Facilitators and Barriers to Uptake of an Extended Seasonal Malaria Chemoprevention Programme in Ghana: A Qualitative Study of Caregivers and Community Health Workers

Abstract

BackgroundSeasonal Malaria Chemoprevention (SMC) is currently recommended for children under five in areas where malaria transmission is highly seasonal. We explored children’s caregivers’ and community health workers’ (CHWs) responses to an extended 5-month SMC programme.MethodsThirteen in-depth interviews and eight focus group discussions explored optimal and suboptimal ‘uptake’ of SMC to examine facilitators and barriers to caregivers’ uptake.ResultsThere did not appear to be major differences between caregivers of children with optimal and sub-optimal SMC uptake in terms of their knowledge of malaria, their perceptions of the effect of SMC on a child’s health, nor their understanding of chemoprevention. Caregivers experienced difficulty in prioritising SMC for well children, perceiving medication being for treatment rather than prevention. Prior to the study, caregivers had become accustomed to rapid diagnostic testing (RDT) for malaria, and therefore blood testing for malaria during the baseline survey at the start of the SMC programme may have positively influenced uptake. Facilitators of uptake included caregivers’ trust in and respect for administrators of SMC (including CHWs), access to medication and supportive (family) networks. Barriers to uptake related to poor communication of timings of community gatherings, travel distances, absence during SMC home deliveries, and limited demand for SMC due to lack of previous experience. Future delivery of SMC by trained CHWs would be acceptable to caregivers.ConclusionA combination of caregivers’ physical access to SMC medication, the drug regimen, trust in the medical profession and perceived norms around malaria prevention all likely influenced caregivers’ level of uptake. SMC programmes need to consider: 1) developing supportive, accessible and flexible modes of drug administration including home delivery and village community kiosks; 2) improving demand for preventive medication including the harnessing of learnt trust; and 3) developing community-based networks for users to support optimal uptake of SMC.

Factors enabling community health workers and volunteers to overcome socio-cultural barriers to behaviour change: meta-synthesis using the concept of social capital

“…Community health workers and volunteers see themselves as agents of change who accompany the members of the community as they change their lives [ 18 ]. They use their local knowledge to explain health in simple terms and can address traditional false beliefs [ 14 , 16 ].…”

“…For example, an evaluation of the uptake of a malaria programme found that there were no differences in the knowledge, perceptions or understanding of the chemoprevention offered between those who took up the programme and those who had suboptimal uptake. The facilitators of uptake were rather the trust that the caregivers had for the medical experts and CHWs, the community networks that reinforced the usefulness of the programme and the learnt trust of those who were in the programme [ 18 ]. Trust is determined by the values of cooperation, empathy and open communication and was the basis of defining (in the eyes of the community) a good or bad health worker [ 26 ].…”

Preventing malaria in the Peruvian Amazon: a qualitative study in Iquitos, Peru

“…Previous studies suggest that societies that emphasize governmental responsibility for health may take low personal responsibility for protective measures and have increased passivity in terms of control [ 47 ], thereby burdening society with the cost of treating malaria. While promoting personal responsibility for general health is a well-developed approach, there is limited little research investigating its effectiveness for malaria prevention, other than a study identifying that most malaria preventive practices are personal measures (diligent bed net use, protective clothing), and that taking personal responsibility for malaria prevention empowers people to protect themselves [ 48 ]. The demand by participants for educational interventions targeted towards the most disadvantaged areas aligns with significant evidence suggesting education can increase personal responsibility for malaria prevention [ 49 ], with the probability of dying from malaria inversely related to education and income [ 50 ].…”

Are We Using the Right Approach to Change Newborn Care Practices in the Community? Qualitative Evidence From Ethiopia and Northern Nigeria

“…[17][18][19] Having an empathetic, caring, and trusting relationship with the community is considered fundamental to the workers' success. 11,14,15,[20][21][22][23] Trust comes from CHWs being embedded in the community-that is, an "insider"-whom community members identify with and have confidence in. 13,14 Being an insider also means that CHWs understand and are direct witnesses to communities' needs and challenges and are well placed to know how to address them.…”