Alafaka Tobin M.B, B.S

Home , Abonnema, Ahoada East, Asarama, Buguma, Chokocho, Emohua

A COMPARISON OF UPTAKE OF INTERMITTENT PREVENTIVE

TREATMENT OF MALARIA IN PREGNANCY IN URBAN AND RURAL

PUBLIC PRIMARY HEALTH CARE CENTRES IN RIVERS STATE

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

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

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

DEDICATION

This book is dedicated to my husband Mr. Derefaka Tobin whose words of encouragement motivated me to commence and complete this dissertation.

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.

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

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

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

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

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 study Table 3.3: Proportional to Size Allocation of ANC Attendees for Urban PHCs 35

Table 3.4: Proportional to Size Allocation of ANC Attendees for Rural PHCs 36

Table 4.1: Socio-demographic Characteristics of ANC Clients 51

Table 4.2: Obstetric History of Urban and Rural Respondents 53

Table 4.3: Comparison of Accessibility Factors in Urban and Rural Groups 54

Table 4.4: Comparison of the Correct Knowledge of Malaria and IPTp 55

Table 4.5: Comparison of Aggregate Malaria and IPTp Knowledge Score in Urban and Rural 56 Groups. Table 4.6: Comparison of Experiences of Side Effects in Urban and Rural Areas 57

Table 4.7: Client Related Factors Affecting Uptake Two or More Doses of IPTp in Urban and 58 Rural Groups Table 4.8: Multivariate Analysis of Uptake of two or more doses of IPTp with client related 62 factors - Urban. Table 4.9 Multivariate Analysis of Uptake of two or more doses of IPTp with client related 63 factors- Rural. Table 4.10 Comparison of IPTp Uptake Among Urban and Rural Groups 64

Table 4.11 Socio-Demographic Characteristics of Focus Group participants 66

Table 4.12 Distribution of Women Recruited into the FGDs 67

Table 4.13 Reasons why ANC Attendees may not take 2 tablets on SP 71

Table 4.14 Suggestions to tackle Barriers on IPTp Uptake 73

Table 4.15 Comparison of Facility Performance when the components of IPTp were assessed 74 in Urban and Rural PHCs Table 4.16 Comparison of Aggregate Facility IPTps Scores in Urban and Rural PHCs 75

Table 4.17 Socio-Demographic Characteristics of ANC Heads 76

LIST OF FIGURE

Figure 2.1 Conceptual Framework 12

Figure 3.1 Coding Tree for FGD with ANC Attendees in Urban and Rural Groups 42

Figure 3.2 Coding Tree for In-depth Interviews with ANC Heads 46

Figure 3.3 Coding Tree for Key Informant Interviews with Roll Back Malaria Managers 48

Figure 4.1 Trimester of first ANC Attendance 52

Figure 4.2 Comparison of Use of Optimal Doses of IPTp among Urban and Rural Groups 65

LIST OF ACRONYMS ACT Artemisinin- based Combination Therapy AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Clinic CDC Centre for Disease Control DOT Directly Observed Treatment GFATM Global fund to fight AIDS, Tuberculosis and Malaria GMAP Global Malaria Action Plan GPS Global Positioning System HIV Human Immunodeficiency Virus IEC Information Education Communication IPTp Intermittent Preventive treatment of malaria in pregnancy IRS Indoor Residual Spraying ITN Insecticide Treated Net LGA Local Government Area LLIN Long Lasting Insecticide Net MIP Malaria in pregnancy MDG Millennium Development Goal MOH Medical Officer of Health NDHS National Demographic Health Survey NMCP National Malaria Control Program OPD Out Patients Department PMI Presidents’ Malaria Initiative RPHCMB Rivers State Primary Health Care Management Board SP Sulphadoxine - Pyrimethamine SuNMap Support to Nigeria Malaria Programme USAID United States Agency for International Development WHO World Health Organization WALGA Wakirike Local Government Area (Okrika) SDG Sustainable Development Goals

DEFINITION OF TERMS

IPTp: The administration of anti-malarial drugs in treatment doses at predefined intervals to clear a presumed burden of parasites.

IPT1: This refers to the first dose of IPTP.

IPT2: This refers to the second dose of IPTp.

UPTAKE OF IPTp - SP: This is the utilization of IPTp-SP by pregnant women at the antenatal clinic.

DIRECT OBSERVATION: This is a situation in which a pregnant woman takes

Sulphadoxine-Pyrimethamine (SP) at the antenatal clinic (ANC) under the supervision of a qualified health staff.

DETERMINANTS OF IPTp UPTAKE: These are the factors influencing uptake of intermittent preventive treatment of malaria in pregnancy.

IPTp COVERAGE: Percentage of women aged 15-49 who received two or more doses of

IPTp, at least one of which was received during an ANC visit, to prevent malaria during their last pregnancy that led to a live birth within the last two years.

OPTIMAL IPTP: Refers to uptake of two or more doses of IPT

MISSED OPPORTUNITY FOR IPTP: refers to an ANC visit in which IPTp could have been administered according to the policy but was not

SIDE EFFECTS WITH SP TABLETS: Unintended effect, occurring at normal dose and related to the pharmacological properties of SP tablets.

ABSTRACT

Introduction/ Background

Malaria in pregnancy contributes significantly to perinatal morbidity and mortality. According to the 2014 world malaria report, Nigeria and Democratic Republic of Congo accounted for 39% of the global estimates of malaria deaths and 34% of malaria cases in 2013. In Nigeria, intermittent preventive treatment of malaria in pregnancy (IPTp) coverage has been persistently low though higher in the urban compared with the rural areas. In the health facilities, deviations from prescribed standards in the national guidelines have been observed. The challenges of IPTp implementation in Nigeria are multi-factorial and may vary from place to place. This study aimed at comparing IPTp uptake at antenatal clinics (ANC), health workers’ practice and factors affecting IPTp uptake in urban and rural Primary Health Care Centres (PHCs) in Rivers State.

Methodology

This study was conducted in Okrika (rural LGA) and Obio/Akpor (Urban LGA) in Rivers State.

A comparative cross sectional study design employing both quantitative methods of data collection was employed. Multistage sampling technique was employed in the quatitative aspect of this study. First simple random sampling technique was used to select an urban and a rural

LGA. Subsequently, simple random sampling technique was used to select five and eight PHCs in the urban and rural LGAs respectively. In these PHCs, a checklist was employed to carry out a non-participant observation of IPTp practice. Furthermore systematic sampling was carried out to select a total of 415 and 420 ANC attendees in the urban and rural LGAs respectively. Exit interviews using an interviewer administered questionnaire was conducted with all selected

ANC attendees. IPTp uptake was determined for both urban and rural groups. Client factors that may affect IPTp uptake were identified using bivariate and multivariate analysis.

For the qualitative study, participants for focus group discussions and interviews were purposively selected. A total of 13 FGDs (five in the urban and eight in the rural groups respectively) were conducted with selected ANC attendees to explore client factors that may affect IPTp uptake. A total of 13 in-depth interviews (five in the urban and eight in the rural groups respectively) were conducted with all heads of selected ANCs. Two key informant interviews were conducted with Roll Back Malaria Managers in both selected LGAs. These interviews explored the health service factors affecting IPTp uptake.

Ethical approval was sought from the Ethics Committee of the University of Port Harcourt

Teaching Hospital before the study commenced. Written permission to conduct the study was obtained from the Rivers State Primary Health Care Management Board (RPHCMB) and the

Medical Officer of Health as well as the Local Government Council in the selected LGAs.

Informed consent was obtained from all participants after the nature of the study was explained to them and confidentiality assured.

Results

Uptake of two or more doses of IPTp was higher in the urban PHCs 199 (48.0%) compared with the rural PHCs 161 (38.3%). The factors associated with IPTp uptake in the urban setting were marital status, number of ANC visits and time spent in getting to the ANC. While in the rural group, marital status, experience of side effects with SP tablets and number of ANC visits were factors affecting IPTp uptake.

In the focus group discussion the key findings on IPTp were that ANC attendees had reasons why they may not take two doses of IPTp. In the rural group, unavailability of the drug at the

ANC, the side effects of the drug and receipt of SP tablets from other sources other than ANC were the reasons given. In the rural group, lack of money, receipt of SP tablets from other

15 sources other than ANC and ANC attendees not feeling sick and as such did not think it was necessary to take SP tablets were reasons given.

A total of 13 parameters were used to assess IPTp practice at the PHCs. All PHCs in the urban group had ≥ 50% aggregate practice score. While six out of eight PHCs in the rural group had ≥

50% aggregate practice score.

From the in-depth interviews with heads of ANC, lack of training on IPTp and lack of free SP tablets at the ANC were identified as health facility factors affecting IPTp uptake in both urban and rural groups. In addition poor monitoring and supervision was also identified as health facility factors affecting IPTp uptake by ANC heads in the urban group.

Conclusion

IPTp uptake values obtained in the current study were far below the national target of 100%.

This may be due to deficiencies in key aspects of IPTp practice observed at the ANC. In the urban setting, marital status, number of ANC visits and time spent in getting to the ANC were factors affecting IPTp uptake. While marital status, experience of side effects with SP tablets and number of ANC visits were factors affecting IPTp uptake in the rural group. It is thus recommended that concerted effort be made to address the health service factors affecting IPTp uptake.

CHAPTER ONE

INTRODUCTION

1.1 Background

Malaria is an important disease of tropical countries that results from the transmission of plasmodium parasite after a bite or blood meal of an infected female Anopheles mosquito.1

Pregnant women, young children and travelers or migrants coming from areas with little or no malaria transmission, who lack immunity are mostly affected.2

Malaria infection during pregnancy is an important public health problem which poses an enormous risk to the pregnant woman, her fetus and the newborn child.3 Throughout the world approximately fifty million women living in malaria endemic countries become pregnant annually.4 The symptoms and complications of malaria infection in pregnancy vary with the intensity of malaria transmission and the level of immunity of the pregnant woman.3 High prevalence of malaria during pregnancy has been linked with immune changes and proliferation of the parasite within the placenta.

In 2007, an estimated 32 million pregnancies occurred in malaria-endemic areas in Sub-Saharan

Africa.5 In these areas, the prevalence of malaria was highest among younger women and those having their first and second pregnancies.6 High prevalence of malaria during pregnancy has been linked with immune changes and proliferation of the parasite within the placenta.7

There are over 100 million people at risk of malaria annually in Nigeria and it is estimated that about 50% of the adult population in Nigeria experience at least one episode annually while the under five children have an average of two to four attacks of malaria over the same period.8

According to the 2014 World Malaria Report, Nigeria and Democratic Republic of Congo accounted for 39% of the global estimates of malaria deaths and 34% of malaria cases in 2013.9

The World Health Organization (WHO) in 1998 recommended the use of Intermittent preventive treatment of malaria with Sulphadoxine-Pyrimethamine (IPTp-SP).10 IPTp is defined as the administration of at least two doses of Sulphadoxine-Pyrimethamine in pregnancy at a predetermined interval (usually one month) after quickening has occurred to clear a presumed burden of parasites.11 Nigeria adopted IPTp strategy in the year 2005.12 By 2007, all 39 African countries with stable malaria transmission had adopted the World Health Organization (WHO) three pronged approach: administration of IPTp-SP during the 2nd and 3rd trimester, sleeping under an insecticide treated net (ITN) and prompt case management among pregnant women with symptoms of malaria.12 Subsequently, the World Health Organization observed a slowing of efforts to scale up IPTp-SP in a number of countries in Africa.12 It was subsequently recommended that all possible efforts should be made to increase access to IPTp with SP in all areas having moderate to high transmission in Africa, as part of antenatal care services.12

Over the last decade, different IPTp targets have been set. Initially IPTp coverage target was set at 60% by the year 2005.13 Subsequently, the RBM partners set IPTp coverage target at 80% by

2010. In the National Malaria Strategic Plan 2014-2020, the major target for IPTp is to ensure that 100% of pregnant women utilize IPTp by 2020.14 The 2013 Demographic Health Survey results in Nigeria estimated IPTp coverage to be 15% which was far below the target 100% coverage.15

Low coverage levels of IPTp in Nigeria compromises the effectiveness of IPTp strategy and this is further worsened by poor IPTp delivery practices.16 It has thus been suggested that the problem of low IPTp- SP coverage is a health system problem and improving the health system may improve IPTp-SP coverage.16 However evidence abound that client related factors also affect IPTp coverage.17,18,19

Given that malaria in pregnancy (MIP) is both a maternal and newborn health issue, efforts to prevent malaria in pregnancy (MIP) including IPTp may be channeled through the antenatal clinics (ANC) as statistics show that the majority of pregnant women in sub-Saharan Africa attend ANC at least once and often twice during pregnancy.20

1.2 Problem Statement

Studies have shown that the prevalence of malaria is high among pregnant women.21,22 Malaria in pregnancy contributes significantly to maternal mortality as well as perinatal morbidity and mortality.23 Malaria related deaths account for up to 11% of maternal mortality, 25% of infant mortality, and 20% of under-five mortality thus resulting in 300,000 childhood deaths annually.24

Complications associated with malaria in pregnancy include maternal anaemia, premature delivery and low birth weight which may in turn lead to increased child mortality.25,26 A study in Tanzania found that post-partum haemorrhage was significantly increased in women with placental malaria.27 It has been stated that if postpartum haemorrhage occurs in a women with anaemia which is also a complication of malaria in pregnancy, the risk of mortality is higher.28

Despite the IPTp policy recommendation, studies in many parts of Nigeria have shown low

IPTp coverage.29,30 Facility based studies in Enugu, South-Eastern Nigeria and Shagamu in

South-Western Nigeria found IPTp coverage to be 3% and 14.6% respectively.11,17 For Rivers

State where the current study was conducted, the most recently documented IPTp coverage was

45%.31 This is still way below the 100% IPTp coverage target in the National Strategic plan.14

Differences in IPTp coverage have been noted in rural and urban settings, with the urban settings having a higher coverage.11,30 According to the 2013 Demographic Health Survey in

Nigeria, IPTp coverage (percentage that had two or more doses of IPTp) for urban and rural settings were stated as 19% and 12% respectively.15 In the same survey, a low IPTp coverage of

10% for the south-south which includes Rivers State was also documented.15 These are

19 relatively low considering the fact that ANC utilization rate in Nigeria is estimated to be 61%.15

Similar findings were obtained from the 2010 demographic health survey as well.24 This implies that more than half of the women accessing ANC do not receive IPTp. This is supported by studies that have documented that the persistently low IPTp coverage may be due to health facility related factors rather than client related factors.16 Health facility related factors contribute significantly to the core challenges of IPTp delivery.32 Getting the health facilities to implement IPTp according to the National Guideline for diagnosis and treatment of malaria in

Nigeria has been challenging. Some of the challenges include missed opportunities, SP stock- out among others.16 Patients are expected to buy SP tablets and take them unsupervised.33

Furthermore health workers adhere poorly to the specifications on IPTp strategy as stated in the

National Guideline For Diagnosis and Treatment of Malaria.16 The consequences of these are likely to be increased morbidity and mortality, complications of malaria in both mother and fetus, development of drug resistance and occurrence of congenital malaria in the new born.

1.3 Justification

IPTp-SP has been shown to be effective in preventing malaria related complications in pregnancy.14,34,35,36 The use of SP as intermittent preventive treatment of malaria in pregnancy

(IPTp) has been shown to greatly reduce the impact of malaria in pregnancy and its complications when administered appropriately according to set protocol.37 Over a decade after the IPTp policy recommendation was made, studies in many parts of Nigeria still indicate low coverage of intermittent preventive treatment of malaria in pregnancy (IPTp).11,29 Some other studies carried out in Malawi and Tanzania have reported relatively higher values.38,39

The National Health Policy recommends the Primary Health Care Centres (PHCs) as the entry point into the health care system.40 This implies that proper implementation of IPTp in PHCs may have profound effect on malaria control in pregnancy. The Rivers State government recently embarked on a number of strategies to encourage the utilization of PHCs by pregnant

20 women. These include construction of 132 model Primary Health Centres, provision of transport fare for all pregnant women registering for antenatal care in the health centres and intermittent supply of free SP tablets for IPTp at the ANC.41

Although a number of studies on IPTp have been conducted in Primary Health Care Centres in

Nigeria, it is important to carry out a rural/ urban comparison of IPTp uptake, practice as well as the determinants of IPTp uptake. The challenges of IPTp implementation in Nigeria are multi- factorial and may vary from place to place.11,29 They include both health system challenges such as the level of knowledge of health workers, health workers’ training on IPTp, staff attitude as well as monitoring and supervision. In additions, client related factors such as gestational age at first booking, IPTp knowledge level among pregnant women, availability of SP and clean portable water for DOT at the ANC have also been found to be associated with IPTp uptake. It is therefore important to identify the exact local problems and reasons for weak performance in order to determine workable solutions.

The findings of this study may be helpful in contributing towards the attainment of the third

Sustainable development goal (SDG) which is to ensure healthy lives and promote health for all at all ages. It may also be helpful in reducing already existing rural/urban inequalities in maternal health as well as improving IPTp implementation strategy in urban and rural settings in

Rivers State.

1.4 Research Questions

1. Are there differences in IPTp-SP uptake amongst ANC attendees in PHCs in a rural and

an urban LGA in Rivers State?

2. Are there differences in health workers practice of IPTp in PHCs of a rural and an urban

LGA in Rivers State?

3. Are there differences in the client related factors that affect IPTp uptake in PHCs of a

rural and an urban LGA in Rivers State?

4. Are there differences in the health facility related factors that affect IPTp uptake in PHCs

of a rural and an urban LGA in Rivers State?

1.5 Study Objectives

1.5.1 General Objective

To compare IPTp uptake, Health workers’ practice and factors affecting IPTp uptake in public

PHCs in a rural and an urban LGA in Rivers State.

1.5.2 Specific Objectives

1. To compare IPTp uptake amongst ANC attendees in public PHCs of a rural and an urban

LGA.

2. To compare Health workers’ practice of IPTp in PHCs of a rural and an urban LGA.

3. To identify the client related factors that affect IPTp uptake in PHCs of a rural and an

urban LGA.

4. To identify the health facility related factors that affect IPTp uptake in PHCs of a rural

and an urban LGA.

CHAPTER 2

LITERATURE REVIEW

2.1 Overview

2.1.1 Global Efforts in the Control of Malaria in Pregnancy

Malaria control continues to remain a major challenge especially in Africa where it has constituted a major setback for the crawling socio-economic progress and has thus attracted concerted effort.42 The vector and parasite that cause malaria are highly adaptable in nature thus making malaria control difficult. This may also cause malaria control interventions to be ineffective especially if they are used in isolation.42 Thus Morbidity and mortality attributable to malaria in pregnancy are enormous despite the fact that malaria is preventable and curable.43

Between 1950 and 1970, there was a global malaria eradication campaign which was aborted and subsequently malaria received little attention until recently.44 The first drug used on a large scale in the prevention and treatment of malaria was chloroquine.45

However development of wide spread resistance has resulted in limitation of its use.44 Therefore, chloroquine chemoprophylaxis no longer has a role in national policies for the control of malaria in pregnancy in the Africa region.46 Daraprim was previously indicated for malaria chemoprophylaxis in pregnancy. The previous policy stated that it should be taken as a weekly chemoprophylaxis. Its use was however limited by poor compliance especially outside the clinic setting.

WHO currently recommends intermittent preventive treatment of malaria with sulphadoxine- pyrimethamine (SP).10 IPTp-SP is an integral part of the WHO’s strategy for the prevention and control of malaria in pregnancy, which also includes the use of insecticide treated nets, prompt diagnostic testing and effective treatment. In 2010, data from a number of indicator surveys showed that most African countries were still far from attaining the IPTp coverage target.24 The

WHO identified health workers confusion about SP administration was a possible reason.12 In

October 2012, this confusion was clarified by updating IPTp policy and national health authorities were encouraged to disseminate this update and ensure it is applied.12 The WHO also advocates that all possible efforts be made to improve access to IPTp with SP in areas of moderate to high transmission.12

2.1.2 Roll Back Malaria - Global Action Plan

Malaria continues to adversely affect health and economic development in over 100 countries across the world.25 Roll Back Malaria exerted concerted effort to ensure that by 2015, malaria was no longer a major cause of mortality and ceased to be a barrier to social and economic development and growth anywhere in the world.44

In the Global Strategic Plan 2005-2015, the RBM Partnership reiterates the targets of achieving universal coverage through the use of locally appropriate vector control methods such as long- lasting insecticide treated nets (LLINs), indoor residual spraying (IRS) environmental and biological measures, prompt diagnosis and treatment of malaria cases with effective antimalarial treatments as well as attainment of 100% IPTp coverage.44 It also aimed at achieving the malaria-related Millennium Development Goal by 2015 thus halting and beginning to reverse the incidence of malaria by 2015. Beyond 2015 the RBM target is to ensure that global and national mortality stays near zero for all preventable deaths and universal coverage is maintained for all populations at risk until there is substantial evidence that coverage can gradually be targeted to high risk areas and seasons only, without risk of a generalized resurgence.44

In the GMAP, in addition to achieving substantial and sustained reduction in the burden of malaria the target is also to achieve global eradication of malaria in the long term, when new tools make eradication possible.25 To achieve these targets, the GMAP outlines a three-part global strategy which includes: malaria control to reduce the current burden and sustain control

24 as long as necessary, elimination of malaria over time country by country and development of new interventions as well as researches to support global control and elimination efforts.25

The Global Malaria Action Plan defines two stages of malaria control: scaling-up for impact

(SUFI) of preventive and therapeutic interventions as well as sustained control.25 In scaling-up for impact the goal is to attain universal coverage for all populations at risk with locally appropriate and sustainable malaria control interventions (i.e. LLINs, IRS, IPTp, drugs and diagnostics), supported by strengthened health systems. These will be delivered through various strategies such as mass campaigns, distribution of interventions through already existing public and private-sector outlet. Strengthening health systems, which include capacity building for malaria control, which must begin during scale-up and continue beyond this period.

