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Alonso Y, Lusengi W, Manun'Ebo MF, Rasoamananjaranahary AM, Rivontsoa NM, Mucavele E, Torres N, Sacoor C, Okebalama H, Agbor UJ, Nwankwo O, Meremikwu M, Roman E, Pagnoni F, Menéndez C, Munguambe K, Enguita-Fernàndez C. The social dimensions of community delivery of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria and the Democratic Republic of the Congo. BMJ Glob Health 2022; 7:bmjgh-2022-010079. [PMID: 36319032 PMCID: PMC9628536 DOI: 10.1136/bmjgh-2022-010079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/15/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Intermittent preventive treatment in pregnancy with sulphadoxine pyrimethamine (IPTp) is a key malaria prevention strategy in sub-Saharan African countries. We conducted an anthropological study as part of a project aiming to evaluate a community-based approach to the delivery of IPTp (C-IPTp) through community health workers (CHWs) in four countries (the Democratic Republic of Congo, Madagascar, Mozambique and Nigeria), to understand the social context in order to identify key factors that could influence C-IPTp acceptability. METHODS A total of 796 in-depth interviews and 265 focus group discussions were undertaken between 2018 and 2021 in the four countries with pregnant women, women of reproductive age, traditional and facility-based healthcare providers, community leaders, and relatives of pregnant women. These were combined with direct observations (388) including both community-based and facility-based IPTp delivery. Grounded theory guided the overall study design and data collection, and data were analysed following a combination of content and thematic analysis. RESULTS A series of key factors were found to influence acceptability, delivery and uptake of C-IPTp in project countries. Cross-cutting findings include the alignment of the strategy with existing social norms surrounding pregnancy and maternal health-seeking practices, the active involvement of influential and trusted actors in implementation activities, existing and sustained trust in CHWs, the influence of husbands and other relatives in pregnant women's care-seeking decision-making, the working conditions of CHWs, pregnant women's perceptions of SP for IPTp and persistent barriers to facility-based antenatal care access. CONCLUSIONS The findings provide evidence on the reported acceptability of C-IPTp among a wide range of actors, as well as the barriers and facilitators for delivery and uptake of the intervention. Overall, C-IPTp was accepted by the targeted communities, supporting the public health value of community-based interventions, although the barriers identified should be examined if large-scale implementation of the intervention is considered.
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Affiliation(s)
- Yara Alonso
- ISGlobal Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Wade Lusengi
- Bureau d'Étude et de Gestion de l'Information Statistique (BEGIS), Kinshasa, Congo
| | - Manu F Manun'Ebo
- Bureau d'Étude et de Gestion de l'Information Statistique (BEGIS), Kinshasa, Congo
| | | | | | - Estêvão Mucavele
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo, Mozambique
| | - Neusa Torres
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo, Mozambique
| | - Charfudin Sacoor
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo, Mozambique
| | - Hope Okebalama
- Cross River Health and Demographic Surveillance System, University of Calabar, Calabar, Cross River State, Nigeria
| | - Ugo James Agbor
- Cross River Health and Demographic Surveillance System, University of Calabar, Calabar, Cross River State, Nigeria
| | - Ogonna Nwankwo
- Department of Community Medicine, University of Calabar, Calabar, Cross River State, Nigeria
| | - Martin Meremikwu
- Cross River Health and Demographic Surveillance System, University of Calabar, Calabar, Cross River State, Nigeria
| | - Elaine Roman
- JHPIEGO, a Johns Hopkins University affiliate, Baltimore, Maryland, USA
| | - Franco Pagnoni
- ISGlobal Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Clara Menéndez
- ISGlobal Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,CIBER Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo, Mozambique.,Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
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Okebe J, Dabira E, Jaiteh F, Mohammed N, Bradley J, Drammeh NF, Bah A, Masunaga Y, Achan J, Muela Ribera J, Yeung S, Balen J, Peeters Grietens K, D'Alessandro U. Reactive, self-administered malaria treatment against asymptomatic malaria infection: results of a cluster randomized controlled trial in The Gambia. Malar J 2021; 20:253. [PMID: 34098984 PMCID: PMC8186162 DOI: 10.1186/s12936-021-03761-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/11/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Selectively targeting and treating malaria-infected individuals may further decrease parasite carriage in low-burden settings. Using a trans-disciplinary approach, a reactive treatment strategy to reduce Plasmodium falciparum prevalence in participating communities was co-developed and tested. METHODS This is a 2-arm, open-label, cluster-randomized trial involving villages in Central Gambia during the 2017 and 2018 malaria transmission season. Villages were randomized in a 1:1 ratio using a minimizing algorithm. In the intervention arm, trained village health workers delivered a full course of pre-packed dihydroartemisinin-piperaquine to all residents of compounds where clinical cases were reported while in the control arm, compound residents were screened for infection at the time of the index case reporting. All index cases were treated following national guidelines. The primary endpoint was malaria prevalence, determined by molecular methods, at the end of the intervention period. RESULTS The trial was carried out in 50 villages: 34 in 2017 and 16 additional villages in 2018. At the end of the 2018 transmission season, malaria prevalence was 0.8% (16/1924, range 0-4%) and 1.1% (20/1814, range 0-17%) in the intervention and control arms, respectively. The odds of malaria infection were 29% lower in the intervention than in the control arm after adjustment for age (OR 0.71, 95% CI 0.27-1.84, p = 0.48). Adherence to treatment was high, with 98% (964/979) of those treated completing the 3-day treatment. Over the course of the study, only 37 villages, 20 in the intervention and 17 in the control arm, reported at least one clinical case. The distribution of clinical cases by month in both transmission seasons was similar and the odds of new clinical malaria cases during the trial period did not vary between arms (OR 1.04, 95% CI 0.57-1.91, p = 0.893). All adverse events were classified as mild to moderate and resolved completely. CONCLUSION The systematic and timely administration of an anti-malarial treatment to residents of compounds with confirmed malaria cases did not significantly decrease malaria prevalence and incidence in communities where malaria prevalence was already low. Treatment coverage and adherence was very high. Results were strongly influenced by the lower-than-expected malaria prevalence, and by no clinical cases in villages with asymptomatic malaria-infected individuals. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov, NCT02878200. Registered 25 August 2016. https://clinicaltrials.gov/ct2/show/NCT02878200 .
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Affiliation(s)
- Joseph Okebe
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Edgard Dabira
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Fatou Jaiteh
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium
- Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | - Nuredin Mohammed
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - John Bradley
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Ndey-Fatou Drammeh
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Amadou Bah
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Yoriko Masunaga
- Medical Anthropology Unit, Institute of Tropical Medicine, Antwerp, Belgium
- Amsterdam Institute of Social Science Research, Amsterdam, The Netherlands
| | - Jane Achan
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Malaria Consortium, Cambridge Heath, London, UK
| | | | - Shunmay Yeung
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Julie Balen
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | - Umberto D'Alessandro
- Medical Research Council Unit The Gambia At the London School of Hygiene and Tropical Medicine, Fajara, The Gambia.
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