale (UNICEF-Super Samson Salter) measuring to the nearest 50 g, whilst gestational age was estimated using the date of the last menstrual period. After training, each resource person was given a month’s supply of SP, mebendazole, iron, folic acid and basic supplies
such as gloves, disposable syringes, disinfectant, cotton, gauze, laboratory slides/lancets, stationery and a bicycle to assist in community mobilisation and follow-up of pregnant women. The resource persons were not paid a salary. Recruitment of pregnant women was undertaken in May 2003 to February 2005. Women who consented to participate in the study were given SP as directly observed therapy (DOT) during the second and third trimester as recommended by the policy in Uganda. The procedure for enrolling pregnant women was through creating awareness and home visits by resource persons as well as those who visited DSVs for care; whilst at health units women attended routine services. Pregnant women also received iron and folic acid supplementation, deworming and information on proper nutrition. As part of the intervention, women received an explanation on the benefits of accessing ANC and other services at health units. Exclusion criteria were women who refused to give consent to the study and those who gave a history of allergy to sulphonamide-containing drugs. A structured questionnaire (in Luganda, the local language) was administered by the resource persons to each pregnant woman at (i) recruitment, (ii) before receiving the second dose of SP and (iii) at 36 weeks gestation or at delivery to collect data on sociodemographic characteristics, obstetric history, reported malaria illnesses, care-seeking practices, use of insecticide-treated nets (ITN) and use of IPTp. These data were also collected at health units. The primary outcome measures for the intervention study were the proportion of pregnant adolescents and primigravidae reached by the new approach, the gestational age at recruitment and the proportion of pregnant women who completed the two scheduled doses of SP.
Community delivery of IPTp and use of health interventions
2.3. Definitions Malaria was defined as a febrile illness characterised by feeling hot with headache, joint pains and general weakness. The local term omusujja gw’ensiri, translated as ‘fever caused by mosquitoes’, was used to refer to malaria. This term is also widely used in this region to refer to malaria (Kengeya-Kayondo et al., 1994; Mbonye et al., 2006a). The reference period for reported malaria episodes was 2 weeks prior to the assessment. In the intervention study, access was defined as the proportion of women who received the first dose of SP in the second trimester as recommended by the policy. Compliance with IPTp was defined as the proportion of women who completed two doses of SP and the denominator was the number of women recruited for the first dose at each approach. The term self-treatment used in this study refers to anything from a cool bath to a course of antimalarial of home-stocked drugs. This is distinguished from seeking care at drug shops since this is usually accompanied by consultation and purchase of appropriate medicines.
2.4. The post-intervention study A semistructured questionnaire containing closed and openended questions was administered to 1321 (47.4%) randomly selected women out of 2785 who participated in the intervention study immediately after the intervention study was completed. Two hundred and fifty-three (19.2%) had received SP at health units, whilst 1068 (80.8%) had received IPTp at the new approaches. The structured questionnaire covered the following areas: sociodemographic characteristics; and access and use of IPTp and other health services. For comparison purposes, the tools collected data on the same thematic areas as for the intervention study. Sixty key informant interviews were conducted after the intervention among the resource persons, health workers, women who had participated in the intervention and opinion leaders, since they were regarded to be more knowledgeable on health-related matters in their community. All respondents spoke Luganda, the local dialect, and questions were asked and responses recorded in the local dialect. These were later translated into English. Responses were initially coded separately for the Luganda and English versions and thematic areas were obtained. Data were manually analysed along the defined themes.
