Community-based delivery of intermittent preventive treatment of malaria in pregnancy in Burkina Faso: a qualitative study

Malaria remains a major public health problem worldwide, especially in sub-Saharan Africa with children under 5 years old and pregnant women among the most vulnerable [1]. The World Health Organization (WHO) recommends at least three doses of intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine–pyrimethamine (SP) at least 1 month apart, beginning as early as possible from the start of the second trimester in order to reduce pre-term deliveries, low birth weight, and neonatal deaths [2, 3]. Results from the 2014 Burkina Faso Malaria Indicator Survey (MIS) showed that 68% of recently pregnant women received the first dose of IPTp (IPTp1), 48% received IPTp2, and only 22% received IPTp3 [4].

Low uptake of IPTp has been a common phenomenon across many high-burden malaria endemic countries [1, 5, 6]. It is normally delivered during the course of ANC visits at a healthcare facility. One approach that has been considered in response is delivery of IPTp by community healthcare workers (CHWs). Delivery of malaria services by CHWs is well established for delivery of diagnosis and treatment in children under 5 years of age [7‐10] and in maternal and infant healthcare more broadly [11‐13]. Community-based delivery has specifically been shown to improve IPTp uptake among pregnant women [14, 15] including in a previous study of female CHWs based in Burkina Faso [16] as well as when CHWs were deployed to conduct active malaria testing among pregnant women [17]. The intensified delivery of IPTp through an existing CHW network has the potential to boost the percentage of women reached for the recommended number of IPTp doses and enhance ANC attendance through CHW referrals.

Burkina Faso’s existing health system includes CHWs, known locally as Agents Santé de Base Communautaire (ASBC), who are trained and supervised by facility-level health staff. The CHW approach has been operational since at least 2008. Through the national CHW and community health programme, each village in the country is expected to select two CHWs who have completed primary school; the CHWs are paid CFA 20,000 (approximately USD 35) per month. The training manual for CHWs covers reproductive and maternal health, infectious diseases, including malaria, immunization, hygiene, and nutrition [18]. Most of the work in practice is health promotion and education, since the CHWs are yet to be adequately supplied with drugs and materials. Although CHWs have been taught to provide appropriate malaria treatment, malaria drugs are only available in a few pilot communities. The normal duties of a CHW include visiting women, educating them about various health issues, and referring them to the local health facility when necessary. Providing IPTp was not among the duties performed by CHWs [19] prior to the study.

To address the challenge of low IPTp uptake, the Burkina Faso government, with support from the U.S. President’s Malaria Initiative (PMI), conducted a cluster-randomized trial to determine the effect of community based IPTp (c-IPT) distribution on IPTp uptake and ANC coverage [20]. The intervention involved training existing CHWs to implement community sensitization activities around antenatal care (ANC) and malaria in pregnancy, and to refer pregnant women to ANC for their first dose of IPTp. Based on the WHO recommendation to initiate IPTp at the beginning of the second trimester, CHWs were taught by district-level staff to bring women to ANC for IPTp1 so that trained HCWs could accurately estimate gestational age. CHWs provided subsequent monthly SP doses. In addition, for villages where there was not an existing female CHW, the team recruited a female to work in the CHW role. This trial found an increase in median doses of IPTp among pregnant women in communities with this enhanced programme. At baseline, women received a median of 2.1 doses; by endline, women received a median of 1.8 doses in the control group and 2.8 doses in the intervention group (p-value < 0.0001). The study also found a non-statistically significant increase in the proportion of women attending four ANC visits in the intervention compared to the control group (difference in differences (DiD) = 12.6%, p-value = 0.16). Despite some successes in introducing c-IPTp, more information is needed about the perspectives of facility HCWs and CHWs regarding its implementation. Thus, as a sub-component of the study, HCWs’ and CHWs’ perspectives were assessed for feedback on roll-out of the community-based IPTp programme.

To assess experiences and perceptions of facility HCWs and CHWs regarding implementation of the new c-IPTp programme, a qualitative study was conducted through in-depth interviews with facility based HCWs and CHWs using structured interview guides. Baseline interviews were conducted in May 2017 and endline interviews in August 2018 following programme introduction. The interviews were conducted in intervention areas which received the introduction of c-IPTp. The study was implemented in three of the 13 regions in Burkina Faso (Sud-Ouest [South-West], Centre-Sud [Central-South], and Centre-Est [Central-East]) with the highest rates of malaria transmission. One district was purposefully selected from each of the three regions, based upon its malaria epidemiology, low IPTp coverage, and the presence of active CHWs. The selected districts were Batié, Pô, and Ouargaye. In each district, four health facilities were purposefully chosen based on estimated number of pregnant women and IPTp2 coverage, for a total of 12 health facilities. These facilities served 59 villages in their catchment areas. Each village in the identified health catchment areas had at least two CHWs with at least one trained on malaria case management.

