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C-Channel Issue 12

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C-Channel header  September 2009

Dear Colleagues,

C-Channel No. 12, the monthly e-newsletter from C-Change, connects readers to current research findings in the peer-reviewed literature on social and behavior change communication (SBCC) in the health sector, particularly in the areas of family planning and reproductive health, HIV prevention, malaria prevention, antenatal care, maternal health, and gender norms. C-Change implements programs and conducts research in Africa, Asia, and Eastern Europe on SBCC in these health areas.

Issue No. 12 highlights research on SBCC in: family planning/reproductive health (2 articles), HIV prevention and AIDS treatment (6 articles), integration of family planning/reproductive health programs into HIV prevention and care programs (2 articles), and malaria prevention in pregnancy (1 article) and covers research carried out in Iran, Botswana, Kenya, Mozambique, Nigeria, Swaziland, Tanzania, and Uganda. The first article calls attention to the contribution by family planning programs to reducing maternal mortality throughout the developing world from 1990-2005.

C-Change/Ethiopia recently launched a malaria prevention campaign in the Oromia Region of Ethiopia. The campaign approach is based on the Champion Communities Model, which engages and motivates community members, at all levels, to work towards do-able goals within a defined period of time. Based on this model, C-Change has formed and trained Community Mobilization Committees (CMCs). The CMCs each set the goal for their kebele (ward) for earning Malaria Protection Stickers, then work towards that goal by going house-to-house, talking to community groups, and working with schools to reach their goal. To earn a Malaria Protection Sticker, families must carry out four small, do-able Essential Malaria Actions (EMA), to protect families against malaria. Every family who earns a Malaria Protection Sticker is encouraged to mentor three other families, who in turn can earn stickers. This is one of the qualities of a true Champion Community--families, friends, and neighbors are always encouraging each other to succeed. After a 3-month campaign, communities who have reached their goal are recognized as Champion Communities that are successfully protecting their families against malaria. See http://c-changeprogram.org/where-we-work/ethiopia/ for additional information.

Thank you,
The Knowledge Management Team at C-Change


To view archived issues, visit www.c-changeprogram.org/c-channel



Reproductive Health/Family Planning

1. How increased contraceptive use has reduced maternal mortality

2. Reproductive health in Iran: Pragmatic achievements, unmet needs, and ethical challenges in a theocratic system

HIV and AIDS and Reproductive Health/Family Planning

3. Contraceptive use among HIV infected women attending Comprehensive Care Centre

4. Risky sexual practices among youth attending a sexually transmitted infection clinic in Dar es Salaam, Tanzania

HIV and AIDS

5. Public knowledge and attitudes toward HIV/AIDS and antiretroviral therapy in Kabarole district, western Uganda

6. Impact of five years of peer-mediated interventions on sexual behavior and sexually transmitted infections among female sex workers in Mombasa, Kenya

7. Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland

8. Milking the cow: Young women's construction of identity and risk in age-disparate transactional sexual relationships in Maputo, Mozambique

9. Behaviour change in clients of health centre-based voluntary HIV counselling and testing services in Kenya

10. An evaluation of awareness: Attitudes and beliefs of pregnant Nigerian women toward voluntary counseling and testing for HIV

Malaria

11. Effect of a community-based delivery of intermittent preventive treatment of malaria in pregnancy on treatment seeking for malaria at health units in Uganda
 


Reproductive Health/Family Planning

1. How increased contraceptive use has reduced maternal mortality

Authors: Stover, J 1; Ross, J 2
Institutions: 1 Futures Institute, Glastonbury, CT; 2 Futures Group International, Washington, DC
Source: Maternal and Child Health Journal 30 July 2009 [PubMed; Epub ahead of print]