2.5. Statistical analyses Data were entered into Epi Info version 6.0 (CDC, Atlanta, GA, USA), cleaned and transferred to Stata version 8.2 (Stata Corp., College Station, TX, USA) for analysis. Univariate and bivariate analyses were performed to calculate frequency distributions and factors related to malaria morbidity, care-seeking practices and access and compliance rates to IPTp. For quantitative variables, Student’s t-test and one-way ANOVA were used for normally distributed variables (age and gestation period). The effect of the intervention on use of health services was assessed using a two-sample proportion test. A probit regression model
1091 was used to assess factors associated with use of ANC at health units. The dependent variable was ANC attendance. The model used a dummy variable with 0 as the value for ANC visits <4 and 1 as the value for ≥4 ANC visits. The model was constructed using the enter method and only significant variables at P < 0.05 were retained. The model fit was assessed for robustness using the loglikelihood ratio test and considered sufficient if the P-value was <0.05. Because of the cluster sampling technique for the intervention study, the design effect at analysis was computed by taking the parish as the primary sampling unit. The design effect for all outcome variables was >1.0, indicating that cluster sampling was an appropriate design. The new approaches (DSVs, TBAs, CRHWs and APMs) were analysed as one cluster since there were no statistically significant differences on all outcome variables between the groups, with the health units as another cluster. The sample size calculation for the intervention study was based on the current uptake of malaria chemoprophylaxis in Uganda, estimated at 34% (Uganda Bureau of Statistics, 2001), and to detect a 12% difference between health units and the new approaches. All the calculations assumed a power of 80% and 5% level of significance. The sample size for the post-intervention study was calculated to detect a 10% difference in ANC attendance between the groups of women who accessed IPTp at health units and the new approaches, assuming the current ANC attendance rate of 42% (Uganda Bureau of Statistics, 2001). To achieve comparable groups, the pregnant women who exclusively accessed IPTp (both the first and second dose of SP) at the health units constituted the control group, whilst pregnant women who exclusively accessed IPTp at the new approaches constituted the intervention group. Careseeking practices related to the current pregnancy before the intervention and care-seeking practices during and after the intervention were compared.
3. Results 3.1. Study population A total of 2081 women who accessed IPTp at the new approaches were interviewed on care-seeking practices related to the current pregnancy. The mean age was 23.9 years (range 14—43 years); the majority (69.0%) were aged 20—34 years and adolescents (age 10—19 years) comprised 25.0% (521/2081). Similarly, the majority of these women (76.0%) were dependent on peasant agriculture. The majority of respondents and their spouses (in both delivery approaches) had attained primary education, whilst few had attained secondary education and a small proportion had no education (Table 1). A total of 1055 women were sampled for the post-intervention study. The majority (73.7%) were aged 20—34 years, 59.2% were dependent on peasant agriculture and the majority (60.7%) had attained primary education. The background characteristics that determine care-seeking practices, such as education of respondent, education of spouse and occupational status, were comparable among women in the intervention and post-intervention surveys (Table 1).
1092 Table 1
A.K. Mbonye et al. Background characteristics of pregnant women who participated in the study
Background characteristic
Women utilising the new approaches (baseline) (N = 2081) n (%)
Women utilising the new approaches (post intervention) (N = 1055) n (%)
Age (years) 10—19 20—34 35—50
521 (25.0) 1435 (69.0) 125 (6.0)
177 (16.8) 778 (73.7) 100 (9.5)
0.03 0.02 0.32
Marital status Single Married Widowed/separated
337 (16.2) 1203 (57.8) 541 (26.0)
49 (4.6) 944 (89.5) 62 (5.9)
0.03 <0.001 0.004
Occupation of respondents Peasant agriculture Small-scale business Household work Salaried
1582 (76.0) 92 (4.4) 92 (4.4) 315 (15.1)
625 (59.2) 236 (22.4) 236 (22.4) 67 (6.4)
<0.001 <0.001 <0.001 0.06
Education of respondents No education Primary education Secondary education Tertiary institution
294 (14.1) 1352 (65.0) 383 (18.4) 52 (2.5)
176 (16.7) 640 (60.7) 218 (20.7) 21 (2.0)
0.5 0.06 0.51 0.89
Education of spouses No education Primary education Secondary education Tertiary institution
92 (4.4) 1241 (59.6) 670 (32.2) 78 (3.7)
164 (15.5) 556 (52.7) 296 (28.1) 39 (3.7)
0.008 0.006 0.12 —
3.2. The intervention study
P-value
accessed SP both from health units and from the community approaches.
