This study was conducted in the Ebiriogu community which is located in the Ukawu political ward in Onicha local government area (LGA) of Ebonyi State, Southeast Nigeria. it has three settlements and one public health facility, a primary health centre (PHC) which is the major source of orthodox health care services in the community. The people of Ukawu are mostly Ibos, the dominant tribe of South-East geopolitical zone of Nigeria and their major occupations include farming and trading. Ebonyi State is located in South-Eastern Nigeria with Abakaliki as the state capital. There are three senatorial zones and 13 LGAs in the state. According to the 2006 population and housing census, the population of Ebonyi state is approximately 2,176,947 with landmass of 5,935 square kilometers. Infants make up 4%, the under-five children 20% while women of childbearing age make up 22% of the population . Ebiriogu community was selected because her PHC is not supported by any development partner. This is because for supported facilities, development partners may have demand activities in the community that may confound findings from our study. Additionally, it is hoped that using a community with non-supported facilities will discourage dependence on external partners and promote sustainability in view of recent donor fatigue in Nigeria and other developing countries.
Eligible women were pregnant women in the second trimester of pregnancy or who have experienced quickening and have not had a dose of Suphadoxine-Pyrimethamine in the past one month. Pregnant women with a history of allergy to sulphur drugs, unexplained recurrent jaundice or already on cotrimoxazole prophylaxis were excluded from receiving IPTp-SP.
The study was an intervention study without control or randomization conducted in three phases: baseline, implementation, and post-implementation evaluation.
Data collection methods
At baseline, uptake of IPTp was assessed using questionnaires among 242 pregnant women and women who had given birth within six months prior to the survey. The respondents were recruited from the most patronized immunization and antenatal primary health care clinics in and around the Ebiriogu community over a 4-week period. At the PHC facility, registers were used to collect data on IPTp uptake.
Community-Directed Distributor Training
The intervention included advocacy visits and stakeholder engagements with stakeholders in the community such as Ward Development Committee (WDC) chairmen and members, community and opinion leaders (traditional heads, women group leaders, market leaders, religious leaders, PHC officer-in-charge (OIC), town union leaders, youth leaders, and opinion leaders). The community leaders were encouraged to select two trusted and acceptable female volunteer Community Directed Distributors (CDD) of IPTp-SP per settlement in the community. The CDDs were selected on the basis of being trustworthy and well-motivated individuals with at least junior secondary school education who lived and worked in the community. They should also live and/or work in easily accessible sites where pregnant women can access them for IPTp-SP and other concerns. Priority in the selection of CDDs was given to women with prior childbearing experience in order to ensure the selection of CDDs acceptable to the women.
The CDDs were trained on basic information about pregnancy, malaria, and malaria in pregnancy, estimation of gestational age, eligibility for IPTp-SP administration and side effects, proper use of insecticide treated nets (ITN), counseling of pregnant women, referral to the PHC, interviewing technique and documentation using summary forms. The training module was adapted from the National Guidelines and Strategies for Malaria Prevention and Control during Pregnancy . The training was held for three days in the community after which the CDDs were given tool kit bags containing client visitation forms, registers, ANC referral forms, and IPTp drugs. The training was conducted by the principal investigator and the OIC of the PHC. Prior to the training, the OIC received refresher training on current WHO recommendations for ANC attendance and frequency of IPTp administration. Weekly and two-weekly supportive supervision of the CDDs was conducted by the OIC and research team respectively.
The CDDs identified the pregnant women in the community, provided general counseling on pregnancy care including use of ITN and health-seeking for malaria symptoms to pregnant women and their family members available during the visits, administered IPTp-SP to eligible women and referred them for ANC for prenatal care and receipt of ITNs over a five-month period. They also followed up the pregnant women to encourage ANC attendance and ITN use. The CDDs were carried out community distribution dressed in branded T-shirts, caps and bags with educative pictures and write-ups on prevention of malaria in pregnancy. The CDDs received monthly financial token stipends for their transportation and feeding. The drug supply to CDDs was linked to the PHC in the community and was only obtained from the facility. The facility workers were instructed to capture the proportion of women who came for ANC on account of the intervention in the ANC registers.
Review meetings were held on a two-weekly basis with the CDDs. During the review meetings, drug stock and data collection documents were reviewed, field experiences and challenges shared and addressed. Every woman who received IPT from the CDDs were given a card on which doses and the dates the IPT was given was marked and this was presented whenever she visited a health facility for ANC or was due for another dose in order to avoid inappropriate multiple dosing. The CDDs also came with their own records of IPT administration and verified that pregnant women had not received IPTp in the four weeks preceding the current administration.
A community-wide awareness campaign was used to sensitize community members on general malaria prevention and specifically the prevention of malaria in pregnancy.
The sensitization held in the community hall and involved brief health talks, question and answer sessions and distribution of information and education fliers on prevention of malaria. The leaflets contained pictures and short write-ups in English and Ibo languages conveying information on the prevention of malaria in pregnancy and other preventive practices. The health talks were given in the local dialect by the principal investigator and OIC of the PHC. Additionally, platforms and meetings of social groups in the community and church-based women’s groups and community political groups (cabinet, consultation meetings) were utilized to educate community members. The community town criers were also engaged to disseminate specific messages on the prevention of malaria in pregnancy.
Five months after the intervention, a post-implementation evaluation was domed to assess the proportion of women who received various doses of IPTp-SP using records from CDDs and ANC registers. Change in ANC attendance following the intervention was also computed from the PHC. Satisfaction with community-directed distribution of IPTp and the CDD services was also assessed.
Sample Size Determination
The estimated annual population of pregnant women in the Ebiriogu community calculated as 5% of the total population in the community was 303 as obtained from the Ebonyi State Primary Health Care Development Agency. Since the study was conducted over five months, about half of this (152 pregnant women) was used as the minimum target population for the IPTp-SP distribution
Data management and analysis
Measurement of Variables and Statistical Analysis
The independent variables include the socio-demographic and clinical characteristics of the participants (age, marital status, gestational age of pregnancy and presence of quickening, parity, history of Suphadoxine-Pyrimethamine administration within the last four weeks, antenatal attendance). The dependent variables were the proportion of women who received different doses of IPTp-SP, ITN use, and satisfaction with CDD services. Frequencies and proportions were calculated for categorical variables while means and standard deviations were calculated for quantitative variables. Pre-intervention and post-intervention proportions were compared using chi-square. The level of significance was set at p <0.05 and confidence interval at 95%. The 4th-month post-intervention was used to compare with baseline ANC use, ITN ownership, and use and fever during pregnancy because this was the month in which the highest number of women received IPTp-SP.
The IBM Statistical Package for Social Sciences (SPSS) version 20 was used for data entry and analysis. Frequency tables and figures were used to present the study findings.