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Alafaka Tobin M.B, B.S A COMPARISON OF UPTAKE OF INTERMITTENT PREVENTIVE TREATMENT OF MALARIA IN PREGNANCY IN URBAN AND RURAL PUBLIC PRIMARY HEALTH CARE CENTRES IN RIVERS STATE BY ALAFAKA TOBIN M.B, B.S A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PART FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF FELLOWSHIP OF THE MEDICAL COLLEGE IN PUBLIC HEALTH MAY, 2016 1 DECLARATION I hereby declare that this study, or part of it, has not been and will not be submitted for any other diploma, fellowship or any other examination. ……………..………. ALAFAKA TOBIN M.B, B.S 2 CERTIFICATION This is to certify that this dissertation titled “A Comparison Of Uptake Of Intermittent Preventive Treatment Of Malaria In Pregnancy In Urban And Rural Public Primary Health Care Centres In Rivers State” was carried out by Alafaka Tobin, a Senior Registrar in the Department of Community Medicine, University of Port Harcourt Teaching Hospital under our supervision. ………………………….. ………………..…… Dr. C. I. Tobin-West Dr. C. A. Onoka MD, MPH, FMCPH MBBS, DLSHTM, MPH, MSc, FWACP Senior Lecturer, Consultant Community Medicine Lecturer, Consultant Community Medicine Department of Community Medicine University of Nigeria Teaching Hospital University of Port Harcourt Teaching Hospital Nsukka, Enugu Port Harcourt, Rivers State …………………… Dr. K. E. Douglas Head of Department Community Medicine University of Port Harcourt Teaching Hospital Port Harcourt Rivers State 3 DEDICATION This book is dedicated to my husband Mr. Derefaka Tobin whose words of encouragement motivated me to commence and complete this dissertation. 4 ACKNOWLEDGEMENT I am very grateful to my supervisors, Dr. C.I. Tobin-West and Dr. C. A. Onoka as well as my Head of Department, Dr. K. E. Douglas for the motivation and enormous support they provided throughout this research and my training program. My gratitude also goes to Dr. O. Maduka, my Residency Training Coordinator who was always ready to help and clear any confusion that arose in course of my dissertation. I am also grateful to my consultants, Dr. B. Ordinioha, Dr. M. M. Mezie-Okoye, Dr. S. Babatunde, Dr. I. N. Ojule and Dr. D.S. Ogaji for their support all through my residency training as well as their constructive criticism of my work. I also wish to appreciate the Planning, Research and Statistics (PRS) Department of the Rivers State Primary Health Care Management Board for granting me permission to carry out this research in the Primary Health Care Centres. I also appreciate the nurses in the Primary Health Care Centres for their support all through my research. I also wish to appreciate my colleagues Dr. A. Tella, Dr. I. N. Okeafor and Dr. U. Katchy who conducted peer reviews on my dissertation at different stages of my work. My appreciation beyond expression goes to my husband Mr. D. Tobin for his overwhelming support and understanding all through the residency training programme. My heartfelt appreciation goes to my sweet mother Mrs. G. B. Nembo-Opuiyo whose caring phone calls were indeed a motivation to work hard. Finally, my greatest appreciation goes to my God who gave me the privilege of being alive, healthy and strong. 5 TABLE OF CONTENT Declaration ……………………………………………………………… ii Certification ……………………………………………………………… iii Dedication ……………………………………………………………… iv Acknowledgement ……………………………………………………………… v Table of content ……………………………………………………………… vi List of Tables ……………………………………………………………… viii List of Figure ……………………………………………………………… ix List of Acronyms ……………………………………………………………… x Definition of Terms ……………………………………………………………… xi Abstract ……………………………………………………………… xii CHAPTER ONE ……………………………………………………………… 1 Introduction ……………………………………………………………… 1 1.1 Background ……………………………………………………………… 1 1.2 Problem Statement ……………………………………………………………… 3 1.3 Justification ……………………………………………………………… 4 1.4 Research Questions ……………………………………………………………… 6 1.5 Study Objectives ……………………………………………………………… 6 1.5.1 General Objectives ………………………………………………………... 6 1.5.2 Specific Objectives ………………………………………………………... 6 CHAPTER TWO …………………………………………………………………… 7 Literature Review …………………………………………………………………… 7 2.1 Overview …………………………………………………………………. 7 2.1.1 Global Efforts in the control of malaria in pregnancy …………………….. 7 2.1.2 Roll Back Malaria – Global Action Plan ………………………………….. 8 2.1.3 Global Health Initiative – Presidents’ Malaria Initiative …………………… 9 2.1.4 National Malaria Control Programme and Antimalaria Policy ……………. 10 2.1.5 Conceptual Framework ………………………………………………. 12 2.2 IPTp Uptake among ANC attendees ……………………………………………….. 14 2.3 Health Workers’ Practice of IPTp ……………………………………………….. 17 2.4 Client Related Determinants of IPTp Uptake …………………………………………. 19 2.5 Health Facility Related Determinants of IPTp Uptake ……………………………..... 24 6 CHAPTER THREE ………………………………………………………. 28 Materials and Methods ………………………………………………………. 28 3.1 Study Area ………………………………………………………. 28 3.2 Study Design ………………………………………………………. 29 3.3 Scope of Study ………………………………………………………. 29 3.4 Study Population ………………………………………………………. 30 3.5 Selection of Facility ………………………………………………………. 30 3.5.1 Eligibility Criteria ……………………………………………………… 30 3.5.2 Inclusion Criteria (PHC) ……………………………………………………… 30 3.5.3 Exclusion Criteria (PHC) …………………………………………………….. 30 3.5.4 Sampling Technique ……………………………………………………….. 30 3.6 Survey of ANC Attendees ………………………………………………………. 31 3.6.1 Inclusion Criteria ………………………………………………………. 31 3.6.2 Exclusion Criteria …………………………………………………………. 31 3.6.3 Sample Size Determination ……………………………………………………. 32 3.6.4 Selection ANC Attendees ………………..………………………………………….. 33 3.6.5 Determination of Sampling Interval ………………………………………………. 34 3.6.6 Selection of Random Start ……………………………………………………. 37 3.6.7 Instrument for Data Collection ………………………………………………………. 37 3.6.8 Validation of Instrument for Data Collection ……………………………………… 37 3.6.9 Procedure for Data Collection ……………………………………………………... 38 3.6.10 Data Analysis ………………..…………………………………………… 39 3.6.11 Dependent Variables for comparison of IPTp uptake among Urban and Rural Groups 39 3.6.12 Outcome variables for comparison of IPTp uptake among Urban and Rural Groups 39 3.6.13 Independent Variables for client factors affecting IPTp uptake in Urban and Rural 39 Groups …………………………………………….. 3.6.14 Outcome variables for client factors affecting IPTp uptake in Urban and Rural 39 Groups ……………………………………………………………………………….. 3.6.15 Data Analysis of Questionnaires …………………………………………………... 39 3.7 Focus Group Discussion With ANC Attendees ……………………………………………… 40 3.7.1 Target Population …………………………………………………………….. 40 3.7.2 Selection of Participants ……………………………………………………………. 40 3.7.3 Study Instruments …………………………………………………………….. 41 3.7.4 Validation of Instruments …………………………………………………………… 41 3.7.5 Procedure for Data Collection ……………………………………………………… 41 3.7.6 Data Analysis ……………………………………………………………………. 42 7 3.8 Assessment of Facility ……………………………………………………………………. 43 3.8.1 Study Instruments ………………………………………………………….. 43 3.8.2 Validation of Instruments …………………………………………………………. 44 3.8.3 Procedure for Data Collection …………………………………………………….. 44 3.8.4 Data Analysis ……………………………………………………………………… 44 3.9 In-depth Interviews for Heads of Antenatal Clinics…………………………………………... 44 3.9.1 Target Population …………………………………………………………….. 44 3.9.2 Selection of Participants ……………………………………………………….….. 45 3.9.3 Study Instruments …………………………………………………………….. 45 3.9.4 Validation of Instruments …………………………………………………………… 45 3.9.5 Procedure for Data Collection ……………………………………………………….. 45 3.9.6 Data Analysis ………………………………………………………………………. 46 3.10 Key Informant Interview with Roll Back Malaria Managers ………………………………. 47 3.10.1 Target Population ………………………………………………………………….. 47 3.10.2 Selection of Participants …………………………………………………………….. 47 3.10.3 Study Instruments …………………………………………………………………. 47 3.10.4 Validation of Instruments …………………………………………………………. 47 3.10.5 Procedure for Data Collection ………………………………………………………. 47 3.10.6 Data Analysis ………………………………………………………………………. 48 3.11 Ethical Approval ………………………………………………………………… 49 3.12 Study Limitations ………………………………………………………………… 49 CHAPTER FOUR ………………………………………………………………… 50 Results ………………………………………………………………… 50 4.1 Section 1: Survey of ANC Attendees…………………………………………………... 51 Socio-demographic Characteristics of Respondents……………………….. 51 Obstetric History of Respondents …………………………………………… 52 Client Related Factors Affecting IPTp Uptake …………………………… 54 Bivariate Analysis …………………………………………………… 58 Multivariate Analysis (Urban)……………………………………… 62 Multivariate Analysis (Rural)……………………………………… 63 4.2 Section 2: IPTp Uptake among ANC attendees ……………………………………… 64 4.3 Section 3: Focus Group Discussion ……………………………………………………….. 66 Socio-demographic Characteristics of Focus Group Participant………………….. 66 Distribution of Women Recruited Into The Focus Group Discussion……………… 67 Key Findings from Focus Group Discussion ……………………………………… 68 8 4.4 Section 4: Facility Assessment ……………………………………………………………… 74 4.5 Section 5: In-depth Interview of Heads of ANC……………………………………… 75 4.6 Section 6: Key Informants Interview………………………………………………….. 82 CHAPTER FIVE ……………………………………………………………. 85 5.1 Discussion ……………………………………………………………. 85 5.2 Conclusion ……………………………………………………………. 97 5.3 Recommendations ……………………………………………………………. 98 Future Study ……………………………………………………………. 99 References ……………………………………………………………. 100 Appendices ……………………………………………………………. 110 9 LIST OF TABLES Table 3.1: Number of eligible ANC Attendees in selected Urban PHCs in the month 33 preceding commencement of study Table 3.2: Number of eligible ANC Attendees in selected Rural PHCs in the month preceding 34 commencement of
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