ABSTRACT

It is widely recognized that family planning contributes to reducing maternal mortality by reducing the number of births and, thus, the number of times a woman is exposed to the risk of mortality. Here we show evidence that it also lowers the risk per birth, the maternal mortality ratio (MMR), by preventing high-risk, high-parity births. This study seeks to quantify these contributions to lower maternal mortality as the use of family planning rose over the period from 1990 to 2005. We use estimates from United Nations organizations of MMRs and the total fertility rate (TFR) to estimate the number of births averted—and, consequently, the number of maternal deaths directly averted—as the TFR in the developing world dropped. We use data from 146 Demographic and Health Surveys on contraceptive use and the distribution of births by risk factor, as well as special country data sets on the MMR by parity and age, to explore the impacts of contraceptive use on high-risk births and, thus, on the MMR. Over 1 million maternal deaths were averted between 1990 and 2005 because the fertility rate in developing countries declined. Furthermore, by reducing demographically high-risk births in particular, especially high-parity births, family planning reduced the MMR and thus averted additional maternal deaths indirectly. This indirect effect can reduce a county’s MMR by an estimated 450 points during the transition from low to high levels of contraceptive use. Increases in the use of modern contraceptives have made and can continue to make an important contribution to reducing maternal mortality in the developing world.

Keywords: Family planning, Birth spacing, Maternal mortality ratio

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2. Reproductive health in Iran: Pragmatic achievements, unmet needs, and ethical challenges in a theocratic system

Authors: Mehryar, AH 1; Ahmad-Nia, S 2; Kazemipour, S 3
Institutions: 1 Advanced Institute for Management and Planning Research & Training, Tehran, Iran; 2 Sociology Department, Allameh-Tabatabaei University, Tehran; 3 Center for Population Studies and Research, Ministry of Science, Research & Technology, Tehran
Source: Studies in Family Planning Dec 2007, 38(4): 352-61.

ABSTRACT

Since its revival in 1989, the reproductive health and family planning program of Iran has made great strides in raising the contraceptive prevalence rate and reducing fertility. The majority of couples are using modern methods promoted and provided by the national program, although a sizable proportion of couples continue to depend on the traditional method of withdrawal. The longstanding urban-rural gap in contraceptive prevalence rates has been reduced to about 10 percent, which is mainly the result of better-educated urban couples' continued practice of withdrawal. Despite its enormous success in meeting the needs of married couples, in narrowing the urban-rural gap in access to and use of modern contraceptives, and in reducing fertility, the Iranian family planning program is open to criticism for confining its target audience to married couples and failing to address the issue of abortion. The restrictive aspects of the program are often justified on the grounds of religious values and fear of encouraging sexual promiscuity. Because of the theocratic nature of the political system and the immense power enjoyed by Shiite ulama (religious leaders), no step can be taken to address these restrictions without their implicit support and approval. This study describes some of the ethical issues facing the reproductive health program of Iran and indicates how pragmatic approaches adopted by the ruling Shiite ulama to solve some of the social and medical challenges of a rapidly modernizing society may be extended to overcome ethical hurdles faced by the reproductive health program.

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HIV and AIDS and Reproductive Health/Family Planning

3. Contraceptive use among HIV infected women attending Comprehensive Care Centre

Authors: Mutiso, SM; Kinuthia, J; Qureshi, Z
Institute: Voi District Hospital, Voi, Kenya
Source: East African Medical Journal April 2008, 85(4): 171-7.

ABSTRACT

OBJECTIVE: To determine contraceptive use among HIV infected women attending Comprehensive Care Centre at Kenyatta National Hospital.

DESIGN: Hospital based cross-sectional descriptive study.

SETTING: Comprehensive Care Centre (CCC), Kenyatta National Hospital.

SUBJECTS: The study group was non-pregnant HIV positive women on follow up at the CCC. A total of 94 HIV infected women were interviewed between May 2006 and August 2006 through a pretested interviewer administered questionnaire. Consecutive women willing to participate in the study were interviewed.

MAIN OUTCOME MEASURES: Current contraceptive use, contraceptive methods, source of contraception, reproductive intention and unmet need of family planning.

RESULTS: The mean age of the respondents was 34 years, 47.9% were married, all had formal education and 74.6% were employed. Eighty six percent of the respondents did not have reproduction intentions in the next two years; however, only 44.2% of the respondents were using contraception. Condoms were the most popular (81.5%) contraceptive method. Female condom was used by 10.5% of the respondents. Norplant was the only long-term contraceptive method and was used by only 2.6%. Dual method of contraception was practiced by 13.5% of the respondents. Majority of the respondents obtained contraceptives from private sector (42.9%) with less than 10% getting them from CCC. The unmet need for family planning among the study group was 30%. Marital status and regular sexual partner were significantly associated with contraceptive use.

CONCLUSION: Although majority of respondents did not have reproduction intentions in the next two years, use of contraception was low with only 44% being on a method. Use of long-term contraceptive methods was low among respondents. Majority of the respondents obtained contraceptives away from CCC. The unmet need for family planning was high at 30%.

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4. Risky sexual practices among youth attending a sexually transmitted infection clinic in Dar es Salaam, Tanzania

Authors: Urassa, W 1; Moshiro, C 2; Chalamilla, G 3; Mhalu, F 1; Sandstrom, E 4
Institutions: 1 Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Tanzania; 2 Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Tanzania; 3 Ilala Municipal Council, Dar es Salaam, Tanzania; 4 Karolinska Institute Stockholm, Sweden
Source: BMC Infectious Diseases 19 November 2008, 8:159.

ABSTRACT

BACKGROUND: Youth have been reported to be at a higher risk of acquiring STIs with significant adverse health and social consequences. Knowledge on the prevailing risky practices is an essential tool to guide preventive strategies.

METHODS: Youth aged between 18 and 25 years attending an STI clinic were recruited. Social, sexual and demographic characteristics were elicited using a structured standard questionnaire. Blood samples were tested for syphilis and HIV infections. Urethral, high vaginal and cervical swabs were screened for common STI agents.

RESULTS: A total of 304 youth were studied with mean age of 21.5 and 20.3 years for males and females respectively. 63.5% of youth were seeking STI care. The mean age of coitache was 16.4 and 16.2 years for males and females respectively. The first sexual partner was significantly older in females compared to male youth (23.0 vs 16.8 years) (p < 0.01). 93.2% of male youth reported more than one sexual lifetime partner compared to 63.0% of the females. Only 50% of males compared to 43% of females had ever used a condom and fewer than 8.3% of female youth used other contraceptive methods. 27.1% of pregnancies were unplanned and 60% of abortions were induced. 42.0% of female youth had received gifts/money for sexual favours. The HIV prevalence was 15.3% and 7.5% for females and males respectively. The prevalence of other STIs was relatively low. Among male youth, use of alcohol or illicit drugs was associated with increased risk of HIV infection. However, the age of sexual initiation, number of sexual partners or the age of the first sexual partner were not associated with increased risk of being HIV infected.

CONCLUSION: Most female youth seen at the STI clinic had their first sexual intercourse with older males. Youth were engaging in high risk unprotected sexual practices which were predisposing them to STIs and unplanned pregnancies. There is a great need to establish more youth-friendly reproductive health clinics, encourage consistent and correct use of condoms, delay in sexual debut and avoid older sexual partners in females.

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HIV and AIDS

5. Public knowledge and attitudes toward HIV/AIDS and antiretroviral therapy in Kabarole district, western Uganda

Authors: Kipp, WE a; Alibhai, A a; Saunders, D a; Konde-Lule, J b; Ruhunda, A c
Institutions: a Department of Public Health Sciences, School of Public Health, University of Alberta, Edmonton, Alberta, Canada; b School of Public Health, Makerere University, Kampala, Uganda; c Kabarole Research & Resource Centre, Fort Portal, Uganda
Source: AIDS Care January 2009, 21(1): 118-124. [PubMed]

ABSTRACT

A study on knowledge about HIV/AIDS and antiretroviral therapy (ART) was conducted in the general population of a rural district in western Uganda. Three hundred seventy-two participants were selected by random cluster sampling and interviewed with an interview-administered questionnaire. Data were analyzed quantitatively with descriptive, univariate and linear multivariate statistical analysis with the knowledge score about ART as the dependent variable. The results indicate that the mean knowledge was 7.7 in a scale from 0 to 13. Predictor for better ART knowledge was a higher educational status of the participants. Older participants over 50 years were less ART knowledgeable. Only 19% of the participants have been tested for HIV. The conclusions are that the ART knowledge in this population is remarkably high which is reaffirming and important for achieving a high adherence to ART. Of concern is the low proportion of persons tested for HIV in this general population. Kabarole district seems to be receptive and capable for intensifying HIV testing which is a precondition for the ART roll-out.

