Using equity lens to explore Malaria Intermittent Preventive Treatment in Nigeria: A Qualitative study CURRENT STATUS:

Background : Sulphadoxine pyrimethamine (SP) used as a preventive treatment for malaria is low among pregnant women in Nigeria. However, there is limited evidence on the barriers and facilitators of intermittent preventive treatment (IPTp) use in pregnant women. Thus, this study aimed to explore the barriers and facilitators of IPTp use among pregnant women in Kano state, Nigeria. Methods: This qualitative study used a conventional content analysis method. Purposeful sampling strategy was used to select study participants. A total of 14 key informant interviews were conducted with policy makers, malaria experts and health care providers. Three focus group discussions (FGD) were also conducted among pregnant women. Furthermore, separate three FGDs were conducted among husbands whom were selected using opportunistic maximum variation sampling method. The data were analyzed with MaxqDA 10 software which was used to develop the categories, subcategories and themes. Results: A total of five main categories, 13 subcategories, and 17 themes were identified. Malaria policy implementation, antenatal care attendance, accessibility of intermittent preventive treatment in the communities, strengthening IPTp service delivery were the main facilitators of IPTp use. However, political reluctance, high population density, inadequate budget to implement IPTp related policies were the main barriers of IPTp use. Conclusion: This study revealed key barriers and facilitators of the use of Intermittent preventive treatment using Sulphadoxine pyrimethamine. Our study findings suggest that any strategy for improving the of IPTp use among pregnant women should focus on political reluctance, inadequate budget and strengthen the service delivery


Background
Malaria infection during pregnancy is a major public health problem in some parts of the world It has substantial risks to pregnant mothers, their fetuses and the neonates (1). Intermittent preventive treatment of malaria in pregnancy is given at routine antenatal care visits regardless of whether the pregnant woman is infected with malaria or not (2). Intermittent preventive treatment in pregnancy (IPTp) reduces maternal malaria infection episodes, maternal and fetal anemia, placental 3 parasitaemia, low birth weight and neonatal mortality (3,4).
An estimated 11 million pregnant women living in 38 countries with moderate-to-high transmission rates in sub-Saharan Africa were infected with malaria in 2018 (5). This makes malaria infection in pregnant women 29% of all pregnancies which causes maternal and infant mortality in these countries (5). The new guidelines on antenatal care by world health organization (WHO) recommends increase in the number of contacts between care providers and pregnant women to effective malaria infection prevention in pregnant women (6). These guidelines effectively ensure more opportunities to expand IPTp-using sulphadoxine pyrimethamine (SP). However, WHO has observed a declining effort to scale-up IPTp in a number of African countries, including Nigeria (2).
Several efforts have been made in Nigeria to fight malaria through strengthen government and partners' support. In addition, several activities such as mass media campaign on long-lasting insecticidal net (LLIN) use, intermittent preventive treatment for pregnant women (IPTp), and massive scale up in malaria case management have been implemented to reduce malaria infection in pregnant women (7). However, still many researchers have reported the high prevalence of malaria in pregnancy in different parts of Nigeria, which ranges from 19.7-72.0% (8,9). The percentage of recent national surveys of pregnant women that received at least two doses of IPTp remained low across the country, but the recent report shown a slight increase from 6.5% in 2008 to 13.2% in 2010 (10). Furthermore, pooled data from facilities shown moderate coverage (18.7%) of IPTp with a wide variation of IPTp use across the regional states of Nigeria (10). The recent demographic health survey in Nigeria is also indicated that the total IPTp use was 40.4% (11), which is still low to reach to achieve a malaria free world strategy.
Quantitative studies have been used to determine the burden of malaria and risk factors that affect the use, coverage, and access to IPTp in Nigeria (12)(13)(14). However, quantitative study design could not capture the barriers and facilitators of intermittent preventive treatment (IPT) use among pregnant women. In addition, there is limited evidence in the use of qualitative approach to explore the real barriers and facilitators of IPTp use in pregnant women in Nigeria.
Thus, the current study aimed to explore the barriers and facilitators of IPTp use by pregnant women 4 from the perspectives of different stakeholders in Nigeria with an equity lens. Findings from this study provides information that could be used in malaria control program to improve IPTp use in pregnant women.

