ObjectivesTo identify factors contributing to low uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) in rural Mali.MethodsWe conducted secondary data analysis on Mali’s 2012–2013 Demographic and Health Survey (DHS) to determine the proportion of women who failed to take IPTp-SP due to ineligibility or non-attendance at antenatal care (ANC). We also identified the proportion who reported taking other or unknown medications to prevent malaria in pregnancy and those who did not know if they took any medication to prevent malaria in pregnancy. We conducted qualitative interviews, focus groups and ANC observations in six rural sites in Mali’s Sikasso and Koulikoro regions to identify reasons for missed opportunities.ResultsOur secondary data analysis found that reported IPTp-SP coverage estimates are misleading due to their dependence on a variable (“source of IPTp”) that is missing 62% of its data points. Among all women who gave birth in the two years prior to the survey, 56.2% reported taking at least one dose of IPTp-SP. Another 5.2% reported taking chloroquine, 1.9% taking another drug to prevent malaria in pregnancy, 4.4% not knowing what drug they took to prevent malaria, and 1.1% not knowing if they took any drug to prevent malaria. The majority of women who did not receive IPTp-SP were women who also did not attend ANC. Our qualitative data revealed that many health centers neither administer IPTp-SP by directly observed therapy, nor give IPTp-SP at one month intervals through the second and third trimesters, nor provide IPTp-SP free of charge. Women generally reported IPTp-SP as available and tolerable, but frequently could not identify its name or purpose, potentially affecting accuracy of responses in household surveys.ConclusionWe estimate IPTp-SP uptake to be significantly higher than stated in Mali’s 2012–13 DHS report. Increasing ANC attendance should be the first priority for increasing IPTp-SP coverage. Reducing cost and access barriers, ensuring that providers follow up-to-date guidelines, and improving patient counseling on IPTp-SP would also facilitate optimal uptake.

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Background: Breast cancer, the most common cancer among women worldwide, has a high mortality rate in low-income countries. In sub-Saharan Africa, most breast cancer patients are diagnosed with advanced disease. Some studies have quantified the time delay to diagnosis in sub-Saharan Africa, but very few have used qualitative methods to understand barriers leading to delay. This study analyses barriers throughout a breast cancer patient's pathway from symptom recognition to treatment in Mali. Method: Three focus group discussions were conducted. The model of pathways to treatment was used to structure the results into 4 time intervals: appraisal, help-seeking, diagnosis, and treatment, with a focus on barriers during each interval. Results: The main barriers during the appraisal interval were a low level of breast cancer knowledge among women, their families, and medical professionals, and during the help-seeking interval, mistrust in the community health care centers and economic hardship. Barriers during the diagnosis interval were low quality of health care services and lack of social support, and during the pretreatment interval high costs and lack of specialized services. Conclusion: Multilevel interventions are needed to ensure access, availability, and affordability of a minimum standard of care for breast cancer patients in sub-Saharan Africa.

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Inappropriate use of antimalarial drugs undermines therapeutic efficacy and promotes the emergence and spread of drug-resistant malaria. Strategies for improving compliance require accurate information about current practices. Here we describe Knowledge-Attitude-Practice surveys conducted among health providers and consumers in two Malian villages, one rural and one periurban. All sanctioned providers limited their first choices of antimalarial drug to those recommended by the national malaria control program and reported using correct dosing regimens. However, the majority of consumers in the two villages chose non-recommended treatments for malaria and reported suboptimal treatment regimens when they did use recommended drugs. Antimalarial drugs were also widely available from unsanctioned sources, often accompanied by erroneous advice on dosing regimens. This study demonstrates that even when the most peripheral health providers are well-trained in correct use of antimalarial drugs, additional measures directly targeting consumers will be required to improve drug use practices.

Background“There is no free here,” the words of a Malian husband, illustrate how perceptions of cost can deter uptake of intermittent preventive treatment of malaria in pregnancy (IPTp). The Malian Ministry of Health (MOH) recommends a minimum of three doses of IPTp at monthly intervals. However, despite a national policy that IPTp be provided free of charge, only 35 % of pregnant women receive at least one dose and less than 20 % receive two or more doses.MethodsThis study explored perceptions and experiences of IPTp cost in Mali and their impact on uptake, using qualitative interviews and focus groups with pregnant women, husbands and mothers-in-law. Study team members also interviewed and observed health workers at four health centres, two in Sikasso Region and two in Koulikoro.ResultsDespite national-level policies, actual IPTp costs varied widely at study sites—between facilities, and visits. Pregnant women may pay for IPTp, receive it free, or both at different times. Health centres often charge a lump sum for antenatal care (ANC) visits that includes both free and fee-based drugs and services. This makes it difficult for women and families to distinguish between free services and those requiring payment. As a result, some forego free care that, because it is bundled with other fee-based services and medications, appears not to be free. Varying costs also complicate household budgeting for health care, particularly as women often rely on their husbands for money. Finally, while health facilities operating under the cost-recovery model strive to provide free IPTp, their own financial constraints often make this impossible.ConclusionsBoth actual and perceived costs are currently barriers to IPTp uptake. Given the confusion around cost of services in the two study regions, more detailed national-level studies of both perceived and actual costs could help inform policy and programme decisions promoting IPTp. These studies should evaluate both quantitatively and qualitatively the cost information provided to and understood by pregnant women and their families. Meanwhile, unbundling free and fee-based services, making clear that IPTp is free, and ensuring that it is provided at no cost could help increase uptake. Free community-based distribution might be another route to increased uptake and adherence.

BackgroundThe Government of Mali and the President’s Malaria Initiative conducted a long-lasting, insecticidal net (LLIN) distribution campaign in April 2011 in the Sikasso region of Mali, with the aim of universal coverage, defined as one insecticide-treated net for every two persons. This study examines how households in post- and pre-campaign regions value and care for nets.MethodsThe study was conducted in October 2012 in Sikasso and Kayes in the southeast and western regions of Mali, respectively. The regions were purposively selected to allow for comparison between areas that had already had a mass distribution campaign (Sikasso) and areas that had not yet had a mass distribution campaign (Kayes). Study sites and households were randomly selected. Sleeping space questionnaires and structured interviews with household heads were conducted to obtain information on net use, perceived value of free nets in relation to other malaria prevention activities, and net care and repair practices.ResultsThe study included 40 households, split evenly across the two regions. Forty interviews were conducted with household heads and 151 sleeping spaces were inventoried using the sleeping space questionnaire. Nets obtained through the free distribution were reported to be highly valued in comparison to other malaria prevention strategies. Overall, net ownership and use were higher among households in areas that had already experienced a mass distribution. While participants reported using and valuing these nets, care and repair practices varied.ConclusionNational net use is high in Mali, and comparatively higher in the region covered by the universal distribution campaign than in the region not yet covered. While the Government of Mali and implementing partners have made strides to ensure high net coverage, some gaps remain related to communication messaging of correct and consistent net use throughout the year, and on improving net care and repair behaviour. By focusing on these areas as well as improved access to nets, coverage and use rates should continue to increase, contributing to improvements in malaria control.