Keywords: HIV/AIDS; Uganda; antiretroviral therapy; knowledge

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6. Impact of five years of peer-mediated interventions on sexual behavior and sexually transmitted infections among female sex workers in Mombasa, Kenya

Authors: Luchters, S 1,2; Chersich, MF 1,2; Rinyiru, A 1; Barasa, MS 3; King'ola, N 1; Mandaliya, K 4; Bosire, W 1; Wambugu, S 3; Mwarogo, P 3; Temmerman, M 2
Institutions: 1 International Centre for Reproductive Health, Mombasa, Kenya; 2 International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, Belgium; 3 Family Health International, Nairobi, Kenya; 4 Coast Provincial General Hospital, Mombasa, Kenya
Source: BMC Public Health 29 April 2008, 8:143.

ABSTRACT

BACKGROUND: Since 2000, peer-mediated interventions among female sex workers (FSW) in Mombasa Kenya have promoted behavioural change through improving knowledge, attitudes and awareness of HIV serostatus, and aimed to prevent HIV and other sexually transmitted infection (STI) by facilitating early STI treatment. Impact of these interventions was evaluated among those who attended peer education and at the FSW population level.

METHODS: A pre-intervention survey in 2000, recruited 503 FSW using snowball sampling. Thereafter, peer educators provided STI/HIV education, condoms, and facilitated HIV testing, treatment and care services. In 2005, data were collected using identical survey methods, allowing comparison with historical controls, and between FSW who had or had not received peer interventions.

RESULTS: Over five years, sex work became predominately a full-time activity, with increased mean sexual partners (2.8 versus 4.9/week; P < 0.001). Consistent condom use with clients increased from 28.8% (145/503) to 70.4% (356/506; P < 0.001) as well as the likelihood of refusing clients who were unwilling to use condoms (OR = 4.9, 95%CI = 3.7–6.6). In 2005, FSW who received peer interventions (28.7%, 145/506), had more consistent condom use with clients compared with unexposed FSW (86.2% versus 64.0%; AOR = 3.6, 95%CI = 2.1–6.1). These differences were larger among FSW with greater peer-intervention exposure. HIV prevalence was 25% (17/69) in FSW attending ≥ 4 peer-education sessions, compared with 34% (25/73) in those attending 1–3 sessions (P = 0.21). Overall HIV prevalence was 30.6 (151/493) in 2000 and 33.3% (166/498) in 2005 (P = 0.36).

CONCLUSION: Peer-mediated interventions were associated with an increase in protected sex. Though peer-mediated interventions remain important, higher coverage is needed and more efficacious interventions to reduce overall vulnerability and risk.

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7. Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland

Authors: Weiser, SD 1,2,3; Leiter, K 1; Bangsberg, DR 2,4; Butler, LM 5; Percy-de Korte, F 1; Hlanze, Z 6; Phaladze, N 7; Iacopino, V 1,8; Heisler, M 1,9,10
Institutions: 1 Physicians for Human Rights, Cambridge, Massachusetts; 2 Epidemiology and Prevention Interventions Center, San Francisco General Hospital, University of California San Francisco, San Francisco, California; 3 Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California; 4 Positive Health Program, San Francisco General Hospital, University of California San Francisco, San Francisco, California; 5 Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; 6 Women and Law in Southern Africa Research Trust, Mbabane, Swaziland; 7 Department of Nursing, University of Botswana, Gaborone, Botswana; 8 Department of Medicine, University of Minnesota, Minneapolis, Minnesota; 9 Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan; 10 VA Center for Practice Management and Outcomes Research, Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
Source: PLoS Medicine 23 October 2007, 4(10): e260.

ABSTRACT

BACKGROUND: Both food insufficiency and HIV infection are major public health problems in sub-Saharan Africa, yet the impact of food insufficiency on HIV risk behavior has not been systematically investigated. We tested the hypothesis that food insufficiency is associated with HIV transmission behavior.

METHODS AND FINDINGS: We studied the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was associated with inconsistent condom use with a nonprimary partner (adjusted odds ratio [AOR] 1.73, 95% confidence interval [CI] 1.27-2.36), sex exchange (AOR 1.84, 95% CI 1.74-1.93), intergenerational sexual relationships (AOR 1.46, 95% CI 1.03-2.08), and lack of control in sexual relationships (AOR 1.68, 95% CI 1.24-2.28). Associations between food insufficiency and risky sex were much attenuated among men.