With regard to access, the majority of women with the new delivery system (1905/2062; 92.4%) received the first dose of SP in the second trimester compared with 76.1% (523/687) with health units (P < 0.001). The mean gestational age for all women was 21.4 weeks (range 16—36 weeks). Mean gestational age was 23.1 weeks among women utilising IPTp at health units compared with 20.8 weeks with the new delivery system (P < 0.001). Adherence to two doses of SP was 39.9% (281/704) with health units and 67.5% (1404/2081) with the new delivery system (P < 0.001) (Table 2). Few women (286/1685; 17.0%)
3.3. Effect of the new approaches on access and use of health services Access to ANC and other services at health units was assessed among women who had received IPTp with the new approaches (community level). Before the intervention, only 27/805 (3.4%) of the women reported having attended ANC at least four times as recommended by the policy. After the intervention, the majority of women (558/983; 56.8%) had attended the four or more ANC visits. Similarly,
Table 2 Effect of community-based delivery of intermittent preventive treatment of malaria in pregnancy (IPTp) on access and adherence rates Access and adherence to IPTp
Pregnant women who utilised SP with health units
Pregnant women who utilised SP with the new approaches
P-value
Timing of first dose of SP (weeks of gestation) First dose of SP in second trimester First dose of SP in third trimester Proportion 10—19 years at first dose Proportion primigravidae at first dose Proportion of women adhering to two doses of SP Proportion of women using ITNs
(N = 704) 23.1 weeks 523/687 (76.1%) 164/687 (23.9%) 200/704 (28.4%) 166/704 (23.6%) 281/704 (39.9%) 64/259 (24.7%)
(N = 2081) 20.8 weeks 1905/2062 (92.4%) 157/2065 (7.6%) 521/2081 (25.0%) 435/2081 (20.9%) 1404/2081 (67.5%) 211/1416 (14.9%)
<0.001 <0.001
SP: sulfadoxine/pyrimethamine; ITN: insecticide-treated net.
0.03 0.04 <0.001 <0.001
Community delivery of IPTp and use of health interventions
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Table 3 Effect of community-based delivery of intermittent preventive treatment of malaria in pregnancy (IPTp) on access and use of health services Type of service ANC attendance ≥1 ANC visit 1 ANC visit 2 ANC visits 3 ANC visits ≥4 ANC visits Place where last child was delivered Home TBA Health unit Morbidity since delivery of last child Had malaria Sought treatment when got malaria Source of care Self-treatment at home Health units Drug shops Private clinics
Care-seeking practices before the intervention
Care-seeking practices post intervention
P-value
839/2081 (40.3%) 529 (65.7%) 198 (24.6%) 51 (6.3%) 27 (3.4%) N = 805
1011/1055 (95.8%) 35 (3.6%) 133 (13.5%) 257 (26.1%) 558 (56.8%) N = 983
<0.001 <0.001 0.01 0.002 <0.001
108 (13.4%) 421 (52.3%) 276 (34.3%) N = 805
146 (14.0%) 465 (44.5%) 434 (41.5%) N = 1045
906/1830 (49.5%) 767/1861 (41.2%)
443/1045 (42.4%) 405/436 (92.9%)
0.01 <0.001
371 (48.4%) 128 (16.7%) 125 (16.3%) 143 (18.6%) N = 767
31 (7.7%) 146 (36.0%) 116 (28.6%) 112 (27.7%) N = 405
<0.001 <0.001 0.02 0.03
0.89 0.02 0.02
ANC: antenatal care; TBA: traditional birth attendant.
