Preventing Malaria in Pregnancy Through Community-directed Interventions: Evidence from Akwa Ibom State, Nigeria

Published in the Malaria Journal, this article shares findings of a study to assess the degree to which community-directed interventions (CDI) can improve access to malaria prevention in pregnancy. According to the article, despite massive anti-malaria campaigns across the subcontinent, effective access to intermittent preventive treatment (IPTp) and insecticide-treated nets (ITNs) among pregnant women remain low in large parts of sub-Saharan Africa. The results presented in this article suggest that the inclusion of community-based programmes can substantially increase effective access to malaria prevention, and also increase access to formal health care access in general, and antenatal care attendance in particular in combination with supply side interventions.

In an attempt to improve effective access to malaria prevention in pregnancy, Jhpiego - an international non-profit health organisation affiliated with The Johns Hopkins University -launched the project evaluated in this paper with funding support from ExxonMobil Foundation in 2008. Six local government areas in Southern Nigeria were selected for a malaria in pregnancy prevention intervention. Three of these local government areas were selected for a complementary community-directed intervention (CDI) programme. Under the CDI programme, volunteer community-directed distributors (CDDs) were appointed by each village and trained to deliver ITNs and IPTp drugs as well as basic counselling services to pregnant women.

The primary objective of the intervention was to increase effective access to malaria prevention among pregnant women. Specific targets were increasing ITN use, and increasing access to IPTp in the form of two doses of SP during pregnancy. The effectiveness of the intervention is evaluated through five health access indicators: the probability of a woman (1) reporting to access ante-natal care (ANC) services during her pregnancy at least once; (2) reporting to have slept under a ITN during pregnancy; (3) reporting to have slept under a ITN the night before the interview; (4) reporting having taken any malaria prevention drugs; (5) reporting having taken at last two doses of SP (each dose of SP consists of three tablets).

According to the evaluation, all five outcome measures improved in both the treatment and control areas over the observation period. The most substantial improvements were observed in terms of ANC center visits and IPTp. In the control group, the fraction of women taking the proper two doses of IPTp increased from 6 percentage points to 27 percentage points; in the treatment group, the corresponding percentage of women increased from 9 percentage points to 66 percentage points. The fraction of women visiting an ANC center at least once increased from 50 to 72 percentage points, and from 69 to 0.90 percentage points in the control and treatment areas, respectively. The improvements for ITN use were more moderate, with increases of less than 5 percentage points in the control areas, and of about 10 percentage points in the treatment areas.

While ITN uptake was also increased through the CDI programme, progress was more limited compared to IPTp. This difference may be partly explained by limited availability of ITNs in some study areas; one may also view it as evidence for the slow pace at which local behaviour can be changed even if health goods are freely provided, and even if free distribution campaigns are supported by educational programmes. From a policy perspective, two things are stressed in the article: first, the additional costs generated by the CDI programme appear rather small when compared to larger health campaigns. The second is that CDI programmes do not appear to crowd out formal health care visits.

The results of this study suggest that CDI programmes may offer a simple and effective way to increase uptake of malaria prevention. In the context of malaria, CDI programmes should not try to substitute other anti-malaria programmes, but rather complement and support larger programmes by increasing the effective access to, and use of, distributed resources. Given the slow adoption of nets and preventive treatment in many areas with massive distribution campaigns, CDI strategies definitely appear a highly attractive option to improve the efficiency of these national and regional efforts. More generally, the training and involvement of community volunteers through health facility staff has the potential to strengthen ties with the formal health sector and to increase its reach into often underserved rural or marginalised communities. In the case of Akwa Ibom State, the CDI programme was considered a success both by health authorities and by local communities and their leaders, and was, as a result of the positive feedback, expanded to all six study LGAs in 2010.