CONCLUSIONS: Food insufficiency is an important risk factor for increased sexual risk-taking among women in Botswana and Swaziland. Targeted food assistance and income generation programs in conjunction with efforts to enhance women's legal and social rights may play an important role in decreasing HIV transmission risk for women.

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8. Milking the cow: Young women's construction of identity and risk in age-disparate transactional sexual relationships in Maputo, Mozambique

Authors: Hawkins, K a; Price, N b; Muss, F c
Institutions: a Centre for Development Studies, Head of the Participatory Evaluation and Research Unit Options Consultancy Services Ltd, London, UK b Director of the Centre for Development Studies, Swansea University, UK c Monitoring, Evaluation and Research Population Services International, Maputo, Mozambique
Source: Global Public Health March 2009, 4(2): 169-82.

ABSTRACT

Sexual relationships between young women and older men involving economic transactions have been offered as a likely explanation for gender differences in HIV prevalence in many parts of sub-Saharan Africa. This study employed peer ethnography to explore young women's construction of social identity and risk within age-disparate transactional sexual relationships in Maputo, Mozambique. Peer ethnography, a rapid approach derived from the anthropological method and based upon training members of the target group to carry out in-depth qualitative interviews with their peers, was adopted in order to gather ethnographic data within a short timeframe to produce actionable results for the design of a communications intervention. The study highlights young women's perception of agency and power in these relationships. Through a strategy of extracting financial and material resources from men based on the power of their sexuality, young women construct a positive identity and esteem linked to perceptions of modernity and consumption and their ability to access consumer goods. Current behaviour change HIV prevention messages have little meaning in relation to young women's perceived goals, in a context in which structural conditions offer few opportunities and limited hope for a secure economic future.

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9. Behaviour change in clients of health centre-based voluntary HIV counselling and testing services in Kenya

Authors: Arthur, G 1; Nduba, V 2; Forsythe, S 3; Mutemi, R 4; Odhiambo, J 2; Gilks, C 5
Institutions: 1 Camden Primary Care Trust and University College, London, UK; 2 Center for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya; 3 National Institute of Public Health, Cuernavaca, Mexico; 4 United Nations Children’s Fund, Kenya; 5 Imperial College, London, UK
Source: Sexually Transmitted Infections December 2007, 83(7): 541-6.

ABSTRACT

OBJECTIVE: To explore behaviour change, baseline risk behaviour, perception of risk, HIV disclosure and life events in health centre-based voluntary counselling and testing (VCT) clients.

DESIGN AND SETTING: Single-arm prospective cohort with before-after design at three (one urban and two rural) government health centres in Kenya; study duration 2 years, 1999-2001.

SUBJECTS: Consecutive eligible adult clients.

MAIN OUTCOME MEASURES: Numbers of sexual partners, partner type, condom use, reported symptoms of sexually transmitted infection, HIV disclosure and life events.

RESULTS: High rates of enrollment and follow-up provided a demographically representative sample of 401 clients with mean time to follow-up of 7.5 months. Baseline indicators showed that clients were at higher risk than the general population, but reported a poor perception of risk. Clients with multiple partners showed a significant reduction of sexual partners at follow-up (16% to 6%; p<0.001), and numbers reporting symptoms of sexually transmitted infection decreased significantly also (from 40% to 15%; p<0.001). Condom use improved from a low baseline. Low rates of disclosure (55%) were reported by HIV-positive clients. Overall, no changes in rates of life events were seen.

CONCLUSION: This study suggests that significant prevention gains can be recorded in clients receiving health centre-based VCT services in Africa. Prevention issues should be considered when refining counselling and testing policies for expanding treatment programmes.

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10. An evaluation of awareness: attitudes and beliefs of pregnant Nigerian women toward voluntary counseling and testing for HIV

Authors: Okonkwo, KC 1; Reich, K 2; Alabi, AI 2; Umeike, N 2; Nachman, SA 1
Institutions: 1 Division Infectious Diseases, Department of Pediatrics, Stony Brook University, Stony Brook, New York; 2 West African AIDS Group, Ikeja, Lagos, Nigeria
Source: AIDS Patient Care & STDs 26 April 2007, 21(4): 252-60.