pre-intervention the proportion of women who delivered their last child at health units was 34.3% (276/805) and this increased to 41.5% (434/1045) among women who had accessed IPTp at the new approaches (Table 3). Morbidity and care-seeking practices were assessed for the current pregnancy. The proportion of women reporting a malaria illness pre intervention was 49.5% (906/1830), whilst the proportion of women who sought care when they had malaria was 41.2% (767/1861). At the end of the intervention, the proportion of women who reported malaria illnesses decreased to 42.4% (443/1045) and the proportion of those who sought care increased to 92.9% (405/436). The source of care for malaria before and after the intervention varied. Whereas a large proportion of pregnant women at baseline (371/767; 48.4%) had resorted to self-treatment, only 7.7% (31/405) of women resorted to self-treatment after the intervention. The proportion of women seeking care at health units increased from 16.7% (128/767) to 36.0% (146/405). Similarly, seeking care at drug shops increased from 16.3% (125/767) to 28.6% (116/405) (Table 3). ANC use (four visits) was assessed among women who utilised IPTp with the new approaches (Table 4). The following factors were associated with increased use of ANC: women who utilised IPTp with health units and with APMs were likely to attend the four visits of ANC as recommended by the policy in Uganda. Similarly, adolescents aged 10—19 years, women with secondary education, women who delivered at health units and distance <2 km to a health unit were associated with increased ANC attendance. Use of services for women who accessed IPTp at health units was compared with those who accessed IPTp in the
community. A higher proportion of women who accessed IPTp at health units attended the four recommended ANC visits (76.1% vs. 56.8%; P < 0.001); similarly, deliveries at health units were higher (65.5% vs. 41.5%; P < 0.001) as well as care-seeking at health units (47.8% vs. 36.1%; P = 0.03) (data not shown).
3.4. Reasons for low uptake of IPTp among women attending ANC We investigated the reasons for low uptake of IPTp among women attending ANC. The results observed with the new approaches could be due to the fact that the resource
Table 4 Factors associated with access to antenatal care at health units Covariate
Odds ratio
95% CI
P-value
Using IPTp with the health units Secondary education Age (10—19 years) Using IPTp with APMs Women who delivered at health unit Distance <2 km to health unit
2.6
2.0—4.8
0.001
2.4 2.2 2.1 1.9
2.1—6.5 2.0—5.3 1.3—5.3 1.3—2.9
0.002 0.003 0.005 0.001
1.8
1.2—3.2
0.009
IPTp: intermittent preventive treatment pregnancy; APM: adolescent peer mobiliser.
of
malaria
in
1094 persons encouraged women to attend ANC and to benefit from other services at health units. The following factors were ranked in order of frequency in which they were mentioned: the high costs involved in accessing SP at health units; having to walk long distances; and the burden of household work. Some of the women said they had to convince their husbands in order to get permission to care for the children while the women were away. Some women who got the first dose of SP at health units said that they did not get the second dose because at the time of the ANC visit there was no stock of SP.
4. Discussion These results show that the new approach of delivering IPTp is feasible and effective. Women received IPTp at the community level while they also accessed ANC, delivery care and treatment of malaria and other ailments at health units. One of the key aspects of the intervention was a community mobilisation and awareness of malaria prevention in pregnancy and appropriate treatment of malaria in general. This was possible because the intervention utilised community resource persons who were already engaged in other health promotion activities, thus delivery of IPTp was an additional effort. This did not only lead to effective delivery of IPTp but was important for sustainability of this approach. The results show that there was increased access and compliance to IPTp associated with the new approaches. As previously indicated, access to resource persons and their ability to make frequent home visits, especially CRHWs and APMs, were important factors for reaching pregnant women early with IPTp (Mbonye at al., 2007). The importance of trust varied with the different approaches the women used to access IPTp. Trust in different providers, including health workers, was reflected by women’s choices on the sources of IPTp. The factors that most influenced access to ANC were age, education, source of IPTp, women who delivered at health units and distance to health units. In Uganda, young women and those with higher education are more likely to attend ANC and to deliver at health units compared with women with no education or primary education (Uganda Bureau of Statistics, 1995, 2001). An interesting finding from this study is the influence of the source of IPTp on use of health services. This is possibly related to the explanations given by the resource persons, the trust the pregnant women had in them and the quality of care offered. However, this study did not measure the quality of care at the new delivery approaches and we recommend future studies to take this aspect into consideration. We note that relatively few adolescents and primigravidae were utilising the new approaches, yet these are the most vulnerable to malaria in pregnancy. This finding has implications on the acceptability of the new approaches by this group. Stigmatisation of adolescent pregnancy has previously been documented in the study community, whilst adolescents and primigravidae are not considered at risk of malaria in pregnancy (Mbonye et al., 2006b). We recommend a further study to assess ways of reaching adolescents and primigravidae with IPTp and other malaria prevention interventions.
