This study followed a quasi-experimental design with a control and intervention arm and it was conducted at two union councils of Tharparkar. Tharparkar is considered a backward community with people belonging to low socioeconomic strata and it constitutes biggest desert area of Sindh, Pakistan. Each UC has 5 villages with estimated population of 30,000 and they access health services from Basic Health Units present in their community(17). The study took place from January to November 2019.
Health Education based Intervention: The intervention group with 100 women in one selected UC has received one and half-hour health education session per week for eight weeks with a total duration of health education of twelve hours. Researchers have developed modules for education session, which cover health education and were based on behavioural theories. Each session followed a separate module. There were a total of four modules which covered topics such as malaria transmission, clinical features of malaria, complications caused due to malaria during pregnancy, and strategies to prevent malaria during pregnancy.. These sections were named, ‘understanding malaria in pregnancy’ and ‘the main preventive measures for malaria in pregnancy’ respectively, and lasted for approximately 30 minutes. The third section was “Insecticide treated nets which lasted for about 30 minutes. Participants were oriented to the use and maintenance of their LLINs, how to prevent malaria, and how to seek medical advice in case malarial symptoms arose. The fourth section which lasted for 30 minutes, was an interactive session named, “commitment for malaria prevention during pregnancy”. During this session, real stories and scenarios with experiences of the LLIN use, as identified from previous studies were highlighted, followed by brainstorming among the participants and the facilitator(18-22).
Sample size calculation: The sample size was calculated with 80% power and alpha error of 0.50 to determine 30% improvement in use of LLINs among pregnant women after the intervention. This resulted in a sample of 200 pregnant women for this study with 100 participants in each group.
Sampling technique: A multistage random sampling technique was used in this study to select the study participants. First, the two intervention and control union councils were selected from a list of forty-four union councils in the district (Primary Sampling Unit). Next, one union council was assigned to control and the other to intervention arm. In each union council ten villages were selected from a list of villages through simple random sampling method (secondary sampling Unit) and in each village ten pregnant women were selected through simple random sampling method from the list provided by the local lady health workers. Pregnant women and mothers of children with 6 months of age were interviewed in their homes. By this way, we interviewed 200 women included in the study. Those women who were ill and did not belong to the study area at the time of the interviews were excluded (Fig.1).
Data collection: Pre and post measurements were made by modifying Malaria Indicator Survey questionnaires developed by the Roll Back Malaria Partnership Monitoring and Evaluation Reference Group. The tool was initially pre-tested by piloting on 20 pregnant women in adjacent union council with similar kind of population before the study (23). The validity and reliability of tool was established through piloting the tool prior to start the data collection process. The health education intervention was prepared and pre-tested by delivering it to a sample of 20 pregnant women in adjacent area. The intervention was delivered in local language and was appraised by a midwife, health educationist, experts in this field and an Obstetrics and Gynaecology specialist for necessary corrections and modifications. The variables include the baseline characteristics and knowledge about malaria of the selected participants at the first contact. Other variable includes health seeking behaviour of participants, training of health care workers, training of pregnant women in management of malaria. Four data collectors were trained before to start the data collection process. The data collector introduced himself/herself to the respondent and explained the objectives of the study. Pattern and time required for the interview was also conveyed to the respondent before the start of the interview.
Statistical analysis: The statistical analyses were performed to see the effect of the several individual characteristics on the outcomes of interest (knowledge and use of LLINs) by using appropriate bivariate analysis such as chi-square test for categorical variables and t-test for continuous variables. Paired and unpaired t test were used to see the effectiveness of health education with and within the groups. Main outcome of interest was knowledge about malaria and LLINs use among pregnant women. Pre-intervention survey was conducted before the intervention and post intervention survey was conducted three months after the intervention. Statistical Package Social Science version 23 was used for data analysis (24).
Ethical approval: Ethical approval was obtained from Ethics Review Committee at the Health Services Academy, Islamabad, Pakistan (F.No.7/82/2017-IERB). Written informed consent was obtained from all participants in the form of signatures or thumb impressions. The participants were assured that they would not be subject to any undue discomfort during the interview and participants were informed that they would not receive any monetary incentive for participating in the study. They had been informed of their right to refuse to participate in the study at any time during the interview. The respondents were assured of the confidentiality of the information that they provided.