Study setting and design
This study was conducted in Kano state, located in the North West of Nigeria. Kano state is the second most populous state in the country, with an estimated 13.4 million people. The maternal mortality ratio in Kano regional state is 1,025 per 100,000 live births in 2014 (15). Malaria prevalence in Kano regional state of Nigeria is high, with an estimated prevalence of 32.4% which is above the national average (11). We chose Kano state because it is the second-most populous state in Nigeria and malaria endemic area in the country. Conventional content analysis qualitative study design was used as the research method in this study due to the inductive nature of the design.

Participants and sampling
Fourteen participants were selected from various administration levels of malaria programs for key informant interview using purposive sampling method. The sampling method was used because of the managerial position and their interaction with study participants. Focus group discussions (FGDs) comprised of pregnant women and Husbands which were homogenous regarding the sex of participants. Three FGDs were conducted with pregnant women in different antenatal units in the hospitals using maximum variation opportunistic sampling approach in selecting pregnant women.
Pregnant women differ in terms of wealth index and educational status. Three other FGDs were also conducted for husbands in the community. Each focus group was consisted 8-12 participants.

Data collection tool and study procedures
Semi-structured key informant and focus group discussion interview guides were developed and used for data collection. The topics covered in the interview include major challenges hindering the implementation of IPTp policies, attendance of women for ANC care, IPTp distribution in ANC units, accessibility of IPTp in the communities, knowledge of malaria adverse effects during pregnancy, facilitators and barriers for the uptake of IPTp. Adequate data were collected during interview and FGDs to address the study aim, because similar instances were reported by the participants and the theme was saturated.

Data processing and analysis
Data were analyzed using conventional content analysis. Some of the transcripts were first translated from the local language to English and verified by experts. The transcripts from in-depth interviews and FGDs were analyzed using a coding scheme developed from the topics. The codes were highlighted to show concepts; similar codes were summarized to form categories. Each category was defined as a sub-category and the theme was developed. The themes were linked to the research questions. The MaxqDA 10 software was used in data management and to assist in finding presentation.

Quality control and assurance
Five of the 20 interviews were double-coded by the researcher for completeness and accuracy. The interviews were given to another researcher to check the notes and codes. A discussion was done to 6 resolve discrepancies between the interviewer and the second researcher. Some interviews were taken back to the interviewee after the analysis to be sure that the words were correctly interpreted.
The interviews and data analysis were done at the same time in other to identify other areas that must be explored further and seek explanations for the unexpected results.

Results
A total of 68 key informants were interviewed in this study. One national malaria director, one state malaria coordinator, six malaria experts (three from the ministry of health and three from maternal and child health) were among the key informants.  The categories are presented as follow: Category 1: Implementation of malaria policies Table 2 shows category 1 with six sub-categories and six themes. The two most important subcategories, frequently mentioned by the participants identified were finance and political obstacles.
These sub-categories were explained by informants as follow:

1-1 Financial obstacle:
This sub-category was derived from the topics discussed with the national and Kano state malaria program coordinators. Most influential key informants believed that the major barrier for poor implementation of policies is the financial limitation.
One of them said that "The major barrier is finance limitation; the government relies on foreign aids to fight malaria which is not enough because of the high population. If you compare Nigeria with other countries that eliminated malaria, their population is less than a local government in Nigeria".

Category 2: Attendance of women for ANC
Of the four sub-categories shown in Table 2, educational status of pregnant women and husband's support were the most important. Women with these qualities will not relay all the time on her husband to visit the ANC unit.''

Category 3: Distribution of IPTp in hospitals
There were two sub-categories under IPTp distribution in hospital categories [ Table 2]. The most important sub-category was availability of IPTp in ANC wards.

3-1 Availability:
The three FGDs conducted for pregnant women in all the public hospitals showed that they didn't receive free IPTp. Some, in the Murtala Mohammed Specialist Hospital said they were given hematinic as part of the free drugs, but IPTp was not included in the package. In the Aminu Kano teaching hospital, the informants confirmed that IPTp prescribed for the pregnant by the doctors at their expense. A health care provider in Murtala Mohammed specialist hospital said: "It has been many years that we distributed IPTp and mosquito nets for pregnant women in this unit."

Category 4: Accessibility of IPTp in the communities
Under accessibility of IPTp there was only one sub-category which was out of pocket payment and mostly mentioned by the husbands interviewed from the community and community heads [ Table 2].

4-1 Out of pocket payments for IPT
The FGDs conducted in the community revealed that most of the men confirmed they did not buy IPTp for their wives when they were pregnant. Most of their reasons were ignorance and affordability. About six of them said their wives attended hospitals just for delivery. Some informants complained about the amounts they charged in primary health care (PHC) units for drugs. A community head mentioned that "We need the government to provide us with free drugs in the PHC units, especially the IPT some can't afford to pay the fees."

Category 5: Strengthening IPTp service delivery
Under strengthening IPTp service delivery main category, there were two sub-categories such as supervised treatment and providing relevant information to pregnant women and community involvement [ Table 2].

5-1 Supervised treatment:
A malaria expert mentioned supervision of treatment as an important step to facilitate the uptake and the coverage in the health facility. He said that "The training of nurses and midwives about IPTp should be given much attention because they are the best people to corporate with, in this situation, directly observed therapy should be done in all health facilities as a routine."

5-2 community involvement:
Most of the participants emphasize on its importance. A malaria expert mentioned that "Health education on IPTp use is very important in the community, it will make the pregnant women, husbands and community members know about the malaria risks during pregnancy. A community head in one of the rural areas said "We have a small group of dedicated men in this area. We use the monthly sanitation day to spray insecticide here and the people have no problem with it. We can use the same approach for IPTp.

Discussion
The findings of this qualitative study provided insight which is worth to be considered because it based on opinions and facts from key informants. The interviews were helpful in understanding that all hands of malaria stakeholders must be on deck if Nigeria wants to reach sustainable development  (16,17). The results indicate that poor ANC attendance by pregnant women, as mentioned by majority of malaria experts and health care providers, is one of the major barriers of IPTp use and delay of visit to the third trimester which leads to receive only dose. Similar studies reported from Ghana and Malawi indicated that irregular and late ANC visits are the key factors for low uptake of IPTp (18,19).
In the majority of the in-depth interviews with malaria experts were raised unavailability of SP in most of the ANC units as the main concern. This finding is similar to the previous quantitative studies reported from Southern and Western parts of the country in which free IPTp is out of stock in ANC units (20,21). In this study, most of the husbands living in the rural community did not know the significance of IPTp which intern to poor support to the women. This finding asserts the importance of awareness creation in the community through media and IPTp campaigns (22). Most of the 11 respondents in the community mentioned that the SP at the PHC units is allegedly sold to patients which the poor can't afford. However, SP is given to the pregnant women free of charge. This finding is similar to the study reported from Uganda in which women are asked to pay for SP when it is out of stock (16). Malaria experts observed the significance of community involvement to IPTp service use.
Community members should be attached to IPTp programs in such a way that the implementation committee from the PHC collaborates with the community leadership. For example, a community head suggested that SP should be distributed like mosquito nets, this is similar to the recent systematic review, which indicates the effectiveness of community delivered model of malaria interventions, including the IPTp in reducing the burden (23).
In this study, there was no indication that the pregnant women were afraid to take SP, in fact, when responding to questions about willingness to take IPTp if given, most of them agree to take SP to protect themselves and their unborn from malaria. This disagree with the findings reported from Kenya and Mali in which some women fear taking IPTp (24).

Limitations
This study has two major limitations. The first limitation is the interviews might be biased due to purposive sampling. However, this limitation was taken into consideration before sampling by assuring the diversity of participants to rule out the bias. The second limitation relates to the focus group discussion for pregnant women, which was done in the hospitals. This environment might be uncomfortable for some of the pregnant women.

Conclusion
Our findings revealed the key barriers and facilitators of the use of IPTp-SP. The main barriers were malaria policy implementation, antenatal care attendance, accessibility of intermittent preventive treatment in the communities., strengthening IPTp service delivery was the main facilitator. The finding suggests several approaches for improving the use of IPTp among pregnant women The stakeholders should create awareness and empowerment programs using different platforms through community involvement strategies to facilitate the uptake of SP. This makes the women relatively self -reliant to take the IPTp. The government should have more political will and allocate 12 more funds to fight malaria. Strengthen the service delivery system through facility initiated supervision across public hospitals and PHC units is important.