RBM partners observed that funding requirements for malaria control had increased remarkably in the past decade thus in 2010, they decided to create a resource mobilization committee charged with the responsibility of developing a resource mobilization strategy.47

2.1.3 Global Health Initiative – Presidents’ Malaria Initiative (PMI)

The PMI is a core component of the Global Health Initiative along with HIV/AIDS, and tuberculosis.48 It is led by the U.S. Agency for International Development (USAID) and is implemented jointly by USAID as well as CDC. The PMI was launched in June 2005 as a 5 year, $1.2 billion initiative to rapidly scale up malaria prevention and treatment interventions as well as to reduce malaria related mortality in sub-Saharan Africa.49 PMI’s goal was expanded to achieve Africa-wide impact by targeting to reduce the burden of malaria by half in 70 percent of the at-risk populations in the continent, thus ensuring that malaria is not a significant public health problem and invariably promoting development throughout the African region.50 PMI works in collaboration with host country government in Africa and builds on existing national programs.49 Some PMI activities include conducting country needs assessments, development of

25 annual Malaria Operational Plans, participation in national malaria partner coordination mechanisms, complementing and expanding on monitoring and evaluation strategies.2 PMI's interventions include improving access to and use of four interventions: Long-lasting insecticide-treated nets, Artemisinin-based combination therapies (ACTs), intermittent preventive treatment for pregnant women and indoor residual spraying with approved insecticide, where appropriate.48 To help deliver these interventions and make sure they are having the desired impact, PMI also focuses on: Strengthening infrastructure (including logistics, management, communication and training). Other strategies include, providing commodities (including antimalaria drugs, rapid diagnostic tests, insecticide-treated nets and appropriate insecticides for residual spraying).2

2.1.4 National Malaria Control Programme and Antimalaria Policy

For effective malaria control in Nigeria, there is a National Malaria Control Programme and a

National Antimalaria Policy in place. The goal of the National Malaria Control Programme was to half malaria burden by the year 2010 and subsequently ensure it no longer constitutes a public health problem.51 It has adopted the Roll Back Malaria interventions which include prompt and effective case management, intermittent preventive treatment of malaria in pregnancy and integrated vector management via use of long lasting insecticide treated nets, in door residual spraying and environmental management.8 Other interventions include advocacy, communication and social mobilization, effective programme management, monitoring and evaluation, partnership and collaboration.8 There is a National Malaria Control Committee which consists of National, State and some LGA Malaria Programme Managers And Officials, as well as representatives from the private sector and international agencies.8 The committee meets at the end of each year and is responsible for reviewing the activities of the year and planning those of the next year.8 The programme works towards implementation of the policy in all states in the country. The policy covers all areas of malaria care and prevention in Nigeria. It

26 contains information on malaria situation in Nigeria, essential antimalaria drugs and rational use of antimalaria drugs in disease management at the home and in the Health Facility. In addition, it also provides information on indications for referral, chemoprophylaxis in Pregnancy, children and adults with Sickle cell anaemia and non-immune visitors/residents. Furthermore, it also provides information on the properties of antimalaria drugs currently in use in Nigeria, management of antimalarial drug supply, monitoring and evaluation as well as research.8

Support to National Malaria Programme (SuNMap) is supporting malaria control at the national and state level by focusing on previous experiences and liaising with international agencies to proffer solution.52

More recently, the second edition of the National Guidelines and strategies for malaria prevention and control during pregnancy was released.53 In addition, the National Malaria

Strategic Plan 2014-2020 was also released.14 These documents both have similar content and recommended that all pregnant women should receive three or more doses of IPTp up to the time of delivery with an interval of one month between each dose in line with the WHO updated

IPTp policy. Furthermore the strategic plan outlines the objectives of the National Malaria

Elimination programme. The objective for IPTp is to ensure that 80% of pregnant women receive at least two doses of IPTp by 2017 and 100% by 2020.

Fig. 1.1 – Conceptual Framework Adapted from Factors Influencing the uptake of Intermittent preventive treatment of malaria in pregnancy in the Bosomtwe District of Ghana by Antwi54

2.1.5. Conceptual Framework

This conceptual framework is a general overview of some of the determinants of IPTp uptake in

PHCs and how they are linked to each other. These factors were identified from previously conducted studies.54,55 It seeks to give a framework within which this study was conducted.

These determinants are divided into client related determinants and health facility related determinants.

The client related determinants include gestational age at booking, pregnant women’s knowledge of malaria and IPTp, socio-demographic factors, accessibility to ANC and clients previous experiences of side effects with SP. The socio-demographic factors of the respondents give their general characteristics such as the age, marital status, parity, educational background and occupation. These factors tend to influence pregnant women’s knowledge of IPTp, gestational age at first booking, total number of antenatal clinic visits as well as accessibility to

ANC hence IPTp uptake.

The health facility related determinants of IPTp uptake to be considered in this study include practice of DOT, staff training and knowledge of IPTp, supervision and monitoring of IPTp activities as well as availability of SP in ANC. Adequate monitoring and supervision of IPTp activities may identify and control implementation deficiencies at the facility level such as SP stock-outs and non-adherence to the IPTp policy by health workers as well as IPTp training deficiencies. Appropriate training of staff on IPTp may improve their knowledge of the program and hence influence their adherence and commitment to policy implementation positively. This may invariably result in improved knowledge impartation to the clients at the ANCs through health education and one-on-one counseling. Furthermore, SP and water availability would also be ensured at all times so that there are no interruptions in the program.

2.2 IPTp Uptake Among ANC Attendees

In 2009, WHO reported that attainment of high coverage of IPTp had remained elusive for many countries in Sub-Saharan Africa.56 A study published in the Lancet on Infectious Diseases found that methods to protect pregnant women from malaria are still underutilized in sub-Saharan

Africa.57 A systematic review by Thiam et al found that 83% of the 47 countries studied had a malaria IPT policy.58 However in these countries, only 25% of pregnant women received at least one dose of IPTp. It was also documented in that same publication that the coverage of IPTp was lowest in areas of high-intensity transmission of malaria. Studies have also shown that some

ANC attendees do not receive IPTp-SP during ANC.18,59,60 Between 2007 and 2009, Achang-

Kimbi et al carried out two cross-sectional surveys in Government Health Centres in

Cameroon.59 They administered questionnaires to 287 parturient women and found that about

9.5% of them didn’t receive IPTp-SP. Another related study carried out by Exavery et al in six districts of Tanzania reported that about 27.9% of their respondents received zero dose of

IPTp.18 Similarly a study carried out in Cross Rivers State which assessed the utilization of intermittent preventive treatment with sulfadoxine-pyrimethamine for the prevention of malaria in pregnancy reported that about 13.7% of respondents did not use IPTp.61 Furthermore, another related study carried out in Nigeria between 2010 and 2011 reviewed medical records of patients to obtain information about the number of doses of IPTp received by ANC attendees.37 This study reported that 75% of booked pregnant women did not receive any dose of IPTp. The high zero dose of IPTp recorded in that study may be because data was obtained from medical records and some health workers fail to record doses of IPTp administered to ANC attendees.

Though efforts have been made over the years to scale up IPTp coverage, it has been observed that the 2nd dose coverage still remains much lower than first dose coverage and much lower than the 100% coverage target.9,18 In a study carried out by Gikandi et al in Kenya, four districts were purposively selected to provide detailed longitudinal data on changing access to malaria

30 interventions.62 This study found that IPTp 1 and 2 coverage were 53% and 22% respectively.

Another related study by Mutulei et al reported that IPTp 1 and 2 were 56.5% and 43.5% respectively.63 In addition, a study carried out in Calabar in 2012 which assessed utilization of

IPTp among women attending antenatal clinics in Cross Rivers State reported that 53.1% and

24.2% of respondents received IPTp 1 and IPTp 2 respectively.61 Furthermore a cross-sectional study carried out in a western province in Zambia reported that IPTp 1 and 2 uptake were found to be as high as 71.2% and 56.6% respectively.55 This high uptake values may be as a result of possible selection bias, which the authors recognized as a limitation of the study. Selection bias may have occurred because eligible women for the study were selected from the postnatal clinic, under-five clinic as well as women accessing other services at the facility. Thus these women are more likely to utilize health services including IPTp.

Qualitative studies have explored the reasons why women take the first dose but not the second dose of IPTp.64,65A qualitative study carried out by Pell et al assessed prevention and management of malaria during pregnancy.64 It was a comparative study carried out at four sites in three countries (Ghana, Kenya, Malawi). This study explored the reason why women do not take the complete dose of IPTp. The most frequently reported reasons were experience of side effects such as nausea, vomiting, itching, dizziness and weakness. Another related study by

Mubyazi et al reported that some ANC attendees throw the SP tablets away because of fear of occurrence of Steven Johnson’s Syndrome.65 Furthermore, Mbonye et al carried out an intervention study in Uganda.66 That study assessed the effect of a new strategy on adherence to

IPTp in Uganda. The intervention comprised of training of midwives and provision of mama kit.

This study found that the main reasons why women adhered to the two doses of IPTp were because midwives explained the benefits (for the mother and foetus) of receiving IPTp to them and health care staff provided good customer care by greeting all patients and creating a friendly environment.

Studies have also shown rural/urban differences in IPTp uptake.11,15 In 2007, Onoka et al assessed demand side influences of IPTp and found that IPTp coverage was higher in urban than in rural settings.11 In this study, a household survey was conducted and data was collected from

1307 women who were delivered of a live baby within the one-year period preceding the study as well as through exit poll from 146 women attending antenatal clinics (ANC) in 28 centres.

IPTp coverage among all respondents for the first dose was 13.7% (16.9% in urban areas and

8.6% in rural areas) while the overall second dose coverage was 7.3% and higher as well for the urban compared with the rural area. Similar rural/urban differences were recorded in the exit interviews as well. Other related studies had similar findings.15,30,60 Findings from the 2008

Nigeria demographic and health survey also showed that there was a difference in IPTp coverage in rural and urban areas.30 That of urban areas was found to be 8% while the coverage in the rural areas was 4%. Furthermore, in the 2010 malaria indicator survey, IPTp coverage increased slightly to 18.7% and 11.5% in urban areas in urban and rural areas respectively.24

This rural/urban disparity may have been due to the difference in the percentage of pregnant women receiving antenatal care from a skilled attendant which was found to be 75.8% and

51.8% in urban and rural areas respectively in the same survey.24

Available evidence shows that the disparity between IPTp coverage and ANC utilization rates are quite remarkable, implying that some of the women attend ANC but do not receive IPTp.

This is referred to as missed opportunity for IPTp. A missed opportunity for IPTp is an ANC visit in which IPTp could have been administered according to the policy but was not. A number of studies have reported a high occurrence of IPTp missed opportunities.57,67,68 Van-Ejiks et al carried out a systematic review to assess the coverage of malaria protection in pregnancy.57

Data for the review was obtained from the most recently conducted national household cluster survey. This review found that generally, IPTp and ITN coverages were low in settings with high antenatal clinic attendance thus revealing that there are missed opportunities for IPTp at the

ANC. In addition, a study carried out in Jinja district in Uganda assessed the determinants of use of IPTp. This study reported that 189(41.6%) ANC attendees missed the opportunity to receive two doses of IPTp during pregnancy.68 Another related study was carried out by Edet et al in secondary health care facilities in Calabar.69 Exit interviews were conducted for 107 pregnant and post natal women. This study reported that as much as 59.1% of respondents had a missed opportunity for IPTp. Thus IPTp missed opportunities at the health facility may be a key determinant of IPTp coverage.

2.3 Health Workers’ Practice of IPTp - SP at the Antenatal Clinic

Since the early 2000s, IPTp strategy has been implemented in a number of health facilities in

Nigeria. However evidence abound that health facilities practice IPTp differently.16,70 Onoka et al in 2010 carried out a cross-sectional study in Enugu North and South Local Government

Areas (LGA) and Udi LGA in Enugu State, south-east Nigeria.16 Data was collected from heads of maternal health units of 28 public and six private health facilities offering antenatal care services in two districts in Enugu State, south-east Nigeria. This study found that about 85% of all health facilities included in the sample provided IPTp but the way in which it was done differed. Only 20.6% of facilities practiced DOTS. Some private providers gave the first dose in the first trimester, the second in the second trimester and then Artemisinin based combination therapy (ACT) once. In another related cross-sectional study by Arulogun et al, the level of knowledge and the practice of IPTp was assessed among health workers in Ibadan North Local

Government Area (LGA) Nigeria.71 Consenting 208 health workers and purposively selected

122 pregnant women who accessed the antenatal services were recruited for the survey and exit interviews were done. IPTp practice was compared with recommendations in the National IPTp guidelines. This study found that the facilities performed poorly when display of posters

33 providing information on IPTp was assessed as 73.6% of health workers admitted they did not have posters on the walls in their facility.

The administration of IPTp-SP under direct observation by health care provider ensures that SP is taken by the pregnant woman and not assumed to be taken.54 Once this event is recorded, it serves a means of monitoring the number of doses as well as the timing of the administration of

SP which are all important in IPTp.54 The World Health Organization’s (WHO) recommendation of Intermittent preventive treatment of malaria in pregnancy (IPTp) to prevent malaria in pregnancy consists of administration of curative dose of an efficacious anti-malarial drug (sulfadoxine-pyrimethamine).72 It is to be administered under the direct supervision of a health care provider during the second and third trimesters of pregnancy at routinely scheduled antenatal clinic visits.53 A cross sectional study carried out by Marielle et al further confirms that administration of IPTp under DOT will result in increased IPTp uptake.73 However, other

Studies have shown that some facilities do not practice DOT for IPTp.29,54 A study carried out by Antwi in Ghana found that 50% of facilities sampled administered SP tablets under the direct observation of the health workers.54 Another related study carried out in South-South Nigeria found that only 16.4% of respondents received SP tablets under the direct supervision of a

Health worker.29 On the contrary a survey by Rumisha et al in 2011 which assessed health facilities readiness for ANC reported that all sampled facilities practiced DOT for IPTp.74 This study also assessed other health facility related aspects of IPTp and found that though supervisory visits were not frequent, all facilities had the IPTp guidelines for staff to refer to.

The availability of the guidelines for staff to refer may have been responsible for the high commitment to DOT.

Some studies have reported that when the women do not swallow SP tablets under the supervision of the health worker, they are not likely to take them at all.65,75 Yoder et al carried out a study which looked at the perspectives of health care providers on the provision of IPTp in

34 health facilities in Malawi.75 The study reported that the health workers persuade women to swallow SP tablets while being observed because they do not expect that tablets taken home will be swallowed. Some ANC attendees have refused taking SP tablets under the direct supervision of health workers. A study carried out in Northern Nigeria found that some of the reasons for refusal of DOT were displeasure about sharing cups, the need to seek permission from their spouses and lack of money to buy water.76 Despite the WHO’s guidelines for implementation of

IPTp strategy and the National Antimalaria Treatment Guidelines, a number of studies have shown that in some facilities where IPTp is practiced, the drug is prescribed for ANC attendees to purchase and take at home unsupervised.16,54 This may be responsible for the low IPTp

coverage rate despite a high ANC utilization rate.

According to Gikandi et al, the observed variations in IPTp practice may result in subsequent development of resistance and unfavorable health outcomes in mother and baby.62 This study thus suggested that changing providers practices at ANC clinics in the delivery of IPT services, supported by community awareness campaigns to educate mothers on the importance of IPT usage, are required to improve IPTp coverage. In another related study, a number of suggestions were made by health workers with regards to improving the delivery of IPTp in health facilities.71 These suggestions include improved availability of SP drug at all times, increased awareness of IPTp, introduction of IPTp to all antenatal clinics nationwide and strict compliance with IPTp guideline.71

2.4 Client Related Determinants of IPTp Uptake

Antenatal Clinics are considered an important entry point to target pregnant women.65 Statistics show that 61% of women attend antenatal clinic at least once during any pregnancy in Nigeria.15

Currently, IPTp is being delivered through routine ANC. Statistics show that ANC utilization rate is high in most sub-Saharan African countries.77 However some pregnant women pay their first visit in the 3rd trimester.19,78 As a result, they are unable to attain the minimum four ANC

35 visits recommended by the WHO.79 This may affect delivery of complete dose of IPTp as the first dose of IPTp should be administered in the 2nd trimester when the growth of the foetus is occurring at its highest velocity (16th - 24th week) as this helps to reduce placental parasitaemia, occurrence of foetal growth reduction and the resultant low birth weight.80 This failure to administer the first dose in the second trimester may result in substantially reduced protection for mother and foetus.81

In a study by Hill et al in Kenya in 2010, the effectiveness of the ANC in the delivery of IPTp and ITN was assessed.82 It was a two-stage cluster household survey conducted over a period of two months. Households in selected clusters were mapped using Global Positioning System

(GPS) software. Thirty-five households were randomly selected from GPS coordinates of all households within each cluster to get 28 households with women of childbearing age as residents. Respondents were all women of reproductive age however pregnant women were given top priority followed by mothers of children aged less than one year. The results of this study showed that the number of doses of SP received was associated with gestational age at first ANC visit, with fewer recently pregnant women receiving a second dose of SP if they first attended ANC in their second or third trimesters. This study thus identified timing of ANC booking as one of the predictors of receipt of two doses of IPTp. This is in keeping with the results of a study carried out in Kenya, which reported that the timing of ANC initiation was significantly associated with uptake of two doses of IPTp.63 Other similar studies have also explored the gestational age at booking as a possible factors affecting IPTp uptake.19,60,83

Furthermore a secondary data analysis of the malaria indicator survey (2010-2011) carried in

Tanzania showed that the proportion of women receiving two or more doses of IPTp was higher among women who booked in the first trimester compared with those who booked in the second and third trimester respectively.19 On the contrary, a cross sectional study carried out in

Cameroon found that gestational age at booking was not significantly associated with IPTp

36 uptake.84 This is consistent with the findings of a study carried out in North-East Tanzania.85

This study reported that there was no evidence of an association between uptake of IPTp and early ANC booking.

The WHO advocated focused antenatal care with at least four goal-oriented visits in the absence of complications. The findings of Simkambale et al were in line with the WHO recommendations. This study found that number of ANC visits was a significant factor affecting

IPTp uptake.55 On the contrary, Exavery et al carried out a cross-sectional study in six rural districts in Tanzania in 2012 and found that women who had four or more ANC visits received two doses of SP tablets in higher proportions than those who did not.18 However the association between number of ANC visits and use of two doses of IPTp was not statistically significant.

This finding was in keeping with those of Onoka et al and Sangare et al respectively.11,68

Apart from failure to book early for ANC and number of ANC visits, several studies have identified other client related determinants that affect the use of IPTp.17,86,87,88 Akinyele et al in

2007 carried out a cross-sectional study in Ekiti State, which assessed Knowledge and utilization of intermittent preventive treatment of malaria among pregnant women attending antenatal clinics in primary health care centers in rural south-west, Nigeria.86 The results of this study showed that though approximately 52.2% of respondents were aware of IPTp, only 23.9% were able to define it. Approximately 61.5% got the timing for administration of IPTp one and two correct. About 67% of respondents identified various brands of SP tablets as the drug recommended for IPTp. About 27.3% reported to have received at least one dose of IPTp during the index pregnancy and all were among those who were aware of IPTp. This study concluded that provision of information about IPTp and the safety of SP tablets in pregnancy may address gaps and deficiencies observed. Similarly, another study carried out in South-West Nigeria found that knowledge was a significant factor affecting IPTp use.17 This study revealed that

37 women who had adequate knowledge of malaria prophylaxis in pregnancy were three times more likely to use IPTp compared with those with inadequate knowledge. On the contrary a study carried out in Jinja Uganda reported that those who were less knowledgeable about the safety of SP use during pregnancy were likely to receive 2 doses of IPTp in higher proportions compared with those were more knowledgeable.68 However, this study found that women’s knowledge of malaria was not a significant factor affecting IPTp uptake. Similarly, a study carried out by Tobin-West et al in Port Harcourt to assess the factors influencing the use of malaria prevention methods found that women’s knowledge of malaria did not significantly affect IPTp uptake.89

Accessibility has been identified as an important factor affecting health service utilization including IPTp. Thus some researchers have argued that women may not use health services if they have to walk long distances to access health care particularly as pregnancy advances.55 A study carried out in Sesheke district of Zambia however found that distance to the health facility did not affect IPTp uptake.55 This may however have been because IPTp was provided during outreach programmes organized for those areas that were far from the health facilities. On the contrary, a study carried out in Kenya reported that distance to the ANC was significantly associated with IPTp uptake.63

Socio-demographic factors could be defined as individual factors that tend to influence behaviour and choice of action in relation to a perceived problem. A number of studies have identified socio-demographic factors as important factors affecting IPTp uptake.84,90,91,92

Mutulei et al carried out a study in Kenya to assess the factors influencing IPTp uptake in pregnancy.63 This study used a cross-sectional study design employing both qualitative and quantitative methods. The target populations were pregnant women coming to public health facilities (dispensaries, health centres, as well as sub-district and district hospitals) for routine

38 antenatal care services. Proportionate method was used to determine the number ANC attendees to be recruited from each facility. The study found out that socio-demographic factors of ANC attendees were significantly associated with IPTp uptake. In addition, a study carried out in

Tanzania by Marchant et al showed that only living in an urban area was significantly associated with uptake of 2 doses of IPTp.80 There was no evidence of any individual factors being associated with second dose coverage beyond living in an urban area. Other factors such as age, marital status, educational level of the woman and household socioeconomic status did not show significant association with second dose coverage of IPTp-SP. Furthermore a secondary data analysis of Zimbabwe Demographic and Health Survey by Vasco et al assessed the predictors of

IPTp uptake among pregnant women.60 This study identified age as a predictor of uptake of two or more doses of IPTp. Thus women in the older age groups ie greater than 20 years were found to be more likely to receive two or more doses of IPTp compared with those in the younger age group ie less than 20 years. Furthermore, a study carried out by Choonara et al assessed the factors affecting the use of different types of malaria preventive methods during pregnancy.93 It was a secondary data analysis of the 2008 – 2009 Kenyan demographic health survey. The findings of this study revealed that age and marital status were important socio-demographic factors affecting use of IPTp. On the contrary, another related study by Leonard et al in

Cameroon found that no socio-demographic factor was significantly associated with IPTp use.84

Some antenatal clinic attendees have expressed concerns about the safety of SP. The fear of likely occurrence of adverse reactions has been identified as one of the barriers to IPTp uptake.11

In a study carried out in Ghana between 2006 and 2007, pregnant women reported a number of adverse effects with IPTp use.94 A cross-sectional analytic study design was employed. Pregnant women who had attained gestational age of 32 weeks and above attending antenatal clinic in the six health facilities that provide antenatal, delivery and postnatal services in the district were recruited for the study. The findings of this study showed that a little over a third (37%) of the

39 pregnant women reported adverse reactions (including nausea, general malaise, body weakness, vomiting etc) with the intake of SP. However, these effects showed no significant association with the number of doses of SP taken. In addition, a comparative qualitative study carried out in

Ghana, Kenya and Malawi reported that though women complained about the side effects of SP tablets, this did not affect compliance as the tablets were generally accepted.64 Available evidence show that such side effects are uncommon.63 A related study was carried out by

Sikambale et al in 2013 in western Zambia.55 A cross sectional design was employed and the findings of this study revealed that most of the respondents in this study were of the opinion that

SP tablets were safe in pregnancy.

2.5 Health Facility Related Determinants of IPTp Uptake

A relatively high ANC utilization rate and a low IPTp coverage, invariably means attendance at antenatal clinic does not guarantee effective delivery of IPTp as favourable provider-related factors need to be in place as well.17,82 The nature of service provision in the antenatal clinics in addition to attendance by pregnant women are important if optimal IPTp coverage is desired.

The effectiveness of IPTp intervention, which is compromised by the low coverage levels of

IPTp in the Nigeria, is further worsened by some health facility related determinants of IPTp uptake. Studies have shown that some health services factors affect IPTp uptake. These include level of knowledge of health workers and training in IPTp, staff attitude, monitoring and supervision of IPTp implementation as well as availability of SP and clean, safe water for DOT at the ANC.20,54,90

At the health facilities interruptions in the supply of SP tablets have the potential of affecting the

IPTp programme negatively.39 A study carried out in Tanzania in 2011 found that SP stock-out was common and frequent and may have contributed to the low IPTp coverage observed in the district.74 Similarly, a study carried out in Bosomtwe district of Ghana found that IPTp coverage

40 could be higher if there were no SP stock-outs. 54 In this study 83.3% of the ANCs visited had

SP in the ANC. About 32.3% of the ANC staff admitted they experienced stock outs of SP in the previous year preceding the study in their facilities. Approximately 50% of respondents admitted that SP stock-outs occurred only once in the last year while 16.7% said stock-outs occurred twice in their facility. Stock-outs of three or more times in the previous year were not mentioned. During the period of stock-outs, the options that the ANC staff resorted to were suspending the IPTp until stocks were replenished, referring the women to other facilities in the district or asking them to go and buy the SP from the open market. Other studies reported SP stock-out in terms of the proportion of facilities experiencing stock-out.74,95 A cross sectional community based study carried out in Tanzania reported that 90% of the facilities included in their study had SP stock out at the time the study was conducted.74 This depicted a lack of readiness of the facilities to provide antenatal care. Similarly another study conducted by

Maheu-Giroux et al which assessed factors affecting providers delivery of IPTp identified SP stock-out as an important barrier to the delivery of IPTp.96 This study concluded that consultations in health facilities experiencing SP stock-out were 60% less likely to deliver IPTp compared with those occurring in facilities which had SP tablets in stock.

It is important for health workers to provide accurate information to pregnant women about

IPTp-SP, the side effects as well as the importance of completing optimal doses of IPTp. In order to achieve this, health workers must understand the national policy and guidelines, which usually reflects the WHO recommendations.97 This understanding may be enhanced by periodic training on IPTp. Training of health care workers periodically on IPTp may help to enhance their knowledge and improve the skills needed for the implementation of the intervention.98,99 It may also serve as a medium to remind them of the importance of IPTp as well as help to refresh their minds on the policy which emphases on the timing of the administration of SP. Training may serve as an incentive and motivate the workers to implement IPTp thus helping to improve

41 the overall coverage of the intervention.66,100 In 2005, Ouma et al conducted a community based cross-sectional study in Asembo and Gem, Western Kenya to assess the effect of health workers’ training on IPTp coverage, two years after the health workers’ training was carried out.101 All 1154 women who had delivered (based on data from Health and Demographic

Surveillance System) in the study area between 30th November 2004 and 28th April 2005 constituted the sampling frame. The results of this study showed that compared with the previous survey conducted in 2002 in the same area, the proportion of women receiving at least one dose of SP increased from 19% to 41% while those receiving two doses or more increased from 7% to 21%. A similar study carried out in Northern Nigerian also reported an increase in

IPTp utilization as well as health workers’ knowledge of IPTp after a training period of two weeks.87

In a study carried out in Enugu, health workers’ knowledge of guidelines for IPTp was assessed with regard to four components: the drug recommend for use in implementing IPTp, time of administration of first and second doses of SP, the strategy for SP administration (directly observed treatment, DOT).(16) This study found out that although most respondents knew the correct number of doses that should be given, the description of when it should be given

(timing) varied significantly. Another related study carried out in Ghana assessed health workers knowledge of IPTp based on 11 questions centred on definition, drug of choice, when to start and when to stop IPTp.54 Others include reason for timing, frequency of administration, interval, side effects, contraindications and advice to women who have these contraindications and benefits of IPTp. The results of this study showed that a greater proportion of the health workers answered these questions correctly. However knowledge of side effects of SP tablets was poor.

Through supervision Health workers would get clarification and technical demonstration on issues around health service delivery.97,102,103 The essence of monitoring and supervision is to

42 ensure that all logistics and resources required for service delivery are in place. Godfrey et al carried out a cross-sectional case study to find out the economic and other contextual determinants of the acceptability and practicability of IPTp services in Tanzania using a case study of two districts namely, Mkuranga and Mufindi.102 This study found out that 97.1% of the respondents in Mkuranga and 100% of their counterparts in Mufindi admitted to have been supervised at their work places by the District Community Health Management Team members.

This study noted that regular provision of supportive supervision of the frontline health workers particularly in the delivery of ANC services (including IPTp) was a strong motivational factor.

CHAPTER 3

MATERIALS AND METHODS

3.1 Study Area

This study was carried out in Okrika and Obio-Akpor local government areas in Rivers State.

Rivers state is bounded by Delta, Imo, Akwa Ibom and Bayelsa States. The population in River

State is 5,198,716 million people of which 2,525,690 are females.104 The state occupies an area of 10,575sq.km.105 The state comprises of 23 Local Government Areas, four of which are urban and the remaining nineteen are rural.106 Its capital is Port Harcourt, a cosmopolitan city made up of two LGAs. It is an oil producing state, with oil and gas exploration and service industries as well as small, medium and large-scale industries. It has a seaport and airport. The health care delivery system in Rivers State is organized in three levels: primary, secondary and tertiary levels. The primary level serves as the entry point for health care utilization. There are a total of

334 PHCs in Rivers State.41 Each PHC has an ANC/maternity unit, which provides ANC including IPTp. A midwife with relevant skills for maternal health service delivery heads the unit. The malaria elimination program in the state is coordinated by the malaria control unit, which is located in the Department of Public Health, in the State Ministry of Health. The unit is structured to carry out interventions with RBM partners, which include implementation of IPTp policy. The results of the Demographic Health Survey 2013 shows that 75.5% of women in

Rivers state received at least one ANC from a skilled provider.15 The maternal mortality ratio in the state was estimated to be 889 per 100,000 live births. In the strategic health development plan, insecticide treated net utilization rate (household with at least one ITN) was estimated to be 12%.

Okrika local government is located on a small island in the mangrove in the Eastern Niger delta region. It is bounded on the south by Port Harcourt and on the north by the Bonny River. The

2006 census statistics show that the population in the LGA is 226,026. The predominant

44 occupations in the area are subsistence trading, farming and fishing. As such the people spend most of their time outdoors thus increasing the risk of been bitten by mosquitoes and developing malaria. There are number of creeks, mangroves and swampy areas in the LGA. These places often serve as breeding sites for the mosquito. There are a total of eleven functional PHCs, one maternity and one general hospital in the LGA. Each PHC has an ANC/maternity unit, which provides ANC including IPTp. A midwife with relevant skills for maternal health service delivery heads the unit. The Roll Back Malaria Manager oversees malaria control activities in the LGA including IPTp.

Obio/Akpor is an urban LGA in the metropolis of Port Harcourt. The Local Government Area covers 260 km2 and holds a population of 878,890. Obio/Akpor has its headquarters at

Rumuodomaya. It is one of the major centres of economic activities in Nigeria. This has resulted in rural/urban migration thus making the LGA to be highly populated. Thus a lot of urban slums have developed and they are characterized by poor housing, poor environmental sanitation and lack of basic amenities. These attributes increase the residents’ susceptibility to malaria. There are several oil and gas exploration and service industries as well as small, medium and large- scale industries in the LGA. The occupational groups are majorly professionals, artisans and small-scale businesses such as traders. There are a total of five health posts, fifteen functional

PHCs, one comprehensive Health centre and one tertiary Hospital in the LGA. Each PHC has an

ANC/maternity unit, which provides ANC including IPTp. A midwife with relevant skills for maternal health service delivery heads the unit. The Roll Back Malaria Manager oversees malaria control activities in the LGA including IPTp.

3.2 Study Design

A comparative cross sectional study employing quantitative and qualitative methods of data collection.

3.3 Scope of Study

Data on IPTp uptake among ANC attendees, IPTp practice, health service and client related determinants of IPTp uptake were collected over a period of four months.

3.4 Study Population

The study population comprised of the heads of antenatal clinics and the antenatal clinic attendees accessing antenatal care in selected PHCs as well as the Rollback Malaria Managers in the selected LGAs.

3.5 Selection of facility

3.5.1 Eligibility Criteria

3.5.2 Inclusion Criteria (PHC)

 PHCs offering antenatal services at the time of commencement of the study.

 PHCs with monthly summary statistics records.

3.5.3 Exclusion Criteria (PHC)

 PHCs in communities that have experienced recent communal conflict that disrupted

health services.

3.5.4 Sampling Technique

Multistage sampling technique was employed.

 Stage I: Selection of LGA

Simple Random Sampling

There are 23 LGAs in Rivers state, 4 urban and 19 rural. One urban and one rural LGA

were randomly selected from a sampling frame of urban and rural LGAs respectively

using computer generated random numbers. The selected LGAs are Obio/Akpor LGA

(urban LGA) and Okrika (rural LGA).

 Stage II: Selection of PHCs in Rural and Urban LGA

Simple Random Sampling

The selection of PHCs was guided by the HMIS data obtained from Rivers State Primary

Health Care Management Board. In WALGA (rural LGA) and Obio/Akpor (urban

LGA), based on the HMIS data available, to attain a minimum sample size of 410

eligible ANC attendees over the study period, eight and five PHCs respectively were

included in sample. These PHCs were randomly selected from a sampling frame of

public PHCs obtained from the Rivers State Primary Health Care Management Board

(see appendix six). The selected PHCs for the urban LGA were Elelenwon, Rumuigbo,

Rupkokwu, Ozuoba and Rumuepirikom PHCs, while the selected PHCs in the rural

LGA were Okujagu, kalio-Ama, Ogoloma, Ogbogbo, Okochiri, George Ama, Ogan-

Ama and Ibaka PHCs.

3.6 Survey of ANC Attendees

3.6.1 Inclusion Criteria (ANC attendees)

 ANC attendees who have had at least one antenatal clinic visit before the interview. This

was used as proof that they have been registered in that facility.

 Only ANC attendees who are 36 weeks gestation and above. (This is in line with the

national antimalaria policy which states that SP should not be administered within the

four weeks period preceding the expected date of delivery).8

3.6.2 Exclusion Criteria (ANC attendees)

 HIV positive ANC clients who are on cotrimoxazole preventive treatment because the

current national guidelines for diagnosis and treatment of malaria states they should not

be given IPTp to avoid sulphonamide over dose.7

 ANC clients who react to sulphonamides.

 ANC clients who are severely ill to respond to the interview.

3.6.3 Sample Size Determination

The formula for calculating sample size for comparison of two proportions was used to determine minimum number of patients to be interviewed.107

2 n = [U√ π1 (1-π1) + π2 (1-π2) + V√ 2π0 (1- π0)]

2 (π1-π2)

Where,

n = Minimum sample size for each group

V = Percentage point of the normal distribution corresponding to

the required 2 sided significance level.

At 5 % significance level, V was1.96

U = one-sided percentage point of the normal distribution corresponding to

100 - power. With power at 80%, 100- 80 = 20

U = 0.84

π1 = Proportion of antenatal attendees that received two doses of IPTp-SP in

rural areas (from a facility based study).

π2 = Proportion of antenatal attendees that received two doses of IPTp-SP in a

comparable population ( urban areas) assuming a 10% difference

π0 = Mean of the two proportions- (π1+π2)/ 2

From a study by Amoran et al, the proportion of antenatal clinic attendees that received two doses of IPTp-SP in a facility based study in a rural area was 14.6%.17

π1= 14.6% (0.146)

π2 = 24.6% (0.246)

π0 = (0.146+ 0.246)/2 = 0.196

48 n = [(0.84 √0.146(1-0.146) + 0.246(1-0.246) + 1.96√2( 0.196)(1-0.196)]2

(0.146- 0.246)2 n = 246

Assuming non-response rate (NR) of 10%, the minimum sample size was calculated with the formula: N = n 1 - NR

= 246/0.9

= 273 The minimum sample size for ANC clients was 273 per group. Hence there were a total of 546 in both groups. Adjusting for design effect, the sample size was = n x DEFF =546 x 1.5

= 819

= 820

Hence the sample size per group was 410.

3.6.4 Sampling Method for Selection of ANC Attendees in Urban and Rural PHCs

Systematic Sampling

Table 3.1 Number of eligible ANC attendees in selected Urban PHCs in the month preceding commencement of study

PHC Number of eligible ANC attendees in each PHC in the preceding month (x)

Rumuigbo 45 Ozuoba 40 Rumuepirikom 38 Elelenwo 35 Rukpokwu 31 TOTAL ((∑ 푥) 189

Table 3.2 Number of eligible ANC attendees seen in selected Rural PHCs in the month preceding commencement of study

PHC Number of eligible ANC attendees seen in each PHC in the preceding month ( x)

Okujagu 40 Ogoloma 40 Ogan-Ama 28 Kalio-Ama 25 Ibaka 24 Okochiri 24 Ogbogbo 22 George-Ama 20 TOTAL 223

3.6.5 Determination of Sampling Interval The sampling interval for each facility was determined using the formula

K = N/n

Where,

N =Estimated total number of pregnant women ≥ 36 weeks in all PHCs over a period of four months n= Study sample size

Determination of Sampling Interval for Urban PHCs

Estimated total number of pregnant women ≥ 36 weeks = (45+40+38+35+31) x 4 in all Urban PHCs over a study period of four months

K = 756

410

= 1.8

K= 2

Determination of Sampling Interval for rural PHCs

Estimated total number of pregnant women ≥ 36 weeks= (40+40+28+25+24+24+22+20) x 4 in all rural PHCs over a study period of four months

K = 892

410

= 2.2

K = 2

Table 3.3 Proportional to size allocation of ANC attendees for Urban PHCs

PHC Number of eligible ANC Proportional sample size attendees in each PHC in for each PHC the preceding month 푥푛 Nf = (x) ∑ 푥

Rumuigbo 45 98 Ozuoba 40 87 Rumuepirikom 38 82 Elelenwo 35 76 Rukpokwu 31 67 TOTAL ((∑ 푥) 189 410

Table 3.4 Proportional to size allocation of ANC attendees for Rural PHCs

PHC Number of eligible ANC Proportional sample size for attendees seen in each each PHC PHC in the preceding 푥푛 Nf= month ∑ 푥 ( x) Okujagu 40 74 Ogoloma 40 74 Ogan-Ama 28 51 Kalio-Ama 25 46 Ibaka 24 44 Okochiri 24 44 Ogbogbo 22 40 George-Ama 20 37 TOTAL 223 410

Proportional to size allocation of ANC Attendees was carried out. This was determined using the formula: 푥푛 Nf = ∑ 푥 Where,

Nf = proportional sample size for each PHC n = study sample size

푥 = Total number of eligible ANC attendees seen in

the month preceding commencement of data collection in each PHC

and ∑ 푥 = Total eligible ANC attendees seen at all selected PHCs in each LGA in the

month preceding commencement of data collection

Thus the number of ANC attendees recruited from each selected PHC was based on the proportion of the total number of eligible ANC attendees seen in the month preceding commencement of data collection in each PHC relative to sum of the ANC attendees (who were

36 weeks gestation and above) seen at all selected PHCs in rural or urban areas in the month

52 preceding commencement of data collection. The reason was to ensure a self-weighted sample as this enabled facilities with higher client turnover to have a higher representation in the sample.

3.6.6 Selection of Random Start

All eligible ANC attendees were assigned numbers serially as they came in for ANC visit each day. The starting participant was randomly selected between the ANC attendees with serial numbers one and two for each day using balloting technique. Subsequently, every 2nd eligible

ANC attendee was selected daily until the required sample sizes for both urban and rural areas were attained over a period of four months.

3.6.7 Instrument for Data Collection

Interviewer administered questionnaire (Appendix I) was administered to eligible clients accessing antenatal care. This questionnaire obtained information on IPTp uptake among ANC attendees. The questions explored socio-demographic factors, timing of ANC booking, clients’ experiences with IPTp-SP, practice of IPTp at the ANC, knowledge about IPTp and other factors affecting IPTp uptake.

3.6.8 Validation of the instrument

The study instruments were pretested among 41 pregnant women attending ANC at Orogbum and Owu-ogono PHCs in Port Harcourt and Ogu/Bolo LGAs respectively. These PHCs are located in another but similar rural and urban community of Rivers State. The number 41 corresponds with 10% of the desired minimum sample size in each selected LGA.108 Findings from the pre-test were used in reviewing the study instruments and was a pointer to the aspect of the instruments that the training of research assistants needed modification. For example when the women were asked if they had received SP tablets and shown an unfamiliar brand, they would say “no”. The pre-test revealed that in most PHCs, SP tablets are dispensed into drug

53 envelopes thus research assistants were trained to describe the SP tablets as “three white tablets to be taken at once”. Samples were shown to the women in drug envelopes rather than in brand packets.

3.6.9 Procedure for Data collection

Data for the entire study was collected over a period of four months. Research assistants were trained to assist with data collection. The training was carried out by the principal researcher using training manual adapted from a manual developed by Global fund to fight AIDS,

Tuberculosis and Malaria (GFATM) in collaboration with other consultants.109 A data collection plan was drawn to serve as a guide for data collection. As pregnant women arrived at the PHC for ANC, each of them picked a serial number from the nurse’s table. With the help of a Health

Worker in the PHC, ANC attendees who met the eligibility criteria were selected. Using the serial numbers, a random start was identified and subsequently every second eligible woman was recruited for the study. Exit interviews were conducted after the respondents had their ANC session for the day. The study was explained to them and informed consent was obtained. Each questionnaire took about 10 to 15 minutes to fill.

At the end of each day’s work, there was a de-briefing of collected data as well as challenges encountered and the next day was planned for. At least once a week collected data was verified by the principal investigator and errors identified were discussed and corrected. A data entry clerk was involved in the entry of data using SPSS software version 21 after data collection had proceeded for two weeks. A second data entry clerk validated data after all data had been entered.

3.6.10 Data Analysis

3.6.11 Independent variables for comparison of IPTp uptake among urban and rural groups: These include proportion that had zero, less than two doses and two or more doses of

IPTp respectively as well as ANC attendees who were offered SP tablets at ANC.

3.6.12 Outcome variables for comparison of IPTp uptake among urban and rural groups:

These comprised of urban and rural groups.

3.6.13 Independent variables for client factors affecting IPTp uptake in urban and rural groups: The independent variables employed for client factors affecting IPTp uptake in this study include age, marital status, educational status, gestational age at ANC booking and number of ANC visits. Others include parity, time to ANC, means of transport, ANC attendees’ knowledge of malaria scores and experience of side effects with SP.

3.6.14 Outcome variables for client factors affecting IPTp uptake in urban and rural groups: The outcome variables were use of less than two doses of IPTp and use of two or more doses of IPTp.

3.6.15 Data analysis of questionnaire

The information obtained from the structured questionnaire was entered and analysed using

Statistical Package for Social Research (SPSS) version 21.

Descriptive statistics were carried out on socio-demographic data and other selected client factors affecting IPTp uptake. Client knowledge (of malaria and IPTp) scores were assessed using a two-point scale as follows:

< 50% ------Below average knowledge

≥ 50% ------Above average knowledge

Chi square test was used to compare categorical variables. Mean age and knowledge scores of respondents were calculated and the student t-test was used to determine if the differences in the mean values were statistically significant. The median parity and number of ANC visits were

55 also computed. Mann-Whitney U test was used to determine if the differences in median values obtained were statistically significant. P values less than 0.05 were considered statistically significant.

Bivariate analysis was done with chi-square test or Fisher’s exact test to examine the relationship between each factors associated with IPTp uptake (independent variable) and uptake of two or more doses of IPTp (dependent variable). All variables were coded into two categories. P values less than 0.1 were considered statistically significant. Multivariate logistic regression analysis was carried out to control for potential confounders. All the factors that were statistically significant with bivariate analysis were tested for multicollinearity using a correlation matrix. The correlation between gestational age at booking and number of ANC visits was one implying multicollinearity. Thus only one of both variables (number of ANC visits) was included in the multivariate analysis model as well as all the factors that were statistically significant. These variables were loaded at once into the multivariate analysis model. Adjusted Odds Ratios generated was used for statistical interpretations. P values less than 0.05 were considered statistically significant.

Analysis of IPTp uptake data was carried out for urban and rural groups. Chi-square was used to compare the differences in proportions. P-values less than 0.05 were considered statistically significant.

3.7 Focus Group discussion with ANC attendees

3.7.1 Target Population

The target population was eligible ANC attendees at selected PHCs in both urban and rural groups.

3.7.2 Selection of participants

The participants were purposively selected by the principal researcher while administering the questionnaire. They were pregnant women who participated in the quantitative study. Twelve

56 participants were recruited for each focus group discussion (FGD). Thus in the urban LGA, a total of 60 participants were recruited for five FGDs. In the rural group, a total of 96 participants were recruited for eight FGDs.

3.7.3 Instrument

Focus group guide developed by the researcher (Appendix II) was used to conduct focus group discussions with eligible ANC attendees.

3.7.4 Validation of instrument

Two focus group discussion sessions were conducted in Orogbum and Owu-ogono PHCs in Port

Harcourt and Ogu/Bolo LGAs respectively to pretest the focus group discussion guide. During the pretest the general response to the question “what is IPTp” was “I don’t know”. Thus during the main FGD sessions, the moderator described IPTp as “when the doctor gives a pregnant woman who is not sick three white tablets to swallow at once” and then went on to ask the women the next question on the guide which is “Why is it done” ?

3.7.5 Procedure for data collection

All focus group discussions were conducted by the principal researcher. Research assistants were trained to assist with note taking and tape recording of the sessions. A schedule was subsequently drawn for the FGDs. Focus group discussions were carried out in a quiet and comfortable environment. The principal researcher enlightened the participants about the aim of the FGD and how it was to be conducted. Consent was obtained from all participants and confidentiality was assured. Each session lasted for about an hour and consisted of 8 to 12 participants, a facilitator (researcher) and a recorder (who was responsible for recording the session). The principal researcher conducted a total of 13 FGDs (five urban and eight rural).

Each FGD consisted of participants attending ANC in the same PHC.

3.7.6 Data Analysis

Figure 4.1: Coding Tree for FGD with ANC Attendees in Rural and Urban Groups

Recorded FGD sessions were transcribed into a word document by the principal researcher.

English language was used for all sessions, thus translations were not required. Quotes were used to represent responses from participants. Non-verbal responses and expressions were noted during transcription. Various notations were used to denote verbal and non-verbal expressions:

(pause) was used to denote a pause in respondents answer, : was used to denote a stretched

58 sound e.g so:, represents a marked rise in pitch, a downward arrow indicates a marked lowering of pitch, words that need to be emphasized are underlined e.g. fever. (( )) was used to represent vocalizations which are not easy to spell out e.g ((sniff)), ((cough)). These word documents were imported into NVivo version 10 software and saved in two different folders

(urban and rural). The auto code function was used to organize all responses to each question into one node for each group (urban and rural). These were subsequently coded to different nodes based on predetermined themes corresponding to the main categories of interest. These themes include: women’s opinion on causes of malaria, women’s opinion on transmission of malaria, women’s opinion on effect of malaria on the pregnant woman and women’s opinion on effect of malaria on the unborn baby. Others include women’s knowledge about IPTp, women’s experiences of side effects with SP tablets, reasons why ANC attendees may not take two tablets of SP as well as women’s suggestions on how to tackle barriers to IPTp uptake.

3.8 Assessment of facility

3.8.1 Instrument for Data Collection

A standardized checklist was adapted and used to carry out a non-participant observation to assess the practice of IPTp and availability of logistics for IPTp implementation. This included the observation of health education sessions, observation of the practice of DOT, inspection of the recordings of DOT in the ANC records registers, availability of SP and potable drinking water for DOTS. The presence of posters on malaria in pregnancy and IPTp-SP, distribution of long lasting insecticide treated nets, the presence of ANC report book for daily summaries and

ANC monthly data returns form as well as the presence of adverse event form for SP were observed. The availability of national antimalaria treatment guideline and policy were also noted.

3.8.2 Validation of instrument

This study instrument was validated at Orogbum and Owu-ogono PHCs in Port Harcourt and

Ogu/Bolo LGAs respectively. The findings of this pretest resulted in the modification of some items on the original checklist. An example was the item “availability of National protocol’’ was changed to “availability of National antimalaria policy” and “availability of IPTp training manual” was changed to “availability of National antimalaria treatment guideline”.

3.8.3 Procedure for Data collection

A schedule was drawn for health facility assessment with dates assigned to each health facility.

