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 married men 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. Approximately 40% of pregnant were rural dwellers, and 60% from urban areas.
Table 2: Categories, sub-categories and themes
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Categories
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Sub-categories
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Codes
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1
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Barriers of Intermittent preventive treatment use
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Policy 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
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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 Husbands’ 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 creation (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 of IPTp (HCP,ME,PW,H)
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IPTp is little or sometimes unavailable in public hospitals,.
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3-2 Coverage of IPTp (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 IPTp (PW,H,ME,CH)
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IPTp 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, the need to 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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Findings are explained below:
Implementation of malaria policies
Financial obstacle: Most key informants revealed financial barrier as the major limitation to effective policy implementation. Based on findings, there is lack of sustainable funding for malaria programs. Governments mainly rely on foreign aids to fight malaria which is not enough, considering the high population growth of the country.
“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). Hence, providing IPTp for all pregnant women is a huge burden on the government". – (Malaria Expert from Murtala Mohammed Teaching hospital)
Political obstacle: According to stakeholders and married men reaching the entire population of Nigeria with malaria interventions requires stronger political commitment. However, participants asserted that there is poor political willingness to this course. Interviewees believe that this has contributed to insufficient investments in the provision of IPT in public hospitals. In their views, political commitment is therefore urgently needed to make further progress in the fight against malaria in the country (FGD -Married Man).
A malaria program focal person complained that “…. 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” - Policy maker (National level)
Attendance of women for ANC
Educational status:
Almost all the focal persons complained about the poor attendance of pregnant women for ANC in Kano state compared to other regions of the country. According to stakeholders, turnout is unsatisfactory and this is fascinated by the poor educational status of women in the locality.
“About 58% of pregnant women 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. Besides, it is during this visits that nurses and midwives give health talk on malaria. Their educational status contributes to their understanding in attending antenatal visits”- Malaria expert (Abdullahi Wase specialist hospital)
Poor male engagements support in maternal care: Policymakers, experts and pregnant women also emphasized on inadequate male engagements and support for maternal care, including provisions of needed financial assistance to support progress of the initiative, ensuring their wives acquire basic education on health, and more importantly going to the hospitals with the wives during ANC visit to be well-informed about the health condition of their spouse (FGD -pregnant woman). Views from experts include: ‘The men should help the society by making sure that their wives are educated and also financially empowered. Women who are resourced will always have the financial means to attend ANC.’’- Malaria expert (Aminu Kano teaching hospital)
Distribution of IPTp in hospitals
Availability of IPTp in healthcare facilities: The findings from almost all the FGDs conducted for pregnant women revealed inadequate availability of free IPTp. Informants confirmed that IPTp prescribed for the pregnant women are to be paid for thereby limiting its access and use, especially among the poor who can’t afford to pay. “we were given hematinic as part of the free drugs, but IPTp was not included in the package- (Pregnant woman-FGD). “It has been many years that we distributed free IPTp and mosquito nets for pregnant women in this unit. - Health care provider
Accessibility of IPTp
Out of pocket payments for IPT: Most of the married men interviewed confirmed that they did not buy IPTp for their wives when they were pregnant due to ignorance and lack of financial affordability (FGD-married man). Majority stated their wives attended hospitals just for delivery. Informants complained about the cost of health care especially at the primary health care (PHC) units because majority of users at that level can’t pay for the 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.”- Community Opinion Leader
Strengthening delivery of IPTp service
Supervision of treatment: Experts mentioned supervision of treatment as an important step to facilitate the uptake and coverage in the health facility. “The training of nurses and midwives about IPTp should be given much attention because they are the best people to corporate with, and in this situation, directly observed therapy should be done in all health facilities as a routine.”-Policy maker (State level)
Community participation:Most participants emphasize on the importance of community involvement. Opinions of experts were that; improved community participation is key to a successful delivery of primary health care (PHC). That is, according to them, active engagements of community members can foster effective delivery of malaria programs, including usage of IPTp. However, based on our findings, only small group of dedicated community members do promote malaria control. Participants therefore proposed that, “just as people use the monthly sanitation day to spray insecticide in the community, the same should be done to promote usage of IPTp” - Community head. This they believe “can make the pregnant women, husbands and community members know more about the malaria prevention during pregnancy”.