A.K. Mbonye et al. Considerable variation in access and use of health units for malaria treatment and prevention has been previously documented. Part of this variation is explained by cultural practices, income status, education levels and prevalence of the disease (McCombie, 1996). It has been concluded that the severity of illness and the cost of accessing services are the two most important factors influencing access to health services (Foster, 1991; McCombie, 1996). In this paper, the observed increase in ANC use, delivery care, ITNs and treatment-seeking patterns for malaria may be due to other ongoing interventions such as HBM of fevers, promotion of ITNs and other malaria prevention interventions. Similarly, there could have been overlap among the comparison groups accessing IPTp and use of health services. However, this was overcome by comparing only women who exclusively accessed two doses of SP at each delivery point. In choosing community-based delivery of IPTp, there is fear that women may be complacent and opt not to use health facility-based interventions. In the design of the intervention study, this was considered and women were encouraged to seek specialised care at health units. Community resource persons were trained to identify any complications and to refer them. Similarly, when considering drug distribution at a community level, there are real dangers such as drug overdose and misuse of the drug leading to drug resistance. In this study, resource persons were trained to follow-up on pregnant women and to identify side effects of SP and to refer such women to health units for management. In addition to this, the study provided cards to all women who received the first dose of SP showing that they were involved in the study in order to avoid inappropriate use of SP and, furthermore, resource persons were trained in explaining the appropriate dose for malaria treatment and prevention with IPTp and the timing of the first and second dose of SP. One of the limitations of this study is the use of the case definition for malaria. The local term omusujja gw’ensiri is commonly used interchangeably with another local term omussujja, which is non-specific and refers to any febrile illness (Kengeya-Kayondo et al., 1994; Mbonye et al., 2006a). Thus, use of this could probably lead to an overestimate of reported malaria. Our findings could have policy implications for malaria prevention in pregnancy, especially the feasibility of linking the new approaches with health units. The resource persons will have to be trained, facilitated and linked to the health units to get SP and basic supplies and for effective supervision. The results will further be disseminated at national, district and subcounty levels to advocate for more resources and budget allocation to prevention of malaria in pregnancy and to promote maternal health programmes. Since most resource persons were already trained and involved in other health promotion activities such as home management of fevers, delivery of IPTp was an additional task and this is important for the sustainability of this approach. Similarly, the involvement of community leaders in the selection of resource persons and monitoring the study together with the investigation team was another way of sustaining the new delivery system. In conclusion, community-based delivery of IPTp is an effective and feasible option that can mitigate the negative effects of malaria in pregnancy. Linking the new approaches
Community delivery of IPTp and use of health interventions
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to the health units could yield complementary results, and we recommend future studies to identify programming modalities on this aspect.
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Authors’ contributions: AKM and PM developed the research proposal, protocol and study design, and participated in data collection and supervision, data analysis and preparation of the manuscript; ICB participated in development of the research proposal, protocol and study design and participated in preparation of the manuscript. All authors read and approved the manuscript. PM and ICB are guarantors of the paper. Acknowledgements: We would like to thank Mr Steven Kalake, Ms Jolly Namuddu, Ms Charity Wamala, all the resource persons, all respondents and study participants, and the local leaders for their support during field work. We wish to thank Ms Olivia Kiconco for data entry. Funding: The Gates Malaria Partnership, London School of Hygiene and Tropical Medicine, with contributions from DBLInstitute of Health Research and Development, Denmark, and the Ministry of Health, Uganda. Conflicts of interest: None declared. Ethical approval: Danish National Committee for Biomedical Research Ethics; Uganda National Council of Science and Technology.
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