The principal investigator carried out non-participant observation using the checklist in appendix III. Each item on the checklist was assessed and recorded as “yes” if observed and a score of one awarded. If it was not observed it was recorded as “no” and the score awarded was zero. A total facility score was obtained for each facility assessed.

3.8.4 Data Analysis

The score gotten by each facility was divided by the maximum attainable score (13) and multiplied by 100 to get a performance percentage. Thus, for each PHC, IPTp practice was assessed using a 2 point scale as shown below:

<50% ------Below average practice

≥50% ----- Above average practice

Fishers exact test was used to test if the differences in practice scores obtained were statistically significant. Mann-Whitney U test was used to test the difference in median practice score.

P-values less than 0.05 were considered statistically significant.

3.9 In-depth interviews for heads of ANC

3.9.1 Target population

The target population comprised of all Heads of antenatal clinic in selected PHCs.

3.9.2 Selection of participants

All heads of the ANC in selected PHCs were included in this study.

3.9.3 Instrument for Data Collection

In-depth interview guide developed by the researcher (Appendix IV) was used to interview heads of antenatal clinics in this study. Information on knowledge about IPTp, practice of DOT and adherence to national antimalaria diagnosis and treatment guideline with regard to IPTp strategy, training opportunities for staff and availability of sulphadoxine-pyrimethamine tablet for IPTp were collected. Questions were also asked about monitoring and supervision of IPTp strategy implementation, the roles of Non Governmental Organization, state malaria control programme and LGA Roll Back Malaria Manager.

3.9.4 Validation of instrument

This study instrument was pretested at Orogbum and Owu-Ogono PHCs in Port Harcourt and

Ogu/Bolo LGAs respectively. Following the pretest two questions were added: “in your opinion what are the health service factors affecting IPTp uptake” and “what recommendations will you make to improve IPTp uptake”.

3.9.5 Procedure for Data collection

All in-depth interviews were conducted by the principal researcher. Research assistants were trained to assist with note taking and tape recording of the sessions. A schedule was drawn for in-depth interviews with dates assigned to each health facility. The principal investigator conducted a total of 13 in-depth interviews (five in the urban and eight in the rural LGA) with

ANC heads in selected PHCs. The principal researcher enlightened the interviewees about the aim of the in-depth interviews and how it was to be conducted. Consent was obtained from all interviewees and confidentiality was assured. These interviews were carried out in a quiet environment in which the interviewees were comfortable. Repeated face-to-face interviews were

61 carried out when necessary. Interview sessions were tape-recorded and notes on verbal and non- verbal gestures were also be made. Each session lasted for 30 to 45 minutes.

3.9.6 Data Analysis

Figure 4.2: Coding Tree for In-depth Interview with ANC Heads

Recorded in-depth interview sessions were transcribed into a word document by the principal researcher. English language was used for all sessions, thus translations were not required.

Quotes were used to represent responses from participants. Non-verbal responses and expressions were noted during transcription. Various notations were used to denote verbal and non-verbal expressions: (pause) was used to denote a pause in respondents answer,: was used to denote a stretched sound e.g so:, represents a marked rise in pitch, a downward arrow indicates a marked lowering of pitch, words that need to be emphasized are underlined e.g. fever and (( )) was used to represent vocalizations which are not easy to spell out e.g ((sniff)),

((cough)). These word documents were imported into NVivo version 10 software and saved in

62 two different folders (urban and rural). The auto code function was used to organize all responses to each question into one node for each group (urban and rural). These were subsequently coded to different nodes based on predetermined themes and subthemes corresponding to the main categories of interest. The main themes and sub-themes include health facility factors affecting IPTp uptake, IPTp practice at ANC, SP tablet source and availability, and suggestions to tackle barriers to IPTp uptake. Information obtained was compared with the Federal Ministry of Health Antimalaria Policy and guidelines for IPTp delivery.

3.10 Key informant interviews with Roll back Malaria Managers

3.10.1 Target population

The target population comprised of the Roll Back Malaria Managers in selected LGAs.

3.10.2 Selection of Roll Back Malaria Managers

The Roll Back Malaria Managers in both selected LGAs were recruited for this study.

3.10.3 Instrument for Data Collection

Key informant interview guide developed by the researcher (Appendix V) was used to interview

Roll Back Malaria Managers in selected LGAs. Information on SP supply chain management and IPTp data collection and collation as well as monitoring and supervision were obtained.

3.10.4 Validation of instruments

The key informant guide was face validated by two consultant Community Physicians.

3.10.5 Procedure for Data collection

The principal investigator conducted a total of two key informant interviews (one in the urban and one in the rural LGA) with Roll Back Malaria Managers in selected LGAs. The principal researcher enlightened the interviewees about the aim of the key informant interview and how it was to be conducted. Consent was obtained from the Roll Back Malaria Managers and confidentiality was assured. These interviews were carried out in a quiet environment in which

63 the interviewees were comfortable. Interview sessions were tape-recorded and notes on verbal and non-verbal gestures were also be made. Each session lasted for 30 to 45 minutes.

3.10.6 Data Analysis

Figure 4.3: Coding Tree for Key Informant Interview with RBM Managers

Recorded interviews were transcribed into a word document by the principal researcher. English language was used for all sessions, thus translations were not required. Quotes were used to represent responses from participants. Non-verbal responses and expressions were noted during transcription. Various notations were used to denote verbal and non-verbal expressions: (pause) was used to denote a pause in respondents answer, : was used to denote a stretched sound e.g so:, represents a marked rise in pitch, a downward arrow indicates a marked lowering of pitch, words that need to be emphasized are underlined e.g. fever and (( )) was used to represent vocalizations which are not easy to spell out e.g ((sniff)), ((cough)). These word

64 documents were imported into NVivo version 10 software and saved in two different folders

(urban and rural). The auto recode function was used to organize all responses to each question into one node for each group (urban and rural). These were subsequently coded to different nodes based on predetermined themes corresponding to the main categories of interest. The main themes include: SP tablet supplies in the LGA, monitoring of SP tablet use, SP stock-out, data on IPTp.

3.11 Ethical Approval

Ethical approval was sought from the Ethics Committee of the University of Port Harcourt

Teaching Hospital before the study commenced. Written permission to conduct the study was obtained from the Rivers State Primary Health Care Management Board (RPHCMB) and the

Medical Officer of Health as well as the Local Government Council in the selected LGAs. All participants for both qualitative and quantitative aspects of the study were given a consent form, which was signed after the nature of the study and benefit was explained to them. The clients were assured of strict confidentiality of their opinion and responses and were free to opt out of the study at any stage without being penalized. Assent for clients below the age of 18 was obtained from their parents or legal guardian. Clients were not penalized for refusal to participate in the study.

3.12 Study Limitations

In this study, client factors affecting IPTp uptake was largely based on self reported evidence.

Patients’ records were not reviewed. This may have introduced some form of social desirability bias. Furthermore the cross sectional nature of the study design for this study did not allow for inference of causation. Thus only associations were examined. Further limitation to this study was the hospital-based nature, may limit the generalization of the findings.

CHAPTER FOUR

RESULTS

This is a facility based rural/urban comparison of IPTp for pregnant women. A total of 835 out of 860 questionnaires were filled giving a response rate of 97%. Of the 835 respondents, 415

(49.7%) and 420(50.3%) were from the urban and rural LGAs respectively. The results are presented in the following sections:

Section 1: Survey of ANC attendees

Section 2: Focus group discussion with ANC attendees

Section 3: Assessment of facility

Section 4: In-depth interviews with Heads of ANC

Section 5: Key informant interviews with Roll Back Malaria Managers

Section 1: Survey of ANC attendees

Table 4.1: Socio-demographic characteristics of urban and rural ANC Attendees

Variable Urban (N = 415) Rural (N = 420) χ2 Test p-value n(%) n(%) statistic Age (year) 15 – 19 14 (3.4) 29 (6.9) 20 – 24 52 (12.5) 70 (16.7) 25 – 29 161 (38.8) 162 (38.6) 30 – 34 150 (36.1) 122 (29.0) 35 – 39 33 (8.0) 33 (7.9) 40 – 45 5 (1.2) 4 (1.0) Mean age 28.6 ± 4.6 27.7 ± 4.8 Student t = 0.005* 2.810 Marital status Married 333 (80.2) 210 (50.0) 118.039** 0.001* Widowed 16 (3.9) 19 (4.5) Single 53 (12.8) 90 (21.4) Co-habiting 12 (2.9) 101 (24.0) Divorced 1 (0.2) 0 (0) Education Tertiary 143 (34.5) 63 (15.0) 85.175** 0.001* Senior secondary 260 (62.7) 279 (66.4) Junior secondary 9 (2.2) 55 (13.1) Primary 3 (0.7) 15 (3.6) No formal education 0 (0) 8 (1.9) Occupation Farming 10 (2.4) 6 (1.4) 63.498 <0.001* Trading 111 (26.7) 144 (34.3) Fishing 6 (1.4) 53 (12.6) Seamstress 83 (20.0) 48 (11.4) Government Work 83 (20.0) 60 (14.3) Hairdressing 63 (15.2) 75 (17.9) Others 59 (14.2) 34 (8.1) *Statistically significant ** Fisher exact

The mean age for urban group was 28.6 ± 4.6 compared with 27.7 ± 4.8 in the rural group. This

mean difference was statistically significant with a p-value of 0.005. In both urban and rural

groups, the majority of the respondents were in the 25-29 age group [161(38.8%) in urban and

162(38.6%) in rural groups respectively].

The majority of the respondents in both urban and rural groups were married [333(80.2%) in

urban and 201(50.0%) in the rural groups respectively]. The majority of the respondents in the

urban and rural groups had senior secondary level of education. The proportion in the urban

67 group was slightly lower 260(62.7%) compared with the rural group 279 (66.4%). In both urban and rural groups, majority of the respondents were traders [111(26.7%) in urban and

144(34.3%) in rural groups respectively].

Obstetric history of urban and rural respondents

350

300

250

200

150

100 Number Number of Respondents 50

0 Urban Rural Ist Trimester 101 80 2nd Trimester 290 274 3rd Trimester 24 66

Figure 4.1: Trimester of first ANC attendance

Most of the respondents in both the urban and rural groups were in their second trimester when they booked for antenatal care. The proportions were slightly higher in the urban 290(69.9%) compared with the rural group 274(65.2%). The median gestational ages at booking were five in both groups.

Table 4.2: Obstetric history of urban and rural respondents

Variables Urban (N = 415) Rural (N = 420) χ2 p-value n(%) n(%) Number of ANC visits < 4 24 (5.8) 64 (15.3) 19.800 0.001* ≥ 4 391 (94.2) 356 (84.7) Median number of ANC 6 6 visits Parity 0 115 (27.7) 106 (25.2) 1 112 (27.0) 111 (26.4) 2 116 (28.0) 124 (29.5) 3 39 (9.4) 41 (9.8) 4 20 (4.8) 27 (6.4) ≥ 5 13 (3.1) 11 (2.6) Median parity 2 3 Mann- 0.001* Whitney U

=65328 *Statistically significant

In the urban group 391(94.2%) had four or more ANC visits compared with 356(84.7%) in the rural group. This difference in proportion was statistically significant with a p-value of 0.001.

The median number of ANC visits for both groups was 6.

In both groups the majority of the respondents had a parity of two [116(28%) in the urban, 124

(29.5%) in the rural group]. The median parity was two in the urban group compared with three in the rural group. This difference in median parity was statistically significant with a p-value of

0.001.

Table 4.3: Comparison of accessibility factors in urban and rural groups

Variables Urban (N = 415) Rural (N = 420) χ2 p-value n(%) n(%) Time to clinic (minutes) ≤ 30 360 (86.7) 409 (97.4)

> 30 55 (13.3) 11 (2.6)

Mean time to clinic 18.8 ± 14.6 13.6±9.6 32.43 0.001*

Means of transportation Public transport 204 (49.2) 277 (66.0) 24.112 <0.001*

Private transport 211 (50.8) 143 (34.0)

*Statistically significant

The majority of respondents in both urban and rural groups spent less than or equal to thirty

minutes to get to the ANC clinic. The proportion in the urban group 360(86.7%) was lower than

that of the rural group rural 409 (97.4%). The mean time to ANC was 18.8 ± 14.6 minutes in the

urban group compared with 13.6 ± 9.6minutes in the rural group. This difference was

statistically significant with a p-value of 0.001.

In the urban group most of the respondents 211(50.8%) used private transport to the ANC

compared with 143(34.0%) in the rural group. This difference in proportion was statistically

significant with a p-value of <0.001.

Table 4.4: Comparison of correct knowledge of malaria and IPTp among ANC attendees

in urban and rural groups

Variables Urban (n = 415) Rural (n = 420) χ2 p-value

Freq. Percent Freq. Percent

Correct knowledge of how malaria is 397 (95.7) 396 (94.3) 0.828 0.363 transmitted

Correct knowledge of the effects of malaria 190 (45.8) 208 (49.8) 1.324 0.250 on the pregnant woman

Correct knowledge of the effect of malaria 143 (34.5) 244 (58.1) 46.902 <0.001* on the unborn baby

Correct knowledge of how a pregnant 286 (68.9) 261 (62.1) 4.238 0.040* woman can protect herself from getting malaria

Correct knowledge about the purpose of 391 (94.2) 399 (95.0) 0.251 0.616 taking SP tablets

Correct knowledge of the dose of SP tablet 97 (23.4) 101 (24.0) 0.052 0.819

(IPT)

Correct knowledge on the interval between 298 (71.8) 272 (64.8) 4.783 0.029* doses

`df = 1 *Statistically significant

The majority of the women in both groups had correct knowledge of how malaria is transmitted.

The proportions were slightly higher in the urban group 397(95.7%) compared with the rural

group 396(94.3%). This difference in proportion was not statistically significant with a p-value

of 0.363. In the urban group, 190(45.8%) had correct knowledge of the effect of malaria on the

pregnant woman compared with 208(49.8%) in the rural group. This difference in proportion

was not statistically significant with a p-value of 0.250. Fewer women had correct knowledge of

the effects of malaria on the unborn baby in the urban group 143(34.5%) compared with

244(58.1%) in the rural group. This difference in proportion was statistically significant with a

p-value of <0.001. In the urban group, 286(68.9%) had correct knowledge of how a pregnant

woman can protect herself from getting malaria compared with 261(62.1%) in the rural group.

This difference in proportion was statistically significant with a p-value of 0.040. In both urban

and rural groups, the majority of respondents had correct knowledge of the purpose of IPTp

[391(94.2%) in the Urban and 399(95.0%) in the rural group]. In the urban group, 298(71.8%)

had correct knowledge on the interval between SP tablet doses compared with 272(64.8%). This

difference in proportion was statistically significant with a p-value of 0.029.

Malaria and IPTp Aggregate knowledge scores in urban and rural groups

Table 4.5: Comparison of malaria and IPTp Aggregate knowledge scores of ANC

attendees in urban and rural groups

Malaria and IPTp Urban (N = 415) Rural (N = 420) t-test p-value Aggregate n(%) n(%) Knowledge scores < 50% 19 (4.6) 34 (8.1)

≥ 50% 396 (95.4) 386 (91.9)

Mean percentage 77.6 ± 14.7 69.7 ± 13.9 7.98 0.001* score Total score obtainable = 25 *statistically significant

More of the urban respondents 396(95.4%) had an aggregate knowledge score of ≥ 50%

compared with 386(91.9%) of rural respondents. The mean knowledge scores were 77.6 ± 14.7

and 69.7 ± 13.9 for urban and rural groups respectively. This difference in mean score was

statistically significant with a p-value of 0.001.

Experiences of side effects in urban and rural groups

Table 4.6: Comparison of experiences of side effects in urban and rural groups

Variable Urban (N = 415) Rural (N = 420) χ2 p-value

n(%) n(%)

Experienced side effects Yes 16 (3.9) 24 (5.7) 1.581 0.209

No 399 (96.1) 396 (94.3)

*Statistically significant

In the urban group 16(3.9%) compared with 24(5.7%) in the rural group experienced side effects

with SP tablets. This difference in proportion was not statically significant with p-value 0.209.

Table 4.7: Client related factors affecting uptake of two or more doses of IPTp in the Urban and Rural Groups Variables Urban Rural Number of IPTp taken (%) χ2 p-value Fisher Number of IPTp taken χ2 p-value exact p (%) < 2 ≥ 2 < 2 ≥ 2 n = 223 n = 192 n = 262 n = 158

Age (year)

< 35 203 (53.8) 174 (46.2) 0.020 0.886 238 145 (37.9) 0.107 0.744 (62.1) ≥ 35 20 (52.6) 18 (47.4) 24 (64.9) 13 (35.1)

Marital status 166 (49.8) 167 (50.2) 10.232 0.001* 117 93 (44.3) 7.954 0.005* Married (55.7) 57 (69.5) 25 (30.5) 145 65 (31.0) Unmarried (69.0)

Education 221 (53.6) 191 (46.4) 0.203 0.651 1.000 244 153 (38.5) 2.615 0.106 Post primary (61.5)

≤ primary 2 (66.7) 1 (33.3) 18 (78.3) 5 (21.7)

Table 4.7 Cont’d: Client related factors affecting uptake of two or more doses of IPTp in the Urban and Rural Groups

Variables Urban Rural Number of IPTp taken (%) χ2 p- Fisher Number of IPTp taken (%) χ2 p-value value exact p < 2 ≥ 2 < 2 ≥ 2 n = 223 n = 192 n = 262 n = 158

Occupation 205 (52.4) 186 (47.6) 4.623 0.031* 251 (62.6) 150 (37.4) 0.171 0.680 Employed/ self employed

Student/ unemployed 18 (75.0) 6 (25.0) 11 (57.9) 8 (42.1)

Time of ANC booking

Early (1st& 2nd trimester) 206 (52.7) 185 (47.3) 2.996 0.083* 205 (57.9) 149 (42.1) 19.192 < 0.001*

Late (3rd trimester) 17 (70.8) 7 (29.2) 57 (86.4) 9 (13.6)

Number of ANC Visits

< 4 7 (29.2) 17 (70.8) 2.996 0.083* 9 (13.6) 57 (86.4) 19.192 <0.001*

> 4 185 (47.3) 206 (52.7) 149 (42.1) 205 (57.9)

*Statistically significant

Table 4.7 Cont’d: Client related factors affecting uptake of two or more doses of IPTp in the Urban and Rural Groups Variables Urban Rural

Number of IPTp taken (%) χ2 p- Fisher Number of IPTp taken (%) χ2 p-value value exact p < 2 ≥ 2 < 2 ≥ 2 n = 223 n = 192 n = 262 n = 158

Parity 0 74 (64.3) 41 (35.7) 7.207 0.007* 64 (60.4) 42 (39.6) 0.243 0.622 ≥ 1 149 (49.7) 151 (50.3) 198 (63.1) 116 (36.9)

Time to clinic (minutes) < 30 181 (57.3) 135 (42.7) 6.691 0.010* 242 (63.0) 142 (37.0) 0.782 0.377

≥ 30 42 (42.4) 57 (57.6) 20 (55.6) 16 (44.4)

Means of transport to ANC Public 99 (48.5) 105 (51.5) 4.373 0.037* 180 (65.0) 97 (35.0) 2.363 0.126

Private 124 (58.8) 87 (41.2) 82 (57.3) 61 (42.7)

*Statistically significant

Table 4.7 Cont’d: Client related factors affecting uptake of two or more doses of IPTp in the Urban and Rural Groups

Variables Urban Rural

Number of IPTp taken (%) χ2 p- Fisher Number of IPTp taken (%) χ2 p-value value exact p < 2 ≥ 2 < 2 ≥ 2 n = 223 n = 192 n = 262 n = 158

Knowledge score about malaria and IPTp < 50% 9 (47.4) 10 (52.6) 0.325 0.569 26 (76.5) 8 (23.5) 3.130 0.077*

≥ 50% 214 (54.0) 182 (46.0) 236 (61.1) 150 (38.9)

Experienced side effects with SP tablets

Yes 7 (43.8) 9 (56.3) 0.667 0.414 10 (41.7) 14 (58.3) 4.654 0.031*

No 216 (54.1) 183 (45.9) 252 (63.6) 144 (36.4)

*Statistically significant

The table above shows the differences in proportions for all selected client related factors affecting uptake of two or more doses of IPTp in the urban and rural groups. In the urban group, marital status, occupation, parity, time of ANC booking, number of ANC visits, time to ANC, means of transport were statistically significant. Marital status, Number of ANC visits, Knowledge about malaria and IPTp, experience of side effects with SP, time of ANC booking, were statistically significant in the rural group.

Table 4.8: Multivariate analysis of uptake of 2 or more doses of IPTp with Client Related

factors in the Urban Group

95% CI Explanatory variables Adjusted p-value odds ratio Lower Upper

Marital status

Married 1

Unmarried 0.528 0.307 0.908 0.021*

Number of ANC visit ≥ 4 ANC visits 1 < 4 ANC Visits 0.374 0.142 0.985 0.046* Parity 0 1 1 0.692 0.433 1.106 0.124 Time to ANC > 30 1 < 30 2.058 1.080 3.921 0.028* Means of Transport Private 1 Public 0.695 0.459 1.053 0.086 Occupation Student/ unemployed 1 Employed/ self employed 1.567 0.413 5.943 0.509

*Statistically significant

After controlling for confounders marital status, number of ANC visits and time to ANC,

remained significant in the urban group.

Table 4.9: Multivariate analysis of uptake of 2 or more doses of IPTp with Client Related factors in the Rural Group

95% CI p-value Explanatory variables Adjusted odds ratio Lower Upper

Marital status Married 1 Unmarried 0.591 0.392 0.893 0.012*

Number of ANC visits ≥ 4 ANC visits 1 < 4 ANC Visits 0.220 0.104 0.464 0.001*

Experienced side effects No 1 Yes 3.910 1.515 10.092 0.005* Knowledge about malaria and IPTp <50% 1 >50% 2.345 0.961 5.723 0.061

*Statistically significant

In the rural group, marital status, number of ANC visits, experience of side effect with SP and women’s knowledge about malaria and IPTp, remained significant after multivariate analysis.

Section 2: IPTp uptake among ANC Attendees

Table 4.10: Comparison of Use and Non Use of IPTp Among Urban and Rural Groups

Variables Urban (N = 415) Rural (N = 420) χ2 p-value

n(%) n(%)

Zero dose 93(22.4) 208(49.5) 66.568 0.001*

At least one dose 322(77.6) 212(50.5)

*statistically significant

Of the respondents who had zero dose of IPTp, a greater proportion 208(49.5%) were in the rural group compared with 93(22.4%) in the urban group. This difference in proportion was statistically significant with a p-value of 0.001.

Figure 4.2: Comparison of Use of Optimal Doses of IPTp Among Urban And Rural Groups

In the urban group, 199 (48.0%) of respondents had 2 doses of IPTp compared with 161 (38.3%) in the rural group.

Section 3: Focus Group Discussion

A total of 13 focus group discussions were carried out, five in the urban and 8 in the rural LGA. Each FGD was carried out with ANC attendees in each of the selected PHCs. Each FGD consisted of eight to twelve participants.

