Barriers to malaria interventions in Ghana
Matilda Aberese-Ako is a medical anthropologist and MARCAD postdoctoral researcher at the University of Health and Allied Sciences (UHAS) in Ghana. The Malaria Research Capacity Development Consortium (MARCAD) research programme is supported by the Developing Excellence, Leadership and Training in Science in Africa (DELTAS Africa). MARCAD is one of the 11 DELTAS Africa programmes. DELTAS Africa funds collaborative networks/consortia led by Africa-based scientists to amplify Africa-led development of world-class research and scientific leaders on the continent, while strengthening African institutions. DELTAS Africa is implemented through AESA (The Alliance for Accelerating Excellence in Science in Africa), a funding, agenda setting and programme management platform created by the African Academy of Sciences (AAS) and the African Union Development Agency (AUDA-NEPAD) and with the support of Wellcome and the UK’s Department for International Development (DFID).
Malaria in pregnancy can have a devastating effect on pregnant women and their unborn children. Consequently, various intervention measures have been put in place to prevent and manage malaria among pregnant women in endemic countries such as Ghana. However, malaria continues to afflict some pregnant women. This study revealed that health system challenges, socio-cultural practices, individual attitudes and household factors influenced the use of the interventions. A holistic approach is needed such as health facilities working with communities and households to ensure effective use of interventions.
Although malaria is preventable, it remains a leading cause of illness and death in sub-Saharan Africa (SSA), which suffered 92% of malaria cases and 93% of malaria deaths worldwide in 2017. The most at-risk populations include children and pregnant women. Malaria in pregnancy is associated with negative outcomes such as illness requiring hospitalization, anemia, aborted pregnancy, low birth weight and still births, especially in first time pregnancies. In SSA, an estimated 25 million pregnant women are at risk of infection by Plasmodium falciparum annually. The World Health Organization (WHO) recommends that malaria in pregnancy (MiP) interventions be included as a component of maternal health care. Ghana adopted the following interventions in 2003: regular use of long-lasting insecticide-treated bed nets (LLINs); directly observed administration of intermittent preventive treatment (DOT) with sulphadoxine-pyrimethamine (IPTp-SP) (a full therapeutic course of antimalarial medicine given to pregnant women at routine antenatal care visits regardless of whether the recipient is infected with malaria); and prompt and effective case management of MiP. Despite this, Ghana, like other SSA countries, did not achieve the Abuja target of 100% access to IPTp and 100% use of LLINs for pregnant women by 2015. This study sought to learn how health systems and individuals, as well as environmental and socio-cultural factors, influence perceptions, attitudes and utilization of MiP interventions in Ghana.
Description of study
A qualitative anthropological study was conducted in eight health facilities and eight communities with high incidence of MiP in two administrative regions of Ghana. A postdoctoral candidate and nine research assistants collected data in two phases, using non-participant observation, in-depth interviews, focus group discussions and case studies. Study participants included health managers and administrators, health care providers, pregnant women, women who had recently delivered, opinion leaders, chiefs, herbalists, pastors, husbands and their mothers. Data collected included health facility management practices, maternal health service and prevention and management of malaria among pregnant women in health facilities. Other areas where data was collected were the study environment, community perceptions and attitudes, and practices for pregnancy and pregnancy-related diseases, including malaria. All ethical procedures were observed. Thematic and grounded theory were used in the analysis of data with the support of qualitative data analysis software Nvivo version 11.
Research outcomes and innovations
Findings of the study suggest that socio-cultural, household, individual and health system factors influenced knowledge, attitudes and utilization of malaria interventions in pregnancy.
Negative pregnancy outcomes such as miscarriage and still birth from malaria and other biomedical causes were sometimes interpreted as spiritual attacks from enemies. So pregnant women were encouraged to seek physical and spiritual protection, which resulted in women visiting prayer centres, herbalists and self-medicating using herbs. This practice contributed to delay in seeking maternal and MiP care in health facilities and compliance with treatment. However, the belief that pregnant women should not be abused and should not be starved contributed positively to the protection of pregnant women from violence and encouraged them to develop regular eating habits.
Healthcare managers reported that sometimes the National Malaria Control Programme (NMCP) failed to supply them with antimalarial drugs and supplies and the National Health Insurance Scheme delayed in reimbursing them for services provided. Healthcare Managers instituted co-payments, rationing drugs and relaxing the DOT policy, which ensured that facilities had funds to pay creditors and purchase drugs and supplies for service delivery. Women who could afford the cost of maternal and MiP services received uninterrupted services. Nevertheless, some women could not afford the cost of maternal health services so they started antenatal care (ANC) visits late or skipped ANC appointments. Consequently, some of them did not receive the recommended five+ doses of SP, others did not obtain LLINs early and some did not obtain other recommended treatment for malaria. Frontline workers felt frustrated and demotivated because they could not provide comprehensive care to clients who could not afford it.
Health system factors such as the organization of ANC services and strategies employed by health workers to administer the SP drug contributed to initial uptake. Women’s trust in the health care system and their belief that they were obliged to take SP contributed to continued uptake. However, inadequate information provided to women, stock outs and fees charged for ANC services contributed to limited access and uptake of SP. Some women were encouraged by their friends and families to attend ANC regularly, so they took in SP consistently. Other women experienced low uptake of SP because they refused to take SP, skipped ANC appointments and delayed in attending ANC.
The nature of health system, socio-cultural, economic, environmental and individual factors influenced the use of LLIN. Health facilities that promptly restocked LLINs ensured that pregnant women who attended ANC received LLINs, but facilities who failed to regularly restock LLINs could not reliably and consistently provide LLINs to women. Receiving appropriate information from health providers and encouragement from public officials improved LLIN use. Women with a history of LLIN use prior to becoming pregnant and women who had young children used LLINs consistently. Experiencing irritating effects of LLINs and preference for traditional methods to ward off mosquitoes reduced LLIN use. Pregnant women whose household and family members used LLINs were influenced positively to use them. Gender power relations between husbands and wives influenced women’s use of LLINs. The type of housing and weather conditions contributed to inconsistent use. Staying out late for business purposes and to socialize exposed pregnant women to mosquito bites, which made the use of LLINs ineffective.
Multiple factors such as the nature of the healthcare system, socio-cultural and individual influences impact the uptake of MiP interventions; therefore, effective control of MiP requires a holistic approach.
To ensure seamless delivery of services in order to achieve the goal of controlling MiP in Ghana, the Ministry of Health, Ghana Health Service, NMCP and the National Health Insurance Scheme must provide a regular supply of antimalarial drugs and medical supplies and products, as well as prompt reimbursement of funds to public, faith-based and private health facilities.
The same factors influence the uptake of the SP drug. Consequently, interventions to improve IPTp-SP uptake must focus on three levels: regular and sufficient supply of SP in health facilities; provision of appropriate and adequate information, education and communication to ANC clients to motivate them to complete five or more doses of SP, and community outreach programs to encourage early and regular ANC visits.
Intensive and regular education must be provided by health providers to pregnant women to improve their knowledge of the effects of malaria in pregnancy and MiP interventions to facilitate prompt utilization of preventive and treatment services.
Distributors of long-lasting insecticide bed nets in health facilities and communities must also provide comprehensive, culturally-appropriate information.
Facility managers must ensure that ANC managers have access to transport to reliably distribute LLINs to health facilities in order to ensure that all pregnant women who seek ANC for the first time receive them for onward use.
Positive socio-cultural beliefs should be further studied and encouraged among communities to promote healthy habits among pregnant women, while negative practices should be discouraged through extensive community education.