Implementation fidelity of intermittent preventive treatment with sulphadoxine pyrimethamine for malaria control in pregnant women in the ningo-prampram district of Ghana in 2018

Asare, Kwabena
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Introduction Ghana is a high malaria transmission area and malaria in pregnancy is a common form of morbidity. In line with World Health Organisation (WHO) recommendations, Ghana adopted the intermittent preventive treatment with Sulphadoxine-Pyrimethamine in pregnancy (IPTp- Sp) intervention in 2004 to control malaria in pregnancy. Due to several bottlenecks in implementation, full coverage of IPTp-Sp delivery to pregnant women has not been achieved yet. The aim of this study is to access the level of implementation fidelity of IPTp-Sp by ANC providers and investigate the associated factors. This will help inform strategies to improve the delivery of IPTp-Sp to pregnant women and improve the control of malaria in pregnancy. Methods The study used an analytical cross-sectional design which involved a retrospective review of maternal health records. The document review was done to obtain information on ANC attendance, intermittent preventive treatment (IPT) receipt and other information on mothers who had delivered in the past 18 months before the survey. Implementation fidelity outcome was defined as ANC providers’ delivery of IPTp-Sp under directly observed therapy (DOT) to pregnant women when they qualified to receive IPTp-Sp as well as non-delivery of IPTp-Sp when pregnant women did not qualify to receive. Implementation fidelity was calculated. A sensitivity analysis of IPTp-Sp delivery was also performed. Logistic regression analysis was used to investigate the relationship between participant factors and implementation fidelity of IPTp-Sp delivered by ANC providers. A generalised structural equation modelling (GSEM) was used to investigate the indirect effects of participant factors on implementation fidelity of IPTp-Sp as delivered by ANC providers. Results The overall implementation fidelity of IPTp-Sp was 87.11%. The drawbacks of implementation fidelity were the non-adherence components of IPTp-Sp delivery by ANC providers. The non-adherence in IPTp-Sp delivery involved failure by ANC providers to deliver IPTp-Sp in some instances to pregnant women who were eligible to receive, the delivery of IPTp-Sp to pregnant women during the first trimester of pregnancy and the delivery of IPT to pregnant women who had received a previous dose of IPT in less than a month ago. In the logistic regression analysis, the significant determinants of implementation fidelity of IPTp-Sp included making four or more ANC visits during pregnancy (OR = 4.73, p=0.000) v compared to making less than 4 ANC visits, attending ANC according to WHO recommended schedules OR = 2.64, p=0.082) compared to an irregular ANC attendance pattern, employment status and parity. Conclusion Education and sensitisation of ANC providers are needed to increase their familiarity and knowledge of IPTp-Sp guidelines as a strategy towards achieving a higher level of implementation fidelity. Concerning ANC attendance, there should be adequate scheduling of subsequent ANC visits at first contact with pregnant women to ensure they attend ANC within the correct fidelity compliant timelines. The scheduling of ANC visits will help position pregnant women in order for them to be delivered with IPT by ANC providers with a high level of implementation fidelity. With regards to further research, this study offers an opportunity for studies that focus on the delivery of IPTp-Sp to obtain enough data to determine the eligibility status of pregnant women to receive IPTp-Sp during ANC visits. This will help reveal the actual gaps in implementation of IPTp-Sp.
A research report submitted to the faculty of health science, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of master of science in epidemiology in the field of implementation science