Table 4.11: Socio-demographic Characteristics of Focus Group Participants Variables Urban (N =49) Rural (N = 79) n(%) n(%) Age 25 – 29 14 (28.57) 29(36.71) 30 – 34 28 (57.14) 37(46.83) 35 – 39 6 (12.25) 12(15.19) 40 – 45 1 (2.04) 1(1.27

Marital Status

Married 25 (51.02) 45(56.96) unmarried 24 (48.98) 34(43.04) Educational Status Primary 1 (2.04) 5(6.33) Secondary 30 (61.22) 62(78.48) Tertiary 18 (36.74) 12(15.19)

Occupation Trading 20 (40.82) 25(31.65) Seamstress 7 (14.29) 11(13.92) Fish mongering 3 (6.12) 20(25.32) Teaching 5 (10.20) 7(8.86) Farming 5 (10.20) 2(2.58) House wife 4 (8.17) 7(8.86) Others 5 (10.20) 7(8.86)

The age ranges of the participants in the urban and rural FGDs were 27 to 40 years and 25 to 40 years respectively. The majority of the women in both groups were in the 30 to 34 years age group [28(57.14%) in the urban and 37(46.83%) in the rural group]. In the urban group and rural groups, 25(51.02%) and 45(56.93%) respectively were married. The majority of women in both

82 groups had secondary level education [30(61.22%) in the urban group and 62(78.48%) in the rural group]. The predominant occupation in both urban and rural groups was trading [20(40.8% in the urban and 25(31.65%) in the rural group].

Table 4.12: Distribution of women recruited into the FGDs

Facility Facility Number of

setting Participants

Rumuigbo PHC Urban 12

Elenlenwon PHC Urban 10

Rupkokwu PHC Urban 10

Rumuepirikom PHC Urban 9

Ozuoba PHC Urban 8

Kalio-Ama PHC Rural 12

Ogbogbo PHC Rural 12

George-Ama PHC Rural 10

Ibaka PHC Rural 10

Ogoloma PHC Rural 10

Ogan-Ama PHC Rural 9

Okochiri PHC Rural 8

Okujagu PHC Rural 8

All FGDs in both urban and rural settings had 8 to 12 participants.

Key Findings from Focus group discussions

Opinion of women on Causes of Malaria

In expressing their views with regards to the cause of malaria, the women in both groups mentioned a number of possible causes of malaria. According to one of the women in the rural group, ‘malaria can be caused by eating too much groundnut oil, living in a dirty environment, bite from mosquito and (pause) breathing polluted air’ [29 year old trader from Ogoloma PHC, rural LGA]. In the urban group, the women laid emphasis on mosquito bite being the cause of malaria. They also listed other possible causes. One of the participants stated, “I know mosquito bite is the major cause of malaria but stagnant water around the house, exposing refuse outside the house as well as bushes and grasses around the house could also cause malaria” [35 year old teacher from Ozuoba PHC, urban LGA]. Some of the participants in the urban group were of the opinion that cough and catarrh particularly in children can cause malaria. One of the women explained, “every time my children want to have malaria, it starts with cough and catarrh” [31 year old trader from Rumuigbo PHC, Urban LGA].

Transmission of Malaria

Women’s Opinion about the Transmission of Malaria

In both urban and rural groups, the women unanimously agreed that malaria is transmitted from one person to another through the bite of mosquito. One of the participants stated “it is the mosquito that transfers malaria from one person to another when it bites” [25 year old hairdresser from Ogan-Ama PHC, Rural LGA]. Some participants in the urban group mentioned the possibility of transplacental transmission of malaria. One participant explained “I agree that mosquito bite can transfer malaria from one person to another. I also know that a pregnant

84 woman who has malaria and does not treat it well can pass it to her unborn baby”[28 year old housewife from Elelenwon PHC, Urban LGA].

Effects of Malaria on Pregnant Women

Opinions about the effect of Malaria on the Pregnant Woman

The views of the women about the possible effects of malaria on the pregnant woman were somewhat similar. In the rural group, one participant listed the effects of malaria as “weakness, vomiting, shortage of blood and unconsciousness” [30 year old fish monger from Okochiri PHC, rural LGA]. To add to the list another participant stated “other effects of malaria on the pregnant woman include high fever which can lead to miscarriage. It can cause dizziness, poor appetite and weakness” [32 year old baker from Rumuepirikom PHC, urban LGA].

Effect of malaria on the unborn baby

Women’s opinion about the effect of Malaria on the unborn Baby

In exploring the possible effects of malaria on the unborn baby, the women in both groups enumerated some possible effects such as anaemia, low birth weight, fetal death. One of the rural participants explained “malaria is a very bad sickness. It can kill the baby in the womb. It can also make the baby to be born with low blood requiring transfusion” [30 year old trader from

Ogbogbo PHC, rural LGA]. Another participant added “malaria can affect the placenta making it difficult for nutrients to pass from the mother to the baby. Sometimes it causes the eyes of the baby to be yellow” [31 year old secretary form Elelenwo PHC]. On the contrary another participant in the same FGD disagreed with the statement that malaria causes yellow eyes. She said “yellow eyes are caused by bacteria infection in the blood not malaria:::” [27 year old seamstress from Elelenwo PHC, urban PHC].

Opinions of women on IPTp

None of the women in both groups knew what IPTp was. However after describing the strategy most of them admitted that they knew about it but didn’t know it was called IPTp. According to one participant “I know that the doctor gave me three white tablets and on the envelope, three start was written. (Pause) I think that should be IPT” [33 year old hairdresser from Ogan-Ama

PHC, rural LGA]. Most of them knew that three tablets were to be taken at once but were not sure of the number of doses to be administered as well as the timing of doses. One participant said “it is when they add it to my routine drugs that I take it but::: I know that they give up to 2 or 3 times” [34 year old civil servant from Rumuepirikom PHC, urban LGA].

Reasons why IPTp is practiced

The participants had varying opinions as to why IPTp is practiced at the antenatal clinic. While some said it was a way of treating malaria in pregnancy, others felt the main aim was prevention of malaria in pregnancy. Others still said it was done to protect the pregnant woman. One participant said

“Malaria in pregnancy is deadly. It can kill both mother and baby if not handled well.

IPTp is done to treat those that already have malaria. It can also prevent malaria like the

Sunday Sunday tablet” [40 year old farmer from Ozuoba PH, urban LGA].

However, some participants insisted that IPTp was for prevention only and not cure. An urban respondent had this to say “the nurse told me that it is for prevention. ACT is for treatment” [34 year old civil servant from Rumuigbo PHC, urban LGA]. Quite a number of participants were not sure what the main purpose of IPTp was. According to one participant,” I don’t know if it’s for prevention or cure but I know that when the nurse asks me to it, I take it” [26 year old trader, from Okujagu PHC, rural LGA].

Experiences of Side Effects with SP tablets

Most participants in both groups said they hadn’t experienced any side effects with SP. In the urban group one of the participants had this to say

“when I take SP tablets it makes me very weak. So I like to take it over the weekend when

I won’t have to go to work. The first time it happened I was scared but when I

complained at the Health Centre I was told that it was the drug. The nurse encouraged

me to rest. After two days I was okay” [28 year old teacher, from Rukpokwu PHC, urban

LGA].

Another urban participant had this to say “I haven’t had any such experience but my neighbor said she doesn’t like taking SP tablets because it makes her vomit too much”[24 year old student, from Ozuoba PHC, urban LGA]. One participant expressed her concern about the possibility of

SP tablets causing miscarriage. She explained

“when my sister had her first pregnancy, she had a miscarriage at 7 months. This

occurred the day after she took SP tablets. She went to one mama that delivers women

but the mama could not save the baby. The same thing happened to another woman I

know. ((Cough)) It may not happen to everybody but I think if your body is too weak to

handle the drug, it can cause miscarriage for you”. [30 year old trader, from George-

Ama PHC, rural LGA].

Reasons why ANC attendees may not take two tablets of SP Table 4.13 Reasons why ANC attendees may not take two tablets of SP

Urban Rural

Unavailability of the drugs at ANC No money

Side effects of the drugs Not sick

Receipt of SP tablets from other sources SP from other sources

In the opinion of the women in the rural group, an important reason why women may not take the recommended two doses of SP tablets at ANC is that they may not have the money to buy the tablets. One of the participants explained “sometimes when they write drugs for you to buy, you may not have the money to buy it” [31 year old seamstress from Kalio-Ama PHC, rural LGA].

Another rural participant had this to say “some women may think that because they are not sick they don’t need to take the tablet. If they reason like that, they may not take the SP tablets” [40 year old hair dresser Okochiri PHC, rural LGA]. In the urban group, unavailability of the drug at the health facility was highlighted as an important reason why women may not receive IPTp.

One participant explained, “when the drug is not available at the health facility, you may decide that you will buy it elsewhere and forget”. [29 year old farmer, from Rumuigbo PHC, urban

LGA]. Some participants in the urban group felt that the side effects experienced with the drug may deter women from taking it. One of the participants put it this way “if a woman has taken the drug before and it worries her body,(( smiles)) when she is given the same drug again she may not take it” [31 year old trader, from Elelenwo PHC, urban LGA]. In both groups, most of the participants pointed out that if a pregnant woman has received SP tablets from other sources, they may not take the tablets given to them at the ANC. On the contrary, one of the participants did not agree that any of these reasons were good enough. She explained “I really don’t see why a pregnant woman will not take any medication given to her at the Health Centre. No excuse is good enough” [27 year old trader from Ogan-Ama PHC, rural PHC].

Suggestions to Tackle Barriers to IPTp Uptake

Table 4.14 Suggestions to tackle barriers to IPTp uptake

Urban Rural

Government should provide free tablets Government should provide free tablets Provision of subsidized tablets Health education at the ANC on the importance of SP tablets.

The women mentioned a number of suggestions as to how to tackle barriers to IPTp uptake identified during the session. One participant in the urban group suggested, “the Government should provide this SP tablet for free at the Health Centre as they used to. That will encourage women to take them” [39 year old house wife from Rukpokwu PHC, urban PHC]. In addition, another participant suggested “if the government cannot make it totally free, they should reduce the price a bit”. [30 year old teacher from Rukpokwu PHC, urban PHC]. Some of the rural participants were of the opinion that emphasis should be made about the importance of taking the

SP tablets during health education sessions at the ANC. They also suggested that provision of free SP tablets by the government may improve IPTp uptake.

Section 4: Facility Assessment

Table 4.15: Comparison of Facility performance when the components of IPTp practice were assessed in urban and rural PHCs

Variables Urban (n = 5) Rural (n = 8) Fisher Freq. Percent Freq. Percent exact p

Health education programme drawn for the 1 (20.0) 3 (37.5) 1.000 quarter includes IPTp Health talk given at ANC on day of visit 4 (80.0) 4 (50.0) 0.565 Presence of posters of IPTp/MIP on the wall 2 (40.0) 0 (0) 0.128 Presence of ANC Report Book for daily 5 (100) 8 (100) - summaries Presence of ANC Monthly Data returns 5 (100) 8 (100) - form SP available at ANC 5 (100) 8 (100) - Practice of SP DOT observed 0 (0) 0 (0) - SP given is recorded in ANC report Book 5 (100) 8 (100) - for daily summaries SP given is recorded in ANC cards of clients 5 (100) 8 (100) - Presence of Adverse Event forms for SP 3 (60.0) 2 (25.0) 0.293 Presence of free, clean water for DOT 4 (80.0) 3 (37.5) 0.266 Availability of IPTp National antimalaria 4 (80.0) 0 (0) 0.007* treatment guideline Availability of Antimalaria treatment policy 0 (0) 0 (0) - *Statistically significant

In both urban and rural groups, all the facilities [5(100%) in urban, 8(100%) in rural] included in

the study had ANC report books for daily summaries, ANC monthly data returns forms and SP

tablets at the ANC, recorded SP given in both the clients card and the ANC report book for daily

summaries. With regards to health education, only 1(20%) and 3(37.5%) of PHCs in both urban

and rural groups respectively included IPTp in their Health education programme for the quarter. 90

In the urban PHCs, 2(40%) had posters on the wall providing information about malaria in pregnancy or IPTp while none of the rural PHCs had. Adverse event forms for SP were available in 3(60%) urban and 2(25%) rural PHCs respectively. All facilities in both groups [0 (0%) urban,

0 (0%) rural] did not practice of DOT. The antimalaria treatment policy was not sighted in any of the facilities in both urban and rural groups. The antimalaria treatment guidelines were seen in

4(80%) urban PHCs. None of the rural PHCs had the guidelines.

Comparison of aggregate facility IPTp practice scores

Table 4.16: Comparison of aggregate facility IPTp practice scores in urban and rural PHCs

Practice score Urban (N = 5) Rural (N = 8)

n(%) n(%)

< 50% 0 (0) 2 (25)

≥ 50% 5 (100.0) 6 (75)

Median percentage score 63 44

Mann-Whitney U = 6.500, p-value = 0.044*

Overall, the urban setting, all facilities 5 (100%) had ≥ 50% average IPTp practice scores compared with 6 (75%) of the rural PHCs. The median aggregate practice scores in both urban and rural PHCs were 63 and 44 respectively. The difference in the median agreggate practice score was statistically significant with a p-value of 0.044.

Section 5: In-depth interviews of heads of ANC

A total of 13 in-depth interviews with all ANC heads were carried out, 5 in the urban group and

8 in the rural group. 91

Table 4.17: Socio-demographic Characteristics of ANC Heads

Variables Urban (5) Rural (8)

Age 40 – 45 2 3 46 – 50 2 4 > 50 1 1 Sex Male 0 0 Female 5 8 Marital Status Married 4 7 Unmarried 1 1 Highest Educational Qualification Midwifery Certification 3 8 Post Midwifery Certificate 2 0

A total of 13 in-depth interviews with all ANC heads were carried out, 5 in the urban group and

8 in the rural group. The age range of ANC heads was between 40 to 52 years. They were all registered nurse/midwives. All ANC heads were females. Two of the heads in the urban group had post midwifery certification, while the other heads in the urban and rural groups had midwifery certification as their highest qualification. Two out of the 13 ANC heads were not married (One head from the urban and rural LGA respectively), while the others were married.

Each ANC head had worked in that capacity for a period of 2 to 3 years.

Findings from in-depth interviews with ANC heads

Health facility factors affecting IPTp uptake

In the opinion of the ANC heads in both urban and rural LGAs, lack of training of all cadre of health workers on the implementation of IPTp as well as patients paying for SP tablets are the major factors affecting IPTp uptake at the PHC. In addition, majority of the heads in the urban

PHCs identified poor monitoring and supervision as an important factor affecting IPT uptake.

With regards to health workers training on IPTp, some interviewees expressed their concerns about the lack of training for health workers on the implementation of IPTp. Of all the PHCS included in this study, none had any staff training on IPTp in the past 2 years. In the rural group one ANC head explained

“I have worked as ANC head in two PHCs over the past four years and I have not had

any training on IPTp. The things I know I learnt from the RBM Manager. Some time ago

the RBM Manager and I also read the antimalaria treatment guidelines together” [ANC

head, rural LGA]

Another ANC head commented, “it’s as though IPTp has been forgotten. In the past few years we have had series of trainings on other aspects of malaria control such as Indoor Residual

Spray, Long Lasting Insecticide treated Nets and Artemisinin-based combination therapy but none on IPTp”. [ANC head, rural LGA]. The ANC heads emphasized that trainings on IPTp should be cascaded to all cadre of staff. This they felt will give a number of health workers a fair share of knowledge. One ANC head stated

“Sometimes as ANC head you may have to go to Port Harcourt for a meeting or

workshop. In such situations, other health workers will have to stand in for you. The

pharmacy technician also needs to be trained because he is the one dispensing the tablets

to the patients” [ANC head, rural LGA]

In their opinion, the ANC heads believe that if the women are not required to pay for SP tablets uptake will be higher. One ANC head explained

“Sometimes a woman may be willing to take the tablet but she may not have the money to

pay for it. When free tablets are available, we give them for free. They don’t pay for it.

Otherwise either they buy in the PHC or outside the PHC if there is SP stock-out” [ANC

head rural LGA].

Another ANC head had a similar explanation “Because we give free tablets when they are available. When those free tablets are not available, the women think that when we ask them to pay for the tablets that we want to make money on them” [ANC head, rural LGA].

In addition to these factors, the ANC heads in the urban PHCs identified monitoring and supervision as a factor that may have profound influence on IPTp delivery at the urban PHCs.

One ANC head explained “if supervisory visits are frequent and focuses on the process of implementation as well as review of statistics, IPTp uptake may improve” [ANC head, urban

LGA]. In Urban PHCs the description of monitoring and supervision were similar to that of the rural PHCs, though fewer visits were reported compared with the rural PHCs. In the rural PHCs, monthly visits by the RBM Manager were reported. While in the urban group, there were occasional visits by the RBM Manager. Occasionally the Medical Officer of Health visited as well as a designated Officer from the State Malaria Control Unit. The main focus during these visits were the review of summary statistics. Supervisory visits by the RBM in the rural LGA appear to be more regular. This may be because she supplies them with their SP tablets and must

94 review statistics before supplying new drugs. One of the rural providers gave this account “the

RBM visits us monthly and reviews ANC utilization statistics as well as SP utilization statistics”.

Health workers Knowledge of IPTp

Other areas explored during the in-depth interviews include health workers knowledge and practice of IPTp, source and availability of SP tablets. All ANC heads correctly explained why

IPTp was practiced and identified the drug used for IPTp as well as the dosage. In the rural group, 5 out of 8 correctly stated that the first dose was to be administered at 16 weeks or when quickening has occurred. While in the urban group, all ANC heads correctly stated the timing of the first dose. Similarly while all ANC heads in the urban group correctly stated the timing of the second dose, only 7 out of 8 in the rural group got the correct timing. Knowledge of side effects in both groups was generally good with all ANC heads correctly listing at least 3 side effects.

However, none of the ANC heads in both groups correctly mentioned remedies for women with known allergy to SP tablets.

IPTp practice at the ANC

Administration of the first and second doses of IPTp

All ANC heads reported that IPTp was provided in their facilities. However some PHCs deviated from the standards prescribed in the National Antimalaria Treatment Guidelines. According to one rural provider “I give the first tablets after fetal movements have been felt but I don’t give a second dose except the woman come down with symptoms of malaria. If the symptoms are mild, then I give a second dose of SP but if the symptoms are severe, then I give coartem”. [ANC head, rural PHC]. On further questioning, this provider said “I know my practice is a deviation from the national guidelines, ((shrugs)) but it works for me so I will continue with it”. [ANC head, rural PHC]. Another rural provider stated, “we give the first dose at about 16 weeks, the second

95 dose after one month but we also give a tablet of piriton at the same time to reduce the occurrence of adverse effects”. In both urban and rural PHCs, IPTp is offered to all HIV positive patients irrespective of whether they are on co-trimoxazole preventive treatment or not.

Practice of DOT

In all PHCs, SP tablets were prescribed for the women to buy and swallow at home. No PHC practiced directly observed treatment (DOT) in both urban and rural LGAs. One rural provider stated her reason for not carrying out DOT as “the women will say they did not eat before coming for ANC and they are not comfortable swallowing tablets on empty stomach, ((shrugs)) and we cannot force them”. [ANC Head, Rural PHC] The reason given by the urban providers for not carrying out DOT were problems related to the logistics of providing portable drinking water and cups. Another reason was that the women may not have the money to buy their tablets when they come for ANC. An urban provider explained “the SP tablets are not provided free of charge for the women. Most of the time they have to buy. If they do not have the money to pay for the drug, there is nothing we can do” [ANC Head, Urban PHC].

SP tablets source and availability at the ANC

With regards to SP tablets source and availability at ANC, this in-depth interview revealed that the rural PHCs get their SP supplies from the Roll Back Malaria Manager most of the time.

According to a rural provider,

‘the Roll Back Malaria Manager supplies us with SP tablets. As soon as our SP stock is

almost finished we alert her. This takes care of problems with logistics of going to the

central medical store in Port Harcourt to purchase SP tablets. On a few occasions when

this is not available, SP tablets are purchased from the state central medical store’.

On the other hand the urban PHCs procure their SP tablets from the central medical store in

Rivers State. One urban provider described the process thus:

‘requisition is made to the board, when the facility’s account is credited, we go to the central medical store to purchase SP tablets. When the State has free SP tablets, the RBM Manager supplies the facility with those tablets and so patients don’t get to pay’.

Most of the rural providers (six out of eight) stated that they never had SP stock out in the last six months. The few that experienced SP stock out employed a number of strategies. One rural provider explained, “We prescribe for patients to buy outside the Health Centre. Sometimes we use Daraprim, we give the women one tablet weekly”. All Urban PHCs had at least one episode of SP stock out in the last 6 months. According to an urban providers account ‘It doesn’t occur frequently. SP stock out occurred once in the past 6 months. We prescribe for them to buy outside the facility. Sometimes we give proguanil’.

Suggestions to tackle barriers to IPTp uptake

Both urban and rural ANC heads were of the opinion that IPTp missed opportunities will reduce if the staff strength at the ANC is increased. Majority of the ANC heads in both groups also felt that missed opportunities will reduce if ANC clients swallow their SP tablets under the direct supervision of the Health worker. Some recommendations were made to tackle health service factors and improve IPTp uptake. One ANC head suggested

“we should begin to administer SP tablets under the direct supervision of the health

worker because that’s the only way to be sure that the woman swallows the tablets

prescribed for her” [ANC head, urban LGA].

Another ANC head emphasized on the need for training of Health workers on IPTp implementation. She suggested

“whenever a new set of staff are employed, they should have at least an in-house

training. At intervals the state should train at the state level as well, then trainees can

step down at their various facilities” [ANC head, rural LGA].

Another recommendation made was that monitoring of IPTp implementation should be more frequent and the scope should be broadened. One ANC head explained

“the malaria control unit in the state should have a more effective monitoring team. The

team should visit the facility and observe the implementation of IPTp and not just focus

on review of utilization statistics” [ANC head, rural LGA].

Another recommendation was to ensure that SP tablets are always available at the PHC.

Section 6: Key informant interview of Roll Back Malaria (RBM) Manager in urban and rural LGAs

Two key informant interviews were carried out with the RBM Manager in each of the selected LGAs.

Socio-demographic Characteristics of Roll Back Malaria (RBM) Managers

In both urban and rural LGAs, the RBM Managers were both female aged 40 and 42 years respectively. They are both indigenes of Rivers State with post secondary education (OND). While the RBM Manager in the urban LGA had worked in that capacity for two years, her counterpart in the rural LGA had worked in that capacity for only one year.

Findings from Key informant interview of RBM Managers in urban and rural LGAs

SP tablet supplies in the LGA

Both RBM Managers confirmed that SP tablets were used for IPTp in the LGA. In the rural

LGA, the RBM manager supplies the PHCs with SP tablets. The quantity of tablets supplied to each facility was based on the facility’s SP tablets consumption rate. She explained

“most of the times I supply the PHCs in my LGA with SP tablets. I get these tablets from

the State Central Medical Store. The quantity of SP tablets I supply to each facility is

based on the consumption statistics they present to me” [RBM Manager rural LGA].

However in the urban LGA, the RBM confirmed the findings from the in-depth interview with

ANC heads. She reiterated that ANC heads make requisition to the board for release of funds to purchase medications including SP tablets. She had this to say

“When funds are released for the purchase of medications, SP tablets are purchased from

the State Central Medical Store. However when the Malaria Control Unit in the State

Ministry of Health have free tablets, they inform me and I distribute it to the facilities in

my LGA”. [RBM Manager, urban LGA].

Monitoring of SP tablet use

With regards to monitoring proper use of SP at the PHC, one important strategy employed in the rural LGA was supervisory visits by the RBM Manager. The RBM Manager in the rural LGA explained “to monitor the use of SP tablets I review SP utilization statistics of previously supplied drugs before replenishing stock”. [RBM Manager, rural LGA] In the urban LGA, the

RBM expressed her difficulty in monitoring proper use of SP tablets. She however reviews the monthly statistics from the PHC and issued advice when necessary. This interview revealed that supervisory visits by the RBM were monthly in the rural LGA while in the urban no particular frequency was maintained.