At baseline, interviews with staff and CHWs established the extent to which they were involved in malaria in pregnancy services. Three providers per facility were selected for interviews including the head of the health facility, one ANC provider, and one CHW supervisor. One CHW from each village was interviewed for the baseline survey with priority given to female CHWs. Interviews were constructed in a semi-structured format with discrete answers (yes, no; number of years) or short open-ended phrases that were entered in a spreadsheet for easy sorting and analysis.

At endline, interviews focused on the experiences of facility HCWs and CHWs in the intervention area with emphasis on uptake of service delivery tasks by CHWs. Interviews assessed their ability to execute assigned roles and responsibilities in order to identify key facilitators and requirements for further implementation of the c-IPTp programme in Burkina Faso (Table 1). Facility HCWs included in the interviews were the officer in charge, the person responsible for CHW supervision, and the person in charge of ANC services. For the endline interview, all HCWs present the day of the interview were included. Endline interviews were conducted at the time of a routine monthly clinic CHW supervisory meeting and included a mix of CHWs attending from the surrounding catchment area villages. The individuals interviewed at endline were not necessarily the same individuals interviewed at baseline. Throughout the programme roll-out study staff also observed programme execution.

The interviews were conducted in French by trained interviewers from both the MOH and Jhpiego. To be eligible for study participation and to provide informed consent, individuals had to be able to complete a consent form. A small number of female CHWs interviewed were not literate and thus used fingerprint to confirm informed consent. Transcript data from HCWs and CHWs interviews were coded and analysed using qualitative content analysis to identify key themes and illustrative quotes. For consistency, one person led the analysis. Codes were constructed a priori using the interview guide and analysed under major themes and sub themes using standard precepts of grounded theory [21, 22]. At endline, ATLAS.ti8 Mac was used to manage sorting of main categories. Summary statements were developed for each theme along with representative quotes.

Ethical approval for this study was obtained from the Johns Hopkins Bloomberg School of Public Health Institutional Review Board (IRB) and the local IRB in Burkina Faso. US Centers for Disease Control and Prevention (CDC) staff were determined not to be engaged in human subjects research by the Office of the Associate Director for Science at the Center for Global Health.

Information about number of interviews is summarized in Table 2 with key characteristics of those interviewed at baseline in Table 3.

IPTp is a life-saving intervention that can reduce morbidity and mortality among pregnant women and their infants. Despite long-standing recommendations, IPTp coverage has lagged, leading to efforts to explore more efficient delivery models such as community-based delivery [14, 15]. This intervention in Burkina Faso, as described in Gutman et al. was found to increase IPTp, to not reduce ANC visits [20] as had occurred in several other studies delivering c-IPTp [23, 24], and to be a safe and acceptable delivery model both from the perspectives of CHWs and facility HCWs.

At baseline, most CHWs felt capable of adding new tasks to their work. Although a few facility HCWs were initially skeptical, their main concern about ensuring well-trained CHWs was addressed by the fact that they themselves were the CHW trainers and supervisors within their own catchment areas. Facility HCWs noted the need for ongoing supervision of CHWs. In addition to training CHWs, facility HCWs held regular meetings to review progress, solve problems, and document women seen either at ANC or in the community. A systematic review of CHWs and malaria service delivery found that across many settings, training, supervision and provision of clear guidance are important factors in ensuring quality delivery of malaria services in the community [25‐27]. In another study in Burkina Faso, a CHW programme did not improve outcomes among children under 5, which the authors attributed to implementation shortcomings related to training, supervision and drug stock-outs [28]. Attention to supply chain and sufficient supplies of SP was critical and has been noted as vital to ensuring CHWs can work effectively [25]. Although there is evidence of decongestion of health facilities when malaria cases are treated in the community [29], including in Burkina Faso [30], c-IPTp does not necessarily have that same impact on facility HCW burden of care due to the need to maintain ANC visits so that women receive other ANC services.

A community-clinic partnership fostered through ongoing engagement was a foundational component of the intervention and has been shown to be critical to success [31, 32], in addition to facilitating strong referral connections [33‐35]. Several CHWs observed that women sometimes expected them to be able to provide more types of services than they were able to and thus referred. They didn’t identify this as an area where women were disappointed in the CHWs necessarily but it does highlight the need for clear community understanding of CHW capacities. Strong connections to a clinic were important to avoid concerns about possible reduced ANC attendance within a c-IPTp delivery programme, which had been seen in other settings [23, 24]. CHWs were motivated by the health of their communities as has been found in other studies [36]. CHWs noted delivering sensitization messages and generally strong community engagement, which has shown to be key in delivery of IPTp and malaria services to pregnant women [23, 37, 38].

Barriers to ANC attendance noted by CHWs are similar to those identified in other studies such as lack of knowledge of the importance of ANC, lack of support from family, and concern about quality of services [39]. Other studies had noted inadequate uptake of IPTp due to concerns among health staff regarding IPTp timing, as well as stock shortages of SP, which was not found in this study [25, 40].

The CHW role in recording and reporting needs to be stressed as it was an area that some CHWs noted was challenging. CