Assessing demand-side barriers to uptake of intermittent preventive treatment for malaria in pregnancy: a qualitative study in two regions of Uganda

Abstract

BackgroundTo prevent malaria infection during pregnancy in endemic areas in Africa, the World Health Organization recommends the administration of intermittent preventive treatment in pregnancy (IPTp) as part of the focused antenatal care package. However, IPTp uptake in most countries remains low despite generally high antenatal care coverage and increased efforts by governments to address known bottlenecks such as drug stock-outs. The study explored factors that continue to impede uptake of IPTp among women who attend antenatal care. This paper focuses on demand-side barriers with regard to accessibility, affordability and acceptability.MethodsThe research was conducted in 2013/2014 and involved 46 in-depth interviews with four types of respondents: (i) seven district health officials; (ii) 15 health workers; (iii) 19 women who attended antenatal care; (iv) five opinion leaders. Interviews were conducted in Eastern and West Nile regions of Uganda. Data was analysed by thematic analysis.ResultsDistrict health officials and health workers cited a range of barriers relating to knowledge and attitudes among pregnant women, including lack of awareness of pregnancy-related health risks, a tendency to initiate antenatal care late, reluctance to take medication and concerns about side effects of IPTp. However, women and opinion leaders expressed very positive views of antenatal care and IPTp. They also reported that the burden of travel and cost associated with antenatal care attendance was challenging, but did not keep them from accessing a service they perceived as beneficial. The role of trust in health workers’ expertise was highlighted by all respondents and it was reported that women will typically accept IPTp if encouraged by a health worker.ConclusionsGiven the positive views of antenatal care and IPTp, high antenatal care coverage and reported low refusal rates for IPTp, supply-side issues are likely to account for the majority of missed opportunities for the provision of IPTp when women attend antenatal care. However, to increase uptake of IPTp on the demand side, health workers should be encouraged to reassure eligible women that IPTp is safe.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1589-7) contains supplementary material, which is available to authorized users.

Access to and use of preventive intermittent treatment for Malaria during pregnancy: a qualitative study in Chókwè district, Southern Mozambique

“…This is in agreement with our previously reported results in the study on IPTp-SP coverage among delivering women conducted in the same setting [17]. Similar studies conducted in Uganda and Mali also found that late and infrequent ANC attendance were important factors influencing poor uptake of IPTp-SP and other malaria preventive measures [23,24]. Therefore, barriers to early ANC seeking behaviour are extremely relevant to the understand and improve the factors that influence IPTp-SP coverage.…”

“…Some studies have reported a linkage between late and infrequent ANC attendance with pregnant women’s cultural beliefs. For example, reluctance to disclose their pregnancy early, the tendency to only starting to attend ANC when the tummy is visible, which in most of the cases happens after the fifth month and a trend to only seek help when sick [10,23,24].…”

Correlates of uptake of optimal doses of sulfadoxine-pyrimethamine for prevention of malaria during pregnancy in East-Central Uganda

“…Level of health facility where ANC was received was significantly related to uptake of IPTp-SP with those receiving ANC at lower level health facilities reporting lower uptake than those who received ANC at hospitals. This finding is in consonance with findings elsewhere which indicated that quality of basic maternal health services was poorer or absent in lower level facilities [26,27,51]. Poor uptake at this level of health facilities could possibly be due to non-adherence to protocols, stockouts of SP, overwhelming patient load and understaffing as reported [26,27].…”

“…To improve IPTp-SP coverage, there is a pertinent need for capacity building of health workers to address the supply side gaps. Additionally, the demand side gaps can be addressed through social behaviour change interventions including health education sessions at health facilities, media campaigns and community engagement during outreach activities at the community level in order to shape women's and community attitudes towards IPTp [26,27]. The findings showed that the factors associated with optimal uptake IPTp-SP in East-Central Uganda were religion, age, wealth status, level of health facility where ANC was received and place of delivery.…”

“…East-Central Uganda is an area of high malaria endemicity [24], very low contraceptive use and high fertility and teenage pregnancy rates [22] and very high rate of poverty [25]. In addition to socio-economic, demographic and health seeking factors, low uptake of IPTp-SP is likely as a result of complacence of health workers to prescribe and encourage uptake of IPTp-SP, high costs of accessing malaria prevention services, lack of awareness and late presentation for ANC, weak leadership and frequent stock-outs of medicines [26,27]. Generally, there is little information to explain the low uptake of IPTp-SP, especially for East-Central Uganda.…”