SP stock-out

In the urban LGA, the RBM Manager was not aware of SP stock out in any of the PHCs in the past 6 months. Similarly in the rural LGA, the RBM Manager was certain that there had been no 99 periods of SP stock-outs. The RBM Manager in the rural LGA explained “no PHC in my LGA experienced SP stock-out in the past six months. It is impossible because I follow them up closely” [RBM Manager, rural LGA].

Data on IPTp

Monthly Statistics are obtained and handled in a similar way in both LGAs. Statistics from all facilities in the LGA are collated in the first week of a new month and submitted to appropriate authorities. One of the RBM Managers had this to say “I collate statistics ((demonstrates with her hands)) from all PHCs in my LGA on a monthly basis. I submit copies to the Medical Officer of Health, Rivers State Ministry of Health and the Rivers State Primary Health Care

Management Board” [RBM Manager, urban LGA].

100

CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1 Discussion

Over a decade after the introduction of IPTp at the ANC in Nigeria, it is disappointing to observe that a number of ANC attendees do not receive any dose of IPTp. The current study reported that less than a quarter of respondents in the urban group and approximately 50% of the respondents in rural group had zero dose of IPTp. The results in the urban setting are similar to that of a study carried out in Cameroon to evaluate the determinants of ANC attendance and IPTp uptake.59

That study reported that only a few of their respondents received zero dose of IPTp. On the contrary, a study carried out in PHCs in an urban setting in Nigeria which accessed the use of

IPTp among pregnant women found that more than 75% of the respondents received zero dose of

IPTp.37 The authors suggested that some possible reasons for the poor uptake include poor awareness of IPTp among Health care providers as well as wrong perception and fear about SP tablets among ANC clients. In the current study, the proportion of women who had zero dose of

IPTp in the rural group was similar to that of a study carried out in a rural town in Western

Nigeria.17 That study assessed IPTp uptake among ANC attendees in three PHCs and found that over 50% of respondents had zero dose of IPTp. On the contrary, a study carried out in a rural setting in Tanzania reported that only about one-third of respondents received zero dose of

IPTp.18 This disparity may have been because the Tanzanian study was carried out after the implementation of an empowerment project. The project sort to improve maternal, newborn and child health. The WHO has reported that the risk of low birth weight among babies decreases as number of doses of IPTp increases. This implies that the risk of low birth weight is highest among those with zero dose.12 This thus points towards the need to identify and address the barriers of IPTp uptake.

101

Uptake of both the first and second doses of IPTp were significantly higher in the urban compared with the rural group. This rural/urban difference in IPTp uptake have been consistently reported in a number of studies.11,30,60 Similar findings were reported in the two most recent

National Demographic Health Survey (NDHS) carried out in Nigeria.15,24 This implies that the women residing in rural areas face a higher degree of barriers to IPTp uptake compared with their urban counterparts. IPTp uptake values were obviously lower in the NDHS as compared to the values obtained in the current study, this may be because NDHS was a community-based study as opposed to the current study which is facility based. Another possible reason for this disparity may have been due to a larger denominator used in the NDHS. The denominator comprised of women who had at least one ANC visit irrespective of gestational age while the current study was restricted to women at 36 weeks gestation. In addition the higher IPTp uptake values obtained in the current study may have been due to the free ANC programme carried out in Rivers State until a few months prior to the commencement of the current study as well as intermittent supply of free SP tablets. However this uptake still falls short of the target in the

National malaria strategic plan to ensure IPTp coverage of 100%.14 Another related study carried out in rural and urban communities in Malawi also found that IPTp coverage was below the national target.92 This calls for the need for concerted effort aimed at scaling up IPTp uptake at the ANC.

IPTp missed opportunities may account for the reason why high ANC utilization is recorded against a low IPTp coverage. In the current study a respondent is said to have IPTp missed opportunity if there was an ANC visit in which IPTp could have been administered according to the policy but was not. ANC attendees who received zero dose of SP had missed opportunities for IPTp. In the current study IPTp missed opportunities were recorded in both urban and rural

102 groups. This is in keeping with the findings from other studies which reported missed opportunities for IPTp among ANC clients.11,68 A study carried out in Enugu assessed IPTp missed opportunities for the first and second doses.11 This study reported a higher level of missed opportunities compared with the current study. This may have been so because the analysis carried out did not disaggregate into rural and urban but rather calculated missed opportunities for the entire study population. In-depth interviews with heads of ANC in the current study identified SP stock out and poor patient compliance as the major reasons for missed opportunities. It may also be because the policy and guideline in use by all PHCs at the time the current study was carried out states that women 36 weeks and above should not be offered

IPTp.7,8 This is contrary to the WHO’s recommendation in the current IPTp policy which allows for women to have IPTp up till the time of delivery.12 Going by the policy currently in use, a number of missed opportunities may arise particularly among those who book in the third trimester. This policy has however been reviewed to meet up with the WHO updates on IPTp and is presently been communicated to various levels of Health Care. These missed opportunities suggest that there are deficiencies in delivery of IPTp at ANC and these may contribute to the low coverage levels.67

With regards to the implementation of IPTp strategy, poor practice may contribute to low levels of IPTp uptake. In the current study, IPTp practice was assessed using a checklist and in-depth interview of heads of ANC. All 13 PHCs included in the current study practiced IPTp even though deviations from the National Guidelines were observed. This finding corroborates with results from a cross sectional study carried out in South-Eastern part of Nigeria.16 This study employed both quantitative and qualitative methods of data collection. The study found that although the majority of the facilities included in the study practiced IPTp, deviations were

103 noted. The deviations in the index study may have been because most of the PHCs in both urban and rural groups didn’t have the National malaria treatment guidelines and policy. It may also be because they hadn’t received any training on IPTp in the past two-year preceding the current study. Furthermore, the current study found that none of the urban/rural PHCs administered SP tablets for IPTp under direct observation of the Health worker. This was in keeping with the findings from the in-depth interviews and non-participant observation carried out in the current study as all heads of ANC clinics admitted to giving the women SP tablets to swallow at home or asking them to buy outside the PHC. On the contrary, a similar study carried out in Ghana reported that the practice of DOTS was observed in half of facilities included in their study.54

However the level/types of facilities included in their study was not mentioned. Some of them may possibly have been secondary or tertiary facilities with more qualified staff. This may also explain why the study recorded high staff commitment to DOT. A related study carried out in the

Western part of Nigeria reported that some respondents received SP tablets under direct supervision of the health worker.86 Similar findings were reported in a study carried out in Rivers

State.29 This study was carried in three rural LGAs in Rivers State in 2008, about three years after the introduction of IPTp strategy. This study reported that a few of ANC attendees received

SP tablets under direct observation of Health workers. This result when compared with the findings of the current study appears to depict deterioration in practice rather than an improvement. In addition, the current study found that none of the ANC heads interviewed mentioned that IPTp should be carried out under the direct supervision of the health worker. This implies that for health workers to effectively deliver IPTp, they need to have well planned and periodic training to enable them acquaint themselves with the National policy, Treatment

Guidelines and the WHO updates on IPTp. Health care providers made similar recommendations

104 in a qualitative study by Mubyazi et al, which assessed the knowledge, attitude and practice of district health managers, antenatal staff and pregnant women in Tanzania.65

In the index study, both urban and rural PHCs had maximum practice scores when availability of

SP tablets at the ANC was assessed. In the rural areas, the availability of SP tablets at the ANC is in keeping with findings from the key informant interview with the Roll Back Malaria Manager who confidently stated that she constantly supplied the PHCs in her LGA with SP tablets. This implies that some factors other than availability of SP tablets are responsible for the shortfall in

IPTp uptake observed in both urban and rural settings in the current study. The urban results for availability of SP tablets at ANC in the current study is similar to those obtained from a qualitative study carried out in the South-Eastern part of Nigeria which looked at the influence of provider factors on IPTp uptake.16 That study reported that all urban public facilities included in the study had SP tablets in stock. On the contrary a study carried out in Tanzania which assessed the availability, accessibility and utilization of malaria interventions among women of reproductive age reported there was SP stock-out in over three quarter of the sampled facilities.74

Their finding may have been because in the 12 months preceding the study, there were no supervisory visits specific to IPTp. In their opinion, frequent SP stock-out has the potential to negatively affect IPTp implementation. Interestingly, a study carried out in Malawi observed a trend with SP stock-out and IPTp uptake at the ANC.91 That study reported that there was SP stock-out in more than half of the facilities included in their study and IPTp uptake declined when SP stock-out occurred. This suggests that a number of facilities do not adhere to WHO’s recommendation that SP tablets be made available at the ANC to enable pregnant women have immediate access to IPTp-SP.12

105

The importance of the use of information, communication and education (IEC) in promoting clarity in the administration of SP for IPTp has been highlighted by the USAID.26 With regards to IEC, in the current study both urban and rural PHCs performed poorly. There were no posters on malaria in pregnancy and IPTp displayed on their walls. This finding corroborates with findings from other studies.26,77 A study carried out in the South-Western part of Nigeria found that the majority of the health workers interviewed admitted that they didn’t have posters providing information about IPTp displayed on the walls in their health facility. Furthermore less than half of both urban and rural PHCs had a health talk that included prevention of malaria in pregnancy. This is in keeping with the results of a study carried out in Tanzania which revealed that less than 50% of the health education sessions carried out in sampled facilities included malaria prevention messages.91 This is unlike the findings from another related study carried out in Tanzania which reported that ANC clients routinely received information about IPTp at the

ANC.102 Their finding may have been so because this information was obtained from interviews with health workers and not non-participant observations like the current study. These findings from the current study imply that there is a paucity of information concerning IPTp at the ANC.

It thus highlights the need to provide adequate awareness for ANC attendees and the general public, on the dangers of malaria in pregnancy as this may potentially improve the uptake of optimal doses of SP and ultimately enhance health outcomes.18

Receiving optimal dose of IPTp offers better protection to the pregnant woman and her unborn foetus compared with sub-optimal doses. The current study identified marital status as an important socio-demographic factors affecting uptake of two or more doses of IPTp in both the urban and rural groups. Those who were married were more likely to receive two or more doses of IPTp compared with those who were unmarried. A study carried out in Bungoma district,

106

Kenya identified marital status as a very significant factor affecting uptake of two or more doses of IPTp.63 This may have been due to financial and other forms of support given by their spouses as reported in the study. In the same study, some of the women admitted that their spouses reminder them about their antenatal visit dates. On the contrary, a related study carried out in

Ghana found that marital status was not a significant factor affecting uptake of two or more doses of IPTp.54 Another study in Sub-Saharan Africa also reported that marital status was not associated with uptake of 2 or more doses of IPTp.90 Similarly, a study carried out in a rural province in Western Zambia found that marital status was not significantly associated with uptake of IPTp.

Other socio-demographic factors explored in this study such as age, educational status, occupation did not significantly affect IPTp uptake as well in both groups. Other studies have reported similar findings.54,91 Machant et al measured coverage of IPTp at the national level in

Tanzania and examined the role of individual, facility, and policy level influences on achieved coverage.91 This study found that socio-demographic factors did not significantly affect uptake of two or more doses of IPTp.

The majority of women in the current study had their first ANC visit in the first and second trimester of pregnancy. This also reflected in the number of ANC visits as the findings of this study shows that the majority of women had four or more ANC visits. In the current study, number of ANC visits was found to be a significant factor affecting uptake of two or more doses of IPTp in both urban and rural groups. Women who had four or more ANC visits were more likely to have two or more doses of IPTp. This is in keeping with the WHO’s recommendation of Focused Antenatal care which promotes four or more ANC visits for pregnant women.78 This recommendation was based on findings from a multi-country

107 randomised control study and systematic reviews which reported that all effective interventions at the ANC can be rendered over at least four ANC Visits.79 This implies that the more the number of ANC visits a woman makes, the more likely she is to receive the recommended number of doses of IPTp. This corroborates with the findings in a study carried out in Zambia.55

Similarly a secondary data analysis carried out in Sub-Saharan Africa found number of ANC visits to be a determinant of uptake of two or more doses of IPTp.90 In the current study though the majority of the women had more than four ANC visits, IPTp uptake values still remained low, as some ANC attendees were not offered SP tablets at the PHC. This suggests that the quality of ANC rather than the number of ANC visits may be of importance in scaling up IPTp uptake. This may also be the reason why a study carried out in rural Uganda which found that frequent ANC visits did not enhance uptake of two or more doses of IPTp-SP.68 These results thus suggest that Policies promoting the implementation of focused ANC may be beneficial in scaling IPTp coverage.

For women in the urban group, time spent in getting to the ANC remained significant even after multivariate analysis and the odds of IPTp use was lower among those who spent less than 30 minutes compared with those who spent 30 minutes or more to the ANC. This implies that the farther away a woman is from the health facility, the more likely she is to use IPTp. A related study by Sangare et al reported similar findings.68 This study found that women who spent less than 30 minutes to the ANC were less likely to use IPTp compared with those who spent more than 30 minutes. On the contrary, a study carried out in Uganda reported that nearness of ANC facility was an important factor related to use of IPTp.66 Thus they recommended that increasing the number of health facilities providing IPTp and maternity services is a priority option with regards to scaling up IPTp use.

108

In the current study, following multivariate analysis, women who had previously experienced side effects with SP tablets were more likely to use two or more doses of IPTp compared with those who had not in the rural group. This is in keeping with the results of a qualitative study by

Pell et al which revealed that though there were complaints from women about the side effects of

SP tablets, it did not however necessarily lead to non-compliance because IPTp was generally accepted (though sometimes begrudgingly) as part of the package of ANC interventions, which was collectively viewed in a positive light.64 Another study by Sikambale et al which employed both qualitative and quantitative methods of data collection found that over three quarter of the women who experienced side effects with SP tablets still took the second dose.55 Results from the FGD sessions in that study showed that the women expressed their willingness to take SP tablets despite the side effects because of the perceived benefits and importance of IPTp.

However this study found that the association between experience of side effect with SP and

IPTp uptake was not significant.

This study explored health service related factors affecting IPTp uptake identified from other related studies as well as those suggested by the heads of ANC. In the current study, lack of staff training has been identified as one of the health service factors affecting IPTp uptake in both urban and rural PHCs. This study found that Health workers did not receive any training on IPTp in the two years preceding the study. This finding is similar to that of studies carried out in Zaria and Kampala.66,87 This lack of training may have contributed to the observed gap in health workers knowledge of IPTp observed from the in-depth interview carried out in the current study. On the contrary a study carried out in Ghana found that more than 50% of health workers interviewed received a formal training on IPTp.54 This increased training in Ghana may have been as a result of the adoption of an integrative approach in controlling malaria in pregnancy. A

109 key component of this approach was improving health workers’ competence through training. In the current study, the ANC heads suggested that IPTp uptake will improve if staff trainings were organized frequently. Similar recommendations have been made in other related studies.71,102 A study which looked at prospects, achievement, challenges and opportunities of scaling up malaria prevention in Tanzania found that there were confusing directives with regards to the administration of IPTp.102 That study suggested that staff training is important because it not only improves the capacity of the health workers to deliver but also increases their morale. Another related study carried out in rural western Kenya assessed IPTp coverage two years after training of Health workers on focused antenatal care and malaria in pregnancy.101 That study found that

IPTp uptake increased in those areas where the training took place. Furthermore, an intervention study carried out in the Northern part of Nigeria showed that knowledge of IPTp as well as utilization increased significantly following Health worker’s training on IPTp.87 A qualitative study on the perceptions of intermittent preventive treatment of malaria in pregnancy and barriers to adherence in Nasarawa and Cross Rivers State was conducted by Diala et al.33 That study reported that none of the health workers interviewed in Nasarawa attended a training on malaria in pregnancy recently. In that study health workers suggested that that trainings should be organized as they are helpful in updating knowledge Health workers training on IPTp is of particular importance because trainings may improve knowledge, which may in turn be passed on to ANC clients during health education sessions. It will thus be worthwhile to ensure that health workers receive training on IPTp periodically. However, Mubyazi et al also points out that training health workers should not be seen as an absolute solution to the problems with IPTp delivery and coverage in isolation of other concerted efforts.102

110

Supervision has been found to be helpful in strengthening communication between health

Facilities and managing authorities.97 It also identifies and addresses challenges faced by health facilities. In the current study ANC heads in both urban and rural PHCs admitted that though supervisory visits from the State Ministry of Health were not frequent, in the last one year, they have had at least one visit from either the MOH or a designated officer from the State Primary

Health Care Management board but these were not specific for IPTp. In addition, the RBM

Manager carried out frequent supervisory visits in the rural group probably because she was charged with the responsibility of supplying SP tablets to the PHCs. Similar findings were reported in a related study carried out in a predominantly rural setting in Ghana, as majority of health workers interviewed admitted to having supervisory visits in the past year from the

District management team or donor agencies.54 On the contrary, a related study carried out in

Tanzania reported that none of the health workers interviewed admitted to having a supervisory visit specific to IPTp in the year preceding the study.74 Evidence from the Malaria Control

Programme in Ghana showed that supportive supervision augmented key interventions aimed at scaling up IPTp 2 coverage.97 Monitoring and supervision should thus be promoted at the PHCs to strengthen communication between appropriate authorities and health facilities to identify and address issues faced by facilities.

With regards to health workers knowledge of IPTp, the current study found that most of the

ANC heads in both groups could not correctly define IPTp. Most of them just described it as being the intermittent preventive treatment of malaria but could not go further though respondents in both groups correctly identified SP tablets as the drug used for IPTp. Knowledge of the timing for IPTp 1 and 2 was generally good in both groups however no health worker identified DOT as the strategy for administration of IPTp. Similarly none of the ANC heads in

111 both groups knew what to do for women with contraindications for SP. Most of them said they would give proguanil, which is contrary to measures outlined in the National Guidelines. A study carried out in Western Nigeria which assessed health workers knowledge of IPTp found that less than a quarter of health workers interviewed, correctly defined IPTp and the timing for administration of the first and second doses.71 They also reported that only a few respondents identified DOT as the strategy for IPTp. On the contrary, a study carried out in Ghana which assessed health workers knowledge of IPTp with similar knowledge components as the index study reported that health workers in their study had a good knowledge of IPTp in about 90% of the components assessed.55 This was not surprising as the same study reported that the health workers receive training on malaria prevention periodically.

The WHO recommends that SP tablets should be made available at antenatal care clinics, so that pregnant women could have immediate access to IPTp-SP during routine ANC.12 Findings from the in-depth interview revealed that a few PHCs in both groups admitted to having at least one episode of SP stock-out within the last 6 months, which lasted for two to four weeks. During such periods, health workers either prescribe for patients to buy outside the facility or resort to using proguanil. A study carried out in Nasarawa and Cross Rivers State had similar findings.33

That study reported that health workers gave free SP tablets when available and wrote prescriptions for patients to buy when SP tablets are out of stock. It is thus difficult to determine if the women actually get SP tablets as prescribed during periods of SP stock-out. A study carried out in Tanzania found that IPTp coverage was lowest in facilities when staff were not currently dispensing SP tablets.85

112

5.2 Conclusion

This study revealed a low IPTp uptake in both urban and rural PHCs when compared with

National IPTp coverage targets. However, uptake of optimal doses of IPTp were higher in the urban compared with the rural group. A number of missed opportunities were recorded in both groups with the rural PHCs having higher proportions of missed opportunities compared with the urban PHCs.

Deviations from prescribed standards were observed in both groups, with regards to IPTp practice at the PHC. Optimal scores in both groups were recorded in areas relating to IPTp summary statistics, availability of SP tablets and SP records in ANC card. More of the urban

PHCs had IPTp practice score ≥ 50% compared with the rural PHCs.

Factors associated with use of optimal doses of IPTp were marital status in the urban and rural groups. Women who were married were more likely to have optimal doses of IPTp compared with those who are not. In addition, other significant factors associated with use of optimal doses of IPTp in the rural group were number of ANC visits and experience of previous side effects with SP tablets.

The heads of ANC interviewed in this study suggested that lack of staff training on IPTp and patients buying SP tablets were health service factors affecting IPTp uptake in the rural PHCs. In addition, most of the ANC heads in urban PHCs recommended that monitoring and supervision will enhance IPTp uptake.

113

5.3 Recommendations

In view of the findings of this study the following recommendations are hereby made:

To the ANC Attendees

1. ANC Attendees should adhere to the instructions of health workers and report back to

them if problems are encountered.

To the Government

1. The updated guidelines for intermittent preventive treatment of malaria in pregnancy

should be circulated to all levels of health care by the National Malaria control

programme.

2. The state Ministry of Health, the Primary Health Care Management board and the

Medical officer of Health should make supervisory visits more frequent and supportive.

3. IEC materials for IPTp and malaria in pregnancy should be distributed by the Ministry of

Health to the PHCs.

4. More frequent training on IPTp and malaria in pregnancy should be organized by the

Primary Health Care Management Board for all cadres of staff.

To the health workers

5. At the Health facility, SP tablets should be administered under the direct supervision of

the health worker.

6. IEC materials on MIP and IPTp should be pasted at strategic locations at the PHC.

7. Standard operating procedures for IPTp should be pasted at strategic locations at the PHC

where they will be accessible to all health workers.

8. Health Education schedules should be drawn up at the beginning of every quarter and

IPTp should be included in the schedule.

114

Further Study

Assessment of IPTp at other levels of Health facilities including the private health facility to provide a holistic picture of the current state of IPTp implementation in Rivers State is hereby recommended.

115

References

1. Tangpukdee N, Duangdee C, Wilairatana P, Krudsood S. Malaria diagnosis: a brief review. Korean J Parasitol. 2009;47(2):93–102.

2. CDC. President’s Malaria Initiative (PMI). Centre for Disease Control. Available from: http://www.cdc. gov/malaria/malariaworldwide/cdc_activities/pmi.html. (Accessed on 7th September 2013).

3. WHO. Malaria in pregnant women. World Health Organization. Available from: http:// www.who.int/malaria/ areas/high_ risk_ groups/pregnancy/en/index.html. (Accessed on 15th October 2013).

4. Menéndez C, D’Alessandro U, Ter Kuile FO. Reducing the burden of malaria in pregnancy by preventive strategies. Lancet 2007;7(2):126–35.

5. Dellicour S, Tatem AJ, Guerra CA, Snow RW, ter Kuile FO. Quantifying the number of pregnancies at risk of malaria in 2007: a demographic study. PLoS Med.; 2010; 7(1):e1000221.

6. Omer SA, Khalil EA, Sharief AH, Ali HA. Pregnancy-associated malaria in Sudan: prevalence and possible risk factors. J Biotechnol. 2010;150:426–426.

7. FMOH. National Guidelines for Diagnosis and Treatment of Malaria. Federal Ministry of Health , National Malaria and vector Control Division Abuja- Nigeria 2011. 8. FMOH .National Anti-Malaria Treatment Policy. Federal Ministry of Health 2005. Available from: http://apps.who.int/medicinedocs/documents/s18401en/s18401en.pdf. (Accessed on 3rd September 2013).

9. WHO.World Malaria Report 2014. World Health Organization 2014. Available from: http://www.who.int/malaria/publications/world_malaria_report_2014/wmr-2014-no- profiles.pdf.

10. WHO: Evidence review group, IPTp with SP, meeting report. Geneva: World Health Organization;2012. Available from: http://www.who.int/malaria/mpac/sep2012/iptp_ sp_erg_meeting_report_july2012.pdf. (Accessed on 3rd September 2013).

11. Onoka CA, Hanson K, Onwujekwe OE. Low coverage of intermittent preventive treatment for malaria in pregnancy in Nigeria: demand-side influences. Malar J. 2012 ;11(1):82.

12. WHO. Updated WHO Policy Recommendation on Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP). Updat Policy Recomm. 2012. World Health Organization 2012.

116

13. Obionu CN. Primary Health Care for developing countries. 2nd edition. Enugu. Evans Printing and publishing;1996. p. 92.

14. FMOH. National Malria Strategic Plan 2014-2020. Malaria Elimination Programme. Federal Ministry of Health 2014.

15. Nigeria Demographic and Health Survey 2013 report. Available from: https:// dhsprogram.com/pubs/pdf/FR293/FR293.pdf.(Accessed 11th March 2014).

16. Onoka CA, Onwujekwe OE, Hanson K, Uzochukwu BS. Sub-optimal delivery of intermittent preventive treatment for malaria in pregnancy in Nigeria: influence of provider factors. Malar J. 2012;11(1):317.

17. Amoran OE, Ariba AA, Iyaniwura CA. Determinants of intermittent preventive treatment of malaria during pregnancy (IPTp) utilization in a rural town in Western Nigeria. Reprod Health.; 2012;9(1):12.

18. Exavery A, Mbaruku G, Mbuyita S, Makemba A, Kinyonge IP, Kweka H. Factors affecting uptake of optimal doses of sulphadoxine-pyrimethamine for intermittent preventive treatment of malaria in pregnancy in six districts of Tanzania. Malar J. 2014;13(1):22.

19. Kibusi SM, Kimunai E, Hines CS. Predictors for uptake of intermittent preventive treatment of malaria in pregnancy (IPTp) in Tanzania. BMC Public Health.; 2015;15(1): 540.

20. USAID. At the Crossroads of Malaria and Antenatal Care, IPTp-SP is Saving Newborn Lives|MCHIP. US Agency for International Development. Available from: http:// www.mchip.net/node/1552 . (Accessed on 4th September 2013).

21. Chessed G, Obak E.O, Yako A.B, Egbuacha K. Prevalence of malaria among pregnant women in Yola South Local Government Area, Adamawa State, Nigeria. Global research science journal 2013; 2(2):147-151.

22. Madukaku CU, Nosike DI, Nneoma CA. Malaria and its burden among pregnant women in parts of the Niger Delta area of Nigeria. Asian Pacific J Reprod.; 2012;1(2):147–51.

23. Schantz-Dunn J, Nour NM. Malaria and pregnancy: a global health perspective. Rev Obstet Gynecol.; 2009;2(3):186–92.

24. Nigeria Demographic and Health Survey 2010. Available from: http:// dhsprogram.com/what-we-do/survey/survey-display-392.cfm.(Accessed on 8th September 2013).

117

25. Roll Back Malaria .Executive Summary-The Global Malaria Action Plan. Roll back malaria partnership, 2008. Available from: www.rollbackmalaria.org/microsites/gmap/3- 2.html

26. MCHIP.Improving provision of quality IPTp services: Use of Rapid Results Initiative in facility-based dissemination of simplified Malaria in Pregnancy guidelines in Kenya. Maternal and Child Health Integrated Programme. Available from: http:// www.mchip.net/sites/default/files/Ngindu_FIGO_Presentation.pdf.(Accessed on 4th September 2013).

27. Uddenfeldt WU, Hastings I, Bergström S, Massawe S, Lipingu C, Brabin BJ. Increased postpartum blood loss in pregnancies associated with placental malaria. Int J Gynecol Obstet. 2007;96(3):171–5.

28. WHO. The department of making pregnancy safer regional report 2009. World Health Organization 2009. Available from: www.who.int/maternal_child_adolescent/ documents/MPSProgressReport09-FINAL.pdf

29. Tobin-West CI, Asuquo EO. Utilization of intermittent preventive treatment of malaria by pregnant women in Rivers State, Nigeria. Int J Prev Med.; 2013 ;4(1):63–71.

30. Nigeria Malaria Indicator Survey 2008. Available from: https://dhsprogram. com/pubs/pdf/MIS8/MIS8.pdf.( Accessed on 4th September 2013).

31. RMOH. Rivers State strategic Health Development plan 2010-2015. Rivers State Ministry of Health 2010. Available from: www.mamaye.org.ng/sites/default/files/ evidence/Rivers State SHDP 05.01.2011.pdf (Accessed on 11th June 2014).

32. Feachem RGA, Phillips AA, Hwang J, Cotter C, Wielgosz B, Greenwood BM, et al. Shrinking the malaria map: progress and prospects. Lancet 2010;376(9752):1566–78.

33. Diala CC, Pennas T, Marin C, Belay KA. Perceptions of intermittent preventive treatment of malaria in pregnancy (IPTp) and barriers to adherence in Nasarawa and Cross River States in Nigeria. Malar J. 2013;12(1):342.

34. Asa OO, Onayade AA, Fatusi AO, Ijadunola KT, Abiona TC. Efficacy of intermittent preventive treatment of malaria with sulphadoxine-pyrimethamine in preventing anaemia in pregnancy among Nigerian women. Matern Child Health J. 2008;12(6):692–8.

35. Aziken ME, Akubuo KK, Gharoro EP. Efficacy of intermittent preventive treatment with sulfadoxine-pyrimethamine on placental parasitemia in pregnant women in midwestern Nigeria. Int J Gynaecol Obstet. 2011;112(1):30–3.

36. Wilson NO, Ceesay FK, Obed SA, Adjei AA, Gyasi RK, Rodney P, et al. Intermittent preventive treatment with sulfadoxine-pyrimethamine against malaria and anemia in pregnant women. Am J Trop Med Hyg. 2011;85(1):12–21.

118

37. Alli L a, Isah a Y, Jamda M a, Adesokan a a. Use of Intermittent Preventive Treatment for Malaria among Pregnant Women in Kubwa , Abuja , Nigeria. Int J Trop Dis Health 2013;3(4):339–45.

38. Holtz TH, Patrick Kachur S, Roberts JM, Marum LH, Mkandala C, Chizani N, et al. Use of antenatal care services and intermittent preventive treatment for malaria among pregnant women in Blantyre District, Malawi. Trop Med Int Heal. 2004;9(1):77–82.

39. Mubyazi GM, Bygbjerg IC, Magnussen P, Olsen O, Byskov J, Hansen KS, et al. Prospects, achievements, challenges and opportunities for scaling-up malaria chemoprevention in pregnancy in Tanzania: the perspective of national level officers. Malar J. 2008;7(1):135.

40. Abodunrin O, Akande T, Osagbemi G. Awareness and perception toward referral in health care: A study of adult residents in Ilorin, Nigeria. Ann Afr Med. 2010;9(3):176.

41. RSPHCMB. Annual Report 2014. Rivers State Primary Health Care Management Board 2014.Available from: http://www.rsphcmb.org.ng/media/multimedia/Annual_ Report_ 2014.pdf. (Accessed on 11th July 2015).

42. NIH. Malaria Prevention and Control Strategies. National Institute of infectious and allergic disease 2011.Available from: www.niaid.nih.gov/topics/malaria/research/Pages/ control.aspx. (Accessed on 10th September 2013).

43. White MT, Conteh L, Cibulskis R, Ghani AC. Costs and cost-effectiveness of malaria control interventions--a systematic review. Malar J.2011;10(1):337.

44. RBM.Global Strategic Plan: Roll Back Malaria : 2005-2015. Roll Back Malaria Partnership; 2005.

45. Travassos M, Laufer MK. Antimalarial drugs: An overview. Available from: http:// www.uptodate.com/contents/antimalarial-drugs-an-overview?source=see_link. (Cited 6th September 2013).

46. WHO. A strategic framework for malaria prevention and control during pregnancy in the African region. WHO 2004. (Accessed on 15th Vovember 2013).

47. RBM. Resource mobilzation strategy for 2012-2015 phase of implementation of the Global Malaria Action Plan. Roll Back Malaria 2012. Available from: http:// www.rollbackmalaria.org/files/files/financing/GMAPFinancialStrategy.pdf. (Accessed on 25th September 2015).

48. USAID/CDC. Presidents malaria initiative, Nigeria Malaria Operational Plan FY2013.Available from: http://www.pmi.gov/countries/mops/fy13/nigeria_mop_ fy13.pdf. (Accessed on 5th September 2013).

119

49. USAID/CDC. President's Malaria Initiative Country Profile of Nigeria. Available from: http://pmi.gov/countries/profiles/nigeria_profile.pdf. (Accessed on 7th September 2013).

50. USAID/CDC.The President’s Malaria Initiative: Fifth Annual Report to Congress, April 2011. Available from: http://reliefweb.int/report/world/president%E2%80%99s-malaria- initiative-fifth-annual-report-congress-april-2011.( Accessed on 5th September 2013).

51. NMCP. Who We Are. National Malaria Control Programme. Available from: http:// www.nmcp.gov.ng/Who-We-Are.( Accessed on 5th September 2013).

52. SuNMAP. Malaria Consortium – SuNMaP: A malaria free Nigeria. Available from www.malariaconsortium.org/media-downloads/114. (Accessed on 5th September 2013).

53. FMOH. National Guidelines and Strategies for malaria control during pregnancy. Federal Ministry of Health 2014.

54. Antwi GD. Factors influencing the uptake of intermittent preventive treatment of malaria in pregnancy in the Bosomtwe district of Ghana. French Embassy Small Grants Humanities and Social Sciencess. Accra 2009. Available from www.infra- nigeria.org/IMG/pdf/ANTWI.( Accessed on 3rd September 2013).

55. Sikambale C, Halwindi H, Baboo KS. Factors Influencing Utilization of Intermittent Presumptive Treatment of Malaria ( IPTp ) Services by Pregnant Women in Sesheke District of Western Province Zambia. Medical Journal of Zambia 2013;40(1).

56. WHO. World Malaria Report 2009. World Health Organization 2009.

57. Van Eijk AM, Hill J, Alegana VA, Kirui V, Gething PW, ter Kuile FO, et al. Coverage of malaria protection in pregnant women in sub-Saharan Africa: a synthesis and analysis of national survey data. Lancet 2011;11(3):190–207.

58. Thiam S, Kimotho V, Gatonga P. Why are IPTp coverage targets so elusive in sub- Saharan Africa? A systematic review of health system barriers. Malar J. 2013;12(1):353.

59. Anchang-Kimbi JK, Achidi EA, Apinjoh TO, Mugri RN, Chi HF, Tata RB, et al. Antenatal care visit attendance, intermittent preventive treatment during pregnancy (IPTp) and malaria parasitaemia at delivery. Malar J. 2014;13:162.

60. Predictors of IPTp Uptake among Pregnant Women in the 2010-11 Zimbabwe Demographic and Health Survey [WP112] - WP112.pdf [Internet]. [cited 2015 Dec 27]. Available from: https://dhsprogram.com/pubs/pdf/WP112/WP112.pdf

61. Esu E, Effa E, Udoh E, Oduwole O, Chibuzor M, Oyo-Ita A, et al. Utilization of intermittent preventive treatment for malaria among pregnant women attending antenatal clinics in health facilities of Cross River State, Nigeria. Res Rep Trop Med. 2013; 4:29.

120

62. Gikandi PW, Noor AM, Gitonga CW, Ajanga AA, Snow RW. Access and barriers to measures targeted to prevent malaria in pregnancy in rural Kenya. Trop Med Int Health. 2008;13(2):208–17.

63. Chepkemoi Ng’etich Mutulei A. Factors Influencing the Uptake of Intermittent Preventive Treatment for Malaria in Pregnancy: Evidence from Bungoma East District, Kenya. Am J Public Heal Res. 2013;1(5):110–23.

64. Pell C, Meñaca A, Afrah NA, Manda-taylor L, Chatio S, Were F, et al. Prevention and management of malaria during pregnancy : findings from a comparative qualitative study in Ghana , Kenya and Malawi. Malar J. 2013;12:247.

65. Mubyazi G, Bloch P, Kamugisha M, Kitua A, Ijumba J. Intermittent preventive treatment of malaria during pregnancy: a qualitative study of knowledge, attitudes and practices of district health managers, antenatal care staff and pregnant women in Korogwe District, North-Eastern Tanzania. Malar J. 2005;4(1):31.

66. Mbonye AK, Yanow S, Birungi J, Magnussen P. A new strategy and its effect on adherence to intermittent preventive treatment of malaria in pregnancy in Uganda. BMC Pregnancy Childbirth 2013;13:178.

67. Andrews KG, Lynch M, Eckert E, Gutman J. Missed opportunities to deliver intermittent preventive treatment for malaria to pregnant women 2003–2013: a systematic analysis of 58 household surveys in sub-Saharan Africa. Malar J. 2015 ;14(1):521.

68. Sangaré LR, Stergachis A, Brentlinger PE, Richardson BA, Staedke SG, Kiwuwa MS, et al. Determinants of use of intermittent preventive treatment of malaria in pregnancy: Jinja, Uganda. PLoS One 2010;5(11):e15066.

69. Olaide BE, Edet E.E, Patience EA, Idang NO. Missed Opportunities for Intermittent Preventive Treatment among Pregnant Women, in a Secondary Health Facility, Cross River State, Nigeria. Journal of Life Sciences 2013;7(11):1147-58.

70. Gross K, Alba S, Schellenberg J, Kessy F, Mayumana I, Obrist B. The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania. Malar J. 2011;10(1):140.

71. Arulogun O. S, Okereke CC. Knowledge and practices of intermittent preventive treatment of malaria in pregnancy among health workers in a southwest local government area of Nigeria. J Med Med Sci. 2012;415–22.

72. Peters PJ, Thigpen MC, Parise ME, Newman RD. Safety and toxicity of sulfadoxine/ pyrimethamine: implications for malaria prevention in pregnancy using intermittent preventive treatment. Drug Saf. 2007;30(6):481–501.

121

73. Bouyou-Akotet MK, Mawili-Mboumba DP, Kombila M. Antenatal care visit attendance, intermittent preventive treatment and bed net use during pregnancy in Gabon. BMC Pregnancy Childbirth 2013;13:52.

74. Rumisha SF, Zinga MM, Fahey CA, Wei D, Bwana VM, Mlozi MRS, et al. Accessibility, availability and utilisation of malaria interventions among women of reproductive age in Kilosa district in central Tanzania. BMC Health Serv Res. 2014;14:452.

75. Yoder PS, Nsabagasani X, Eckert E, Moran A, Yé Y. Perspectives of health care providers on the provision of intermittent preventive treatment in pregnancy in health facilities in Malawi. BMC Health Serv Res. 2015;1–10.

76. Iliyasu Z, Gajida AU, Galadanci HS, Abubakar IS, Baba AS, Jibo AM, et al. Adherence to intermittent preventive treatment for malaria in pregnancy in urban Kano, northern Nigeria. Pathog Glob Health. 2012;106(6):323–9.

77. The partnership for Maternal and Child Health. Opportunities for Africa ’ s Newborns. Practical data policy and programmatic Support for Newborn Care in Africa. World Health Organization 2006. Available from www.who.int/pmnch/media/publications/ oanfullreport. (Accessed on 14th September 2014).

78. Ndyomugyenyi R, Katamanywa J. Intermittent preventive treatment of malaria in pregnancy (IPTp): do frequent antenatal care visits ensure access and compliance to IPTp in Ugandan rural communities? Trans R Soc Trop Med Hyg. 2010;104(8):536–40.

79. Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, et al. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet. 2001 ;357(9268):1565–70.

80. Marchant T, Hanson K, Nathan R, Mponda H, Bruce J, Jones C, et al. Timing of delivery of malaria preventive interventions in pregnancy: results from the Tanzania national voucher programme. J Epidemiol Community Health. 2011;65:78–82.

81. Hill J, Kazembe P. Reaching the Abuja target for intermittent preventive treatment of malaria in pregnancy in African women: a review of progress and operational challenges. Trop Med Int Health 2006;11(4):409-418.

82. Hill J, Dellicour S, Bruce J, Ouma P, Smedley J, Otieno P, et al. Effectiveness of antenatal clinics to deliver intermittent preventive treatment and insecticide treated nets for the control of malaria in pregnancy in Kenya. PLoS One 2013;8(6):e64913.

83. Olliaro PL, Delenne H, Cisse M, Badiane M, Olliaro A, Vaillant M, et al. Implementation of intermittent preventive treatment in pregnancy with sulphadoxine/pyrimethamine (IPTp-SP) at a district health centre in rural Senegal. Malar J. 2008;7:234.

122

84. Leonard N, Eric FB, Judith A-KK, Samuel W. Factors associated to the use of insecticide treated nets and intermittent preventive treatment for malaria control during pregnancy in Cameroon. Arch public Health BioMed Central 2016 ;74(1):5.

85. Anders K, Marchant T, Chambo P, Mapunda P, Reyburn H. Timing of intermittent preventive treatment for malaria during pregnancy and the implications of current policy on early uptake in north-east Tanzania. Malar J. 2008;7(1):79.

86. Akinleye SO, Falade CO, Ajayi IO. Knowledge and utilization of intermittent preventive treatment for malaria among pregnant women attending antenatal clinics in primary health care centers in rural southwest, Nigeria: a cross-sectional study. BMC Pregnancy Childbirth. 2009;9:28.

87. Oyefabi A, Sambo M, Sabitu K. Effect of primary health care workers training on the knowledge and utilization of intermittent preventive therapy for malaria in pregnancy in Zaria, Nigeria. J Med Trop. Med. 2015;17(1):4.

88. Olukemi TO, Emmanuel OA, Olusina AO. The use of intermittent preventive treatment with sulphadoxine-pyrimethamine in pregnancy in Ibadan, Nigeria: Implications for policy. Int J of Pub Health and Epid 2009;1(1):1–6.

89. Tobin-West C, Kanu EN. Factors influencing the use of malaria prevention methods among women of reproductive age in peri-urban communities of Port Harcourt, Nigeria. Niger Postgrad Med J. 2016;23:6–11.

90. Florey L.Preventing Malaria during Pregnancy in Sub-Saharan Africa: Determinants of Effective IPTp Delivery. DHS analytical studies 2013 No. 39. Calverton, Maryland USA: ICF International.Available from: https://dhsprogram.com/pubs/pdf/AS39/AS39.pdf. (Accessed on 3rd September 2014).

91. Marchant T, Nathan R, Jones C, Mponda H, Bruce J, Sedekia Y, et al. Individual, facility and policy level influences on national coverage estimates for intermittent preventive treatment of malaria in pregnancy in Tanzania. Malar J. 2008 ;7(1):260.

92. Mwandama D, Gutman J, Wolkon A, Luka M, Jafali J, Ali D, et al. The use of intermittent preventive treatment in pregnancy and insecticide-treated bed nets for malaria prevention by women of child-bearing age in eight districts in Malawi. Malar J. 2015;14(1):316.

93. Choonara S, Odimegwu CO, Elwange BC. Factors influencing the usage of different types of malaria prevention methods during pregnancy in Kenya. Afr Health Sci. 2015;15(2):413–9.

94. Tutu EO, Lawson B, Browne E. The effectiveness and perception of the use of sulphadoxine-pyrimethamine in intermittent preventive treatment of malaria in pregnancy programme in Offinso district of Ashanti region, Ghana. Malar J. 2011;10(1):385.

123

95. Bausel L, Katherine W. Treatment Uptake and Availability of Antimalarial Drugs for Intermittent Preventative Treatment in Pregnant Women in Malawi. USAID 2014. Delivery project task order 7.Available from: http://apps.who.int/medicinedocs/ documents/s22060en/s22060en.pdf.

96. Maheu-Giroux M, Castro MC. Factors affecting providers’ delivery of intermittent preventive treatment for malaria in pregnancy: a five-country analysis of national service provision assessment surveys. Malar J. 2014;13(1):440.

97. PATH. Community-based approach to intermittent preventive treatment for malaria in pregnancy in Kisumu, Kenya Exploring the value of utilizing. Programme for appropriate technology in Health 2014. (Available from www.path.org/publications/files/ MCHN_ cba_mip_kenya_chw.(Accessed on 14th April 2014).

98. WHO. Intermittent preventive treatment in pregnancy (IPTp). World Health Organization 2015. Available from www.int/malaria/areas/preventive_therapies/pregnancy/en/. (Accessed on 10th December 2015).

99. Chepkemoi N, Mutulei A, Odhiambo T. Providers’ Knowledge of the Guidelines for Intermittent Preventive Treatment for Malaria in Pregnancy: Evidence from Bungoma East District, Kenya. Am J Public Heal Res. 2014 ;2(4):125–35.

100. Ousman B, Stanislas N, Moumouni B, Mathurin D, Rachel W et al. Improving provision of malaria services through provider training in Burkina Faso. Tropical Health Matters 2015. Available from: http://malariamatters.org/improving-provision-of-malaria-services- through-provider-training-in-burkina-faso/

101. Ouma PO, Van Eijk AM, Hamel MJ, Sikuku E, Odhiambo F, Munguti K, et al. The effect of health care worker training on the use of intermittent preventive treatment for malaria in pregnancy in rural western Kenya. Trop Med Int Health. 2007;12(8):953–61.

102. Mubyazi GM, Bloch P, Byskov J, Magnussen P, Bygbjerg IC, Hansen KS. Supply- related drivers of staff motivation for providing intermittent preventive treatment of malaria during pregnancy in Tanzania: evidence from two rural districts. Malar J. 2012;11(1):48.

103. MCHIP. Successful Practices to Increase Intermittent Preventive Treatment in Ghana. Maternal Child Health Integrated programme2014. Available from www.mchip.net/sites/ default/files/Ghana_MIP_brief. (Accessed on 14th April 2014).

104. NPC. State Population. National Population Commission. Available from: http:// www.population.gov.ng/index.php/state-population. (Accessed on 14th December 2014).

105. National Bureau of Statistics. Annual abstract of statistics, 2010 Federal Republic of Nigeria. 2010;619.

124

106. Rivers State Government Official Website. Available from: http://www.riversstate. gov.ng /(Accessed on 1st March 2013).

107. Kirkwood BR, Sterne JAC: Essential Medical Statistics, Blackwell Science Limited, Massachusetts, USA; 2nd edition 2006, Pg 420.

108. Marilyn K Simon Ph.D., Jim G. Disertation and Scholarly Research: Recipes for Success: 2013 Edition: Createspace Independent Publishing Platform. United States of America.

109. GFTAM. Training Manual for preventive Malaria. Global Funds to fight Aids, Tuberculosis and Malaria 2005. Available from www.mohghana.org/uploadfiles/ publications/training manual for preventive Malaria_22APR2012.(Accessed on 9th September 2014).

125

Appendix I: Questionnaire For ANC Clients

Date:…………………………

QUESTIONNAIRE FOR ANC CLIENTS

Health facility Code:……………………………..

Questionnaire Code No.:…………………………

Good day ma. My name is ______. I am working with a research team to assess the determinants of intermittent preventive treatment in pregnancy (IPTp) uptake in this health facility. Your candid responses will be most helpful in improving service delivery of this intervention. Please note that you are not under any obligation to participate in this study. Should you accept to participate, your answers will be treated with utmost confidentiality. Kindly acknowledge your willingness to respond to the following questions by affixing your signature/thumb print here: ______thank you.

SECTION 1: SOCIO-DEMOGRAPHIC FACTORS

1. Age at last birthday

2. Marital Status: a. Married ( ) b. Widowed ( ) c. Single ( ) d. Co-habiting ( )

e. Divorced ( )

3. Highest level of education: a. Tertiary ( ) b. Senior Secondary ( ) c. Junior Secondary

( ) d. Primary ( ) e. No formal education ( )

4. Occupation: a. Farmer ( ) b. Trader ( ) c. Fishing/fish mongering ( ) d. Seamstress

( )e. Government worker ( ) f. Hairdresser ( ) g. Other, please specify:……..…….

126

SECTION 2: OBSTETRIC HISTORY

5. How old was your pregnancy when you registered for antenatal care?......

6. How many antenatal visits have you had? ………………………….

7. What is your present gestational age (how many months old is your pregnancy)?

......

8. How many deliveries have you ever had?......

9. How many pregnancies have you ever had? (Miscarriages, abortions and term deliveries

inclusive)……………………

SECTION 3: ACCESSIBILITY

10. How long (in minutes or hours) will it take you to get to the antenatal clinic from your

house?......

11. What is your means of transportation? a. Public transport ( ) b. Private transport ( )

12. By what means do you normally get to the Health Centre? a. Trekking b. Bicycle

c. Motorcycle d. Vehicle e. Boat f. Others please specify………………………………

SECTION 4: KNOWLEDGE OF MALARIA IPTp

S/N QUESTION YES NO DON’T CLIENT’S SCORE KNOW (incorrect knowledge = 0, Correct knowledge = 1) 13. Malaria is transmitted by

a. breathing bad air

b. eating poison

c. bite of an infected mosquito

d. sharing the same cup with another

person that has malaria

127

e. eating palm oil

f. staying in the sun

g. witch craft

14. What are the effects of malaria on the

pregnant woman?

a. Can cause death

b. Can cause loss of pregnancy/

miscarriage

c. Weight gain

d. Low blood level

15. What are the effects of malaria on the

unborn baby?

a. Abortion

b. Intra uterine death

c. Low birth weight

d. Prematurity

e. Nothing

16. A pregnant woman can protect herself

from getting malaria by

a. Taking SP tablets

b. Sleeping under long lasting

insecticide treated net

c. Using mosquito repellant

d.Wearing protective clothing

especially at night

128

S/N QUESTION YES NO DON’T CLIENT’S SCORE KNOW (incorrect knowledge = 0, Correct knowledge = 1) 17. What is the purpose of taking this

tablet? (Please show sample of SP)

a. To gain weight

b. To make my breast milk flow well

when I deliver

c. To prevent me from getting malaria

d. To give me a lot of blood

e. To cleanse my blood of all diseases

18. What is the recommended number of

doses of SP in pregnancy?

a. 1

b. 2

c. 3

d. 4

19. At what interval should the recommended number of doses be

taken?

a. Daily

b. Weekly

c. Two weekly

d. Monthly

e. Yearly

129

SECTION 5: Practice of IPTp at ANC

20. Did the nurse ever give you this medicine in this pregnancy? (Please show sample of SP)

a. Yes ( ) b. No ( )

21. If yes to 20, how many times were you given this medicine in this

pregnancy?......

22. How many times did you take these SP tablets given to you at ANC?

…………………….

23. If yes to 20, how many times did the nurse ask you to swallow this medicine in her

presence?

a. Once ( ) b. Twice ( ) c. Thrice ( ) d. Four times or more ( ) e. cannot remember (

) f. none ( )

24. If yes to question 20, how many tablets were they? a. One ( ) b. Two ( ) c. Three ( )

d. Four or more ( )

SECTION 6: Experiences with Sulphadoxine/Pyrimethamine (Fansidar)

25. Have you experienced any side effects with SP? a. Yes ( ) b. No ( )

26. If yes to 29, when did you have this experience?

a. Before pregnancy a. Yes ( ) b. No ( )

b. The first time I took it in pregnancy a. Yes ( ) b. No ( )

c. In the index pregnancy a. Yes ( ) b. No ( )

27. What was/were the side effects you experienced?

a. Nausea a. Yes ( ) b. No ( )

b. Vomiting a. Yes ( ) b. No ( )

c. Abdominal pain a. Yes ( ) b. No ( )

d. Convulsion a. Yes ( ) b. No ( )

130

e. Yellow eyes (Jaundice) a. Yes ( ) b. No ( )

f. Excessive weakness a. Yes ( ) b. No ( )

g. Others (Please specify) …………………………………………

28. What did you do?

a. Nothing a. Yes ( ) b. No ( )

b. Went to the hospital a. Yes ( ) b. No ( )

c. Went to the patent medicine vendor a. Yes ( ) b. No ( )

d. Went to the traditional birth attendant a. Yes ( ) b. No ( )

e. Others (Please specify) ………………………………………………..

131

APPENDIX II: FOCUS GROUP GUIDE FOR ANC CLIENTS

We will start by introducing ourselves.

1. What is the cause of malaria

2. How is it transmitted?

3. What are the effects of malaria on pregnant women?

4. What are the effects of malaria on the unborn baby?

5. What is IPTp?

6. Why is it done?

7. How is it done at the antenatal clinic?

8. (a) Have you experienced or heard of side effects associated with taking SP?

(b)What are they?

9. What are the reasons why a pregnant woman will not take the recommended 2 doses of

IPTp?

10. What are the suggestions you will make to improve IPTp uptake?

132

APPENDIX III: OBSERVATION CHECK LIST FOR ANC UNIT

CODE NUMBER: DATE: NAME OF FACILITY:

SN YES NO MAXIMUM FACILITY SCORE SCORE

1. Health education program drawn for the quarter includes IPTp

2. Health talk given at ANC on day of visit.

3. Presence of posters of IPTp/MIP on the wall.

4. Presence of ANC Report Book for daily summaries

5. Presence of ANC Monthly Data returns form

6. SP available at ANC

7. Practice of SP DOT observed

8. SP given is recorded in ANC report Book for daily summaries

9. SP given is recorded in ANC cards of clients

10. Presence of Adverse Event forms for SP

11. Presence of free, clean water for DOT

133

12. Availability of National antimalaria treatment policy

13. Availability of National antimalaria treatment guideline

Any additional observations made: ………………………………………………………….

134

Appendix IV: In-Depth Interview Guide for Heads of Antenatal Clinic

1. What is IPTp?

2. Why is IPTp practiced?

3. How is it to be implemented according to the National malaria treatment policy? ( Probe

to assess knowledge of drug used, frequency and interval of administered doses, side

effects of IPTp, contraindications and what is done for ANC attendees who have these

contraindications)

4. How is IPTp implemented in this facility?

5. How do you manage clients during periods of SP stock out and how often does this

occur?

6. Describe the process involved in getting SP supplies for IPTp.

7. What are the adverse events that your clients have experienced in course of practicing

IPTp-SP? How were they managed?

8. Describe the trainings your staff havehad with regards to the implementation of IPTp-SP?

How often do your staff attend these trainings?

9. How is the monitoring and supervision of the implementation of IPTP-SP carried out in

this facility?

10. In your opinion what are the health service factors affecting IPTp uptake?

11. What challenges do you face while implementing IPTp- SP?

12. Have you discussed these challenges with your supervisor? What was done?

13. What recommendation will you make to improve IPTp uptake?

135

APPENDIX V: Key informant interview guide for Roll Back Malaria officers

1. What drug is used for IPTp in this LGA?

2. Where do you get your drug supply from?

3. How do you distribute the drug the various health facilities in the LGA?

4. How do you monitor the proper use of SP at the PHC?

5. How often do you experience drug shortage?

6. What measures are taken during periods of shortage?

7. How do you obtain data on IPTp from the health facilities?

8. What do you do with this data?

136

APPENDIX VI

COMPLETE LIST (OLD AND NEW) OF HEALTH CENTRES IN RIVERS STATE

S/N LOCAL GOVERNMENT AREAS HEALTH CENTRES 1. *ABUA/ODUAL MODEL PHC AGADA 2. MODEL PHC OGBEMA 3. MODEL PHC ANYU 4. AYAMA HEALTH CENTRE 5. ARUKWO HEALTH CENTRE 6. OKOBOH HEALTH POST 7. OBARANY HEALTH POST 8. EMESU HEALTH POST 9. AMINIGBOKO COTTAGE HOSPITAL 10. EGBOLOM HEALTH POST 11. OGONOKOM HEALTH POST 12. EMOH HEALTH POST 13. IYAK HEALTH CENTRE 14. ELOK HEALTH POST 15. OTAPHA HEALTH CENTRE 16. EMELEGO HEALTH POST 17. OKOLOMADE HEALTH POST 18. OGBOLOMA HEALTH CENTRE 19. ADADA HEALTH CENTRE 20. AKANI HEALTH POST 21. AMURUTO HEALTH POST 22. EMAGO HEALTH CENTRE 23. EMIRIKPOKO HEALTH POST 24. ODAU HEALTH POST

25. *AHOADA EAST MODEL PHC AHODA 26. MODEL PHC IHUGBOGO 27. MODEL PHC OKPOROWO 28. MODEL PHC ULA-UKPATA 29. MODEL PHC IHUAJE 30. EDEOHA PHC 31. OGBELE PHC 32. ODIABIDI PHC 33. IHUOWO PHC 34. IHUABA PHC 35. OCHIGBA PHC 36. ODIEMUDIE PHC 37. UKPEREMINI PHC 38. ODIAJE PHC

137

39. OGBO PHC 40. ULA-EHUDA PHC 41. ABARIKPO PHC

42. * AHOADA WEST MODEL PHC AKINIMA 43. MODEL PHC IKODI-ENGENNI 44. OSHIE HEALTH POST 45. ODAWU HEALTH CENTRE 46. OBHOLOBHOLO HEALTH CENTRE 47. ODIEREKE UBIE HEALTH CENTRE 48. UDODA HEALTH POST 49. MBIAMA HEALTH CENTRE 50. OGBOGOLO HEALTH POST 51. ULA UBIE HEALTH POST 52. UBETA HEALTH CENTRE 53. IGOVIA HEALTH CENTRE 54. UBIO HEALTH CENTRE 55. OGBEDE HEALTH CENTRE 56. UKPELIEDE HEALTH CENTRE 57. OYIGBA HEALTH CENTRE 58. ODAWU HEALTH CENTRE 59. OKOGBE HEALTH CENTRE 60. ODIOKWU HEALTH CENTRE 61. EDAGBERI COTTAGE HOSPITAL 62. UPATABO HEALTH CENTRE 63. OKPARAKI HEALTH POST 64. EBIRIBA HEALTH CENTRE 65. AKIOGBOLOGBO HEALTH POST 66. UBARAMA HEALTH POST 67. OKARKI HEALTH CENTRE

68. *AKUKU TORU COMP PHC ABONNEMA 69. MODEL PHC OBONOMA 70. SOKU COTTAGE HOSPITAL 71. COMP HC IDAMA 72. COMP HC KULA 73. COMP HC ELEM SAGAMA 74. COMP HC ABISSA

75. *ANDONI MODEL PHC UNYEADA 76. MODEL PHC ATABA 77. MODEL PHC NGO 78. AGBALAMA HC 79. AGWUT OBOLO HC 80. AKARADI HC

138

81. ASARAMA HC 82. AJAKAJAK HC 83. EBUKUMA HC 84. EGENDEM HC 85. EKEDE HC 86. IBOTIREM HC 87. IKURU HC 88. ILOTOMBI HC 89. INYOUNG-ORONG HC 90. ISIODUM HC 91. IWOMA HC 92. ORON-IJA HC 93. OTUAFU-OTUNRIA HC 94. OKOROBOILE HC 95. OYOROKOTO HC 96. UNYANGALA HC 97. EGBOMUNG HC 98. AGBALAMA HC

99. *ASARI TORU MODEL PHC ABALAMA 100. MODEL PHC BUGUMA 101. MODEL PHC SAMA 102. MODEL IDO 103. TEMA HEALTH CENTRE 104. IFOKO HEALTH CENTRE 105. ILELEMA HEALTH CENTRE 106. OPROAMA HEALTH CENTRE 107. ANGULAMA HEALTH CENTRE 108. MINAMA HEALTH CENTRE 109. OMEKWEWAMA HEALTH CENTRE 110. SANAGAMA HEALTH CENTRE 111. COTTAGE HOSPITAL KRAKRAMA

112. *BONNY COMP HC BONNY 113. FINIMA HEALTH CENTRE 114. MODEL PHC DEMA-ABBEY 115. ABALAMABIE HEALTH CENTRE 116. INFANT WELFARE CLINIC, GEN. HOSPITAL, BONNY 117. BANIGO HEALTH CENTRE 118. PETERSIDE HEALTH CENTRE 119. GREENS HEALTH CENTRE, GREENS-IWOAMA 120. OLOMA HEALTH CENTRE 121. HALLIDAY HEALTH POST

139

122. *DEGEMA MODEL PHC OBUAMA 123. COMP HC DEGEMA 124. PHC USOKUN 125. PHC BAKANA 126. PHC OGURU-AMA 127. MPHC TOMBIA 128. PHC BUKUMA 129. PHC BILLE 130. PHC KE TOWN

131. *ELEME MODEL PHC ONNE 132. MODEL PHC EBUBU 133. MODEL ETEO 134. MODEL PHC AKPAJO 135. MODEL PHC AGBONCHIA 136. NCHIA HEALTH CENTRE 137. EKARA HEALTH CENTRE, ONNE 138. EKPORO HEALTH CENTRE 139. ALESA HEALTH POST 140. ALODE HEALTH POST 141. ALETO HEALTH POST

142. *EMOHUA MODEL PHC OGBAKIRI 143. MODEL PHC ODUOHA 144. MODEL PHC RUMUEWHOR 145. MODEL PHC IBAA 146. MODEL PHC AKPABU 147. MODEL PHC UBIMINI 148. MODEL PHC NDELE 149. MODEL PHC EGBEDA 150. RUMUJI PHC

151. *ETCHE MODEL PHC ODUFOR 152. MODEL PHC AKWA 153. MODEL PHC OKEHI (GRASSROOT) 154. OZUZU HEALTH CENTRE 155. UMUATURU HEALTH CENTRE 156. CHOKOCHO HEALTH CENTRE 157. IHIE HEALTH CENTRE 158. EGWI HEALTH CENTRE 159. AKPOKU HEALTH CENTRE 160. NIHI HEALTH CENTRE 161. NDASHI HEALTH CENTRE 162. ORWU OGIDA HEALTH CENTRE 163. ULAKWO HEALTH CENTRE 140

164. AFARA HEALTH CENTRE 165. EGBEKE HEALTH CENTRE 166. UMUOHIE HEALTH CENTRE 167. OKOROAGU HEALTH CENTRE 168. UMUAKURU HEALTH CENTRE 169. OBITE HEALTH CENTRE 170. ABARA HEALTH CENTRE 171. UMUGEREM HEALTH CENTRE 172. CHOKOTA HEALTH CENTRE 173. OPIRO HEALTH CENTRE 174. NDASHI HEALTH CENTRE 175. OKPODIM INFANT WELFARE CLINIC 176. UMUOLA HEALTH CENTRE 177. UMUCHEM HEALTH CENTRE 178. UMUOMARA HEALTH CENTRE

179. *GOKANA MODEL PHC KPOR 180. MODEL PHC BOMU 181. MODELK PHC B-DERE 182. MODEL PHC BARAKO 183. MODEL PHC YEGHE 184. MODEL PHC NWEOL 185. BODO PHC 186. LEWE PHC 187. GBE PHC 188. MOGHO PHC 189. BERA PHC 190. TERABOR PHC 191. K-DERE PHC 192. NWEBIARA PHC 193. DEEYOR PHC 194. DEKEN PHC 195. BIARRA PHC

196. *KHANA COIMP HC BORI 197. MODEL PHC BANE 198. MODEL PHC OKWALE 199. MODEL PHC TAABAA 200. MODEL PHC LUAWII 201. MODEL PHC WIIYAKARA 202. MODEL PHC OPUOKO 203. MODELK PHC BEERI 204. MODEL KPEAN 205. MODEL BARALE 206. LUEKU HC

141

207. UEGWERE HP 208. KAANI HC 209. GWARA MHC 210. KPONG HC 211. MODEL PHC NYOGOR 212. KAA HP 213. KABANGHA HP 214. TEKA SOGHO HC 215. ZOR SOGHOI HC 216. LORRE HC 217. LUEBE HC 218. YAE HP 219. BAEN HP 220. KWAWA HC 221. BETEM HC 222. LUUMENE HC 223. KAANI 1 HC

224. *IKWERRE MODEL PHC ADANTA 225. MODEL PHC IGWURUTA 226. MODEL PHC UBIMA 227. MODEL PHC OMADEME 228. MODEL PHC IPO 229. MODEL PHCAPANI 230. MODEL PHC OZUOHA 231. MODEL PHC ALUU 232. MODELPHC OMERELU 233. MODEL PHC ELELE 234. IWC ISIOKPO 235. OMAGWA HEALTH CENTRE 236. OMUNAWA HEALTH CENTRE

237. *OGU/BOLO MODEL PHC OGU 238. BOLO PHC 239. WAKAMA PHC 240. CHUKU-AMA PHC 241. IKPO-AMA PHC 242. OPU-AMA PHC 243. OWO-OGONO PHC

244. *OMUMA MODEL PHC OBIOHIA 245. MODEL PHC OYORO 246. OBIOHIA HC 247. EBERI HC 248. UMUAJULOKE HC 142

249. OFEH HC 250. UMUOGBA HC 251. OHIM OYORO HC 252. UMUOKWA HC 253. UNUNJU HC 254. UMUEZE HC 255. UMUOKE HC 256. OWUAHIAEKE HC

257. * OBIO/AKPOR MODEL PHC RUMUODUMAYA 258. MODELK PHC IRIEBE 259. MODEL PHC RUMUIGBO 260. MODEL PHC RUMUOKWURUSHI 261. MODEL PHC RUMUEME 262. MODEL PHC ENEKA 263. MODEL PHC ELIOZU 264. MODEL PHC RUMUOLUMENI 265. MODEL PHC WOJI 266. MODEL PHC RUMUEPIRIKOM 267. MODELK PHC RUKPOKWU 268. OBIO COTTAGE HOSPITAL 269. RUMUEKINI HEALTH CENTRE 270. OZUOBA HEALTH CENTRE 271. RUMUOPARAELI HEALTH POST 272. CHOBA HEALTH POST 273. COLLEGE OF HEALTH TECHNOLOGY HEALTH CENTRE 274. RUKPOKWU HEALTH POST 275. RUMUODARA HEALTH POST 276. ELELENWOI FSP HEALTH ENTRE 277. 278. *ONELGA MODEL PHC OMOKU 279. PHC NDONI 280. MODELK PHC ASE-ASAGHA 281. MODEL PHC OKWUZI 282. MODEL PHC MGBEDE 283. MODEL PHC EBOCHA 284. C.H.C NDONI 285. AGGAH HEALTH CENTRE 286. OBAGI HEALTH CENTRE 287. OBIRIKOM HEALTH CENTRE 288. OBOR HEALTH CENTRE 289. ELIETA HEALTH CENTRE 290. OHIAGUA HEALTH CENTRE 291. KIRI HEALTH CENTRE

143

292. EGBADA HEALTH CENTRE 293. AMAH HEALTH CENTRE 294. AKABTA HEALTH CENTRE 295. OBITE HEALTH CENTRE 296. IDU-OGBA HEALTH CENTRE 297. OBOBURU HEALTH CENTRE 298. OKPOSI HEALTH CENTRE 299. KREIGANI HEALTH CENTRE 300. OBIGWE HEALTH CENTRE 301. AKABUKA HEALTH CENTRE 302. OGBOGU HEALTH CENTRE

303. *OKRIKA MODEL PHC AYUNGIBIRI 304. MODEL PHC OGOLOMA 305. MODELK PHC OKOCHIRI 306. MODEL PHC IBAKA 307. MODEL PH COGAN-AMA 308. ISLAND MATERNITY FIBRESIMA 309. GEORGE-AMA HEALTH CENTRE 310. KALIO-AMA HEALTH CENTRE 311. ISAKA-AMA HEALTH CENTRE 312. OBA-AMA HEALTH CENTRE 313. OKUJAGU-AMA HEALTH CENTRE 314. I.W.C GENERAL HOSPITAL 315. OGBOGBO HEALTH CENTRE

316. *OPOBO/NKORO MODEL PHC NKORO 317. MODEL PHC QUEEN’S TOWN 318. COMPREHENSIVE HEALTH CENTRE OPOBO 319. MINIMAH HEALTH CENTRE 320. EPELLEMA HEALTH CENTRE 321. KALAIBIMA HEALTH CENTRE

322. *OYIGBO MODEL PHC OBETE 323. MODEL PHC OBEAKPU 324. MODEL PHC MIRIWANYI 325. MODEL PHC UMUSIA 326. MODEL PHC UMUAGBAI 327. COMP PHC OYIGBO 328. EGBERU HEALTH CENTRE 329. MARIHU HEALTH CENTRE

330. *PORT HARCOURT MODEL PHC NAVAL BASE 331. MODEL PHC ELEKAHIA 332. PHC OROGBUM

144

333. PHC MINI 334. PHC AMADI-AMA 335. PHC ABULOMA 336. MODEL PHC CHURCHILL ROAD 337. MODEL PHC OKURU-AMA 338. MODEL PHC AZUABIE 339. MODEL PHC BUNDU 340. MODEL PHC MGBUDUKWU 341. MODEL PHC POTTS JOHNSON 342. MODEL PHC OZUBOKO 343. EVERY WOMAN HEALTH CENTRE(MARINE BASE) 344. SICK BAY PHALGA

345. *TAI MODEL PHC BUNU 346. MODEL PHC KOROIMA 347. MODEL PHC NONWA 348. MODEL PHC KPITE 349. MODEL PHC BOTEM 350. MODEL PHC BALELE 351. BAN GOI PHC 352. BARA OBARA PHC 353. GBAM PHC 354. GBENE-UE PHC 355. GIO PHC 356. KIRA PHC 357. KOROKORO HPC 358. KPORGHOR PHC 359. UE-KEN PHC 360. SIME PHC

SUMMARY:

MODEL PHC - 109 PHC - 217 HEALTH POST - 34

145

APPENDIX VII: TRAINING MANUAL/TIME TABLE OF TRAINING

Part 1: Malaria in pregnancy

Section 1: How is malaria transmitted?

Section 2: Effect of malaria on a pregnant woman

Section 3: Effect of malaria on the unborn baby

Section 4: Strategies for controlling malaria in pregnancy

Part 2: Intermittent Preventive Treatment of Malaria in Pregnancy

Section 1: What is IPTp?

Section 2: Why is IPTp important?

Section 3: Drug for IPTp, dosage and administration

Section 4: Side effects of SP tablets

Part 3: Questionnaire administration

146

Time Table of Research Assistants Training

DAY 1 How is malaria transmitted?

Effect of malaria on a pregnant woman

Effect of malaria on the unborn baby

Strategies for controlling malaria in

pregnancy

DAY 2 What is IPTp?

Why is IPTp important?

Drug for IPTp, dosage and administration

Side effects of SP tablets

Questionnaire administration

147

APPENDIX VIII: MAP OF RIVERS STATE

148

APPENDIX IX: ETHICAL APPROVAL FROM UPTH ETHICAL COMMITTEE

149

APPENDIX X: PERMISSION FROM RIVERS STATE PRIMARY HEALTH CARE MANAGEMENT BOARD TO CARY OUT RESEARCH

150