ABSTRACT

The rate of HIV seroprevalence in Nigeria is troublesome because it is one of the highest prevalence rates worldwide. As in most developing countries, vertical transmission from mother to child accounts for most of the HIV infections in Nigerian children. The purpose of this study was to determine the awareness, attitudes, and beliefs of pregnant Nigerian women toward voluntary counseling and testing (VCT) for HIV. Two hundred forty pregnant women in Awka, Nigeria, completed questionnaires aimed at determining their willingness to accept or reject VCT. Furthermore, participants where questioned about their knowledge of HIV infection, routes of transmission, and treatment options. The majority of the women (87%) approved of VCT; of those who approved, 93% were aware that VCT could reduce the risk of transmission of HIV to their babies. All respondents who accepted VCT were willing to be tested if results remained confidential and 89% would accept if they were tested simultaneously with their partners. 69% of the women who refused VCT attribute their refusal to the social and cultural stigmatization associated with HIV. Overall, the acceptance of VCT appears to depend on the understanding that VCT has proven benefits for the unborn child. Sociocultural factors such as stigmatization of HIV-infected individuals appears to be the major barrier toward widespread acceptance of VCT in Nigeria, thus the development of innovative health education strategies is essential for providing women with information regarding the benefits of VCT and other means of prevention of mother-to-child transmission of HIV (PMTCT).

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Malaria

11. Effect of a community-based delivery of intermittent preventive treatment of malaria in pregnancy on treatment seeking for malaria at health units in Uganda

Authors: Mbonye, AK a; Hansen, KS b; Bygbjerg, IC c; Magnussen, P d
Institutions: a Department of Community Health, Ministry of Health, Kampala, Uganda; b Department of Health Services Research, Institute of Public Health, University of Aarhus, Aarhus, Denmark; c Institute of Immunology, Microbiology and International Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; d DBL Centre for Health Research and Development, Institute of Pathobiology, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
Source: Public Health May 2008, 122(5): 516-25.

ABSTRACT

BACKGROUND: The impact of intermittent preventive treatment (IPTp) on malaria in pregnancy is well known. However, in countries where this policy is implemented, poor access and low compliance have been widely reported. Novel approaches are needed to deliver this intervention.

OBJECTIVE: To assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers can administer IPTp with sulphadoxine-pyrimethamine (SP) to pregnant women, reach those at greatest risk of malaria, and increase access and compliance with IPTp.

STUDY DESIGN: An intervention study compared the delivery of IPTp in the community with routine delivery of IPTp at health units. The primary outcome measures were the proportion of adolescents and primigravidae accessed, and the proportion of women who received two doses of SP. The study also assessed the effect of the intervention on access to malaria treatment, antenatal care, other services and related costs.

RESULTS: More women (67.5%) received two doses of SP through the community approach compared with health units (39.9%; P<0.0001). Women who accessed IPTp in the community were at an earlier stage of pregnancy (21.0 weeks of gestation) than women who accessed IPTp at health units (23.1 weeks of gestation; P<0.0001). However, health units were visited by a higher proportion of primigravidae (23.6% vs 20.0%; P<0.04) and adolescents (28.4% vs 25.0%; P<0.03). Generally, women who accessed IPTp at health units made more visits for malaria treatment (2.6 (1.0-4.7) vs 1.8 (1.4-2.2); P<0.03). At recruitment, more women who accessed IPTp at health units sought malaria treatment compared with those who accessed IPTp in the community (56.9% vs 49.2%). However, at delivery, a high proportion of women who accessed IPTp in the community had sought malaria treatment (70.3%), suggesting the possibility that the novel approach had a positive impact on care seeking for malaria. Similarly, utilization of antenatal care, insecticide-treated nets and delivery care by women in the community was high. The total costs per woman receiving two doses of SP for IPTp were 4093 Uganda shillings (US$ 2.3) for women who accessed IPTp at health units, and 4491 Uganda shillings (US$ 2.6) for women who accessed IPTp in the community.

CONCLUSION: The community approach was effective for the delivery of IPTp, although women still accessed and benefited from malaria treatment and other services at health units. However, the costs for accessing malaria treatment and other services are high and could be a limiting factor in mitigating the burden of malaria in Uganda.

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