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. Moreover, two community heads, 24 husbands from the community, 30 pregnant women attending the antenatal care units, and four health care providers working in the antenatal care units were interviewed. The age of pregnant women ranged from 17- 40 years. Most of them had primary education (50%), 35% had secondary education, and 15% had no formal education. 40% of the pregnant were from low socioeconomic status and 60% from high socioeconomic status. Similarly, 70% of the pregnant women were urban dwellers while 30% rural.
Table 2: Categories, sub-categories and themes
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Sub-categories
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Themes
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1
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Barriers of Intermittent preventive treatment use
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Malaria policies implementation
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1-1 Financial obstacles (NMD,SMC,ME)
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Inadequate budget for implementation of policies
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1-2 Political obstacles (NMD,ME,HCP)
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High population density in endemic areas, corruption in the health system
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1-3 Social obstacles (NMD,ME)
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Political reluctance
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1-4 Geographical obstacles (NMD)
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Hard to reach areas having rivers and mountains
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2
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Attendance of women for ANC care
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2-1 Education (NMD,ME,SMC,HCP)
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Low education status of pregnant women
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2-2 Husband Support (ME,HCP,PW)
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Some husbands don’t support their wives attending ANC due to cultural believes, low educational status or financial status.
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2-3 Awareness (ME,HCP,PW)
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Some pregnant women are not aware of the importance of attending ANC including the effect of Malaria in pregnancy
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3
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Distribution of IPTp in hospitals
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3-1Availability (HCP,ME,PW,H)
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IPTp is little or sometimes unavailable in public hospitals,.
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3-2 Coverage (ME,HCP)
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Low coverage of IPTp
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3-3 Monitoring of IPTp in ANC wards (NMD)
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No proper monitoring to ensure a secure supply of IPTp
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4
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Accessibility of IPTp in the communities
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4-1 Out of pocket payment for IPT (PW,H,ME,CH)
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IPT is not given for free at PHC
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5
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Facilitators of Intermittent preventive treatment use
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Strengthening IPTp service delivery
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5-1 Supervised treatment and providing relevant information to pregnant women (ME,HCP)
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Training of health care providers on IPTp, Improve the quality of services in health facilities, directly observed therapy should be done in all health facilities as a routine
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4-2 Community involvement (CH,H,ME)
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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 sub–categories, 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".
A focal person in the ANC wards of Kano public hospital explained how much the cost of IPT is a huge burden for the government. “We have about 1,200 pregnant women attending the antenatal care monthly in this hospital. In a year we have nearly up to 16,000. How much does a pack of IPTp cost, providing three packs for each of these women costs 4.8 million Naira (13,445 Dollars). So you see, providing IPTp for all pregnant women is a huge burden on the government".
1-2 Political obstacle: Two policymakers raised some important points. A malaria program focal person complained “After we finished training the health workers about malaria issues in pregnancy and how to administer IPT, a local government chairman would just come to give another task changing them from the ANC units” The other policy maker observed the utmost need for government to provide more IPT in public hospitals.
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.
2-1 Educational status: Almost all the focal persons complained bitterly about the attendance of pregnant women for the ANC compared to their actual population in Kano state. They mentioned that the turnout was not satisfying compared to other parts of the country. They believed that many factors contributed to such low education status of pregnant women, financial status, culture and support from husbands.
An expert in maternal and child health says that “About 58% of pregnant attend at least one visit of antenatal care in Kano state. Some of the pregnant women delayed the visits till their third trimester, so this will make them have one of the IPTp doses. It is there the nurses and midwives give them health talk on important issues including malaria. Their educational status determines how serious they take the antenatal visits.
2-1 Support: Policymakers and experts emphasize on male involvement in maternal care because they are the ones mostly with the resources. Malaria experts were mentioned that ‘The men should help the society by making sure that their wives are educated and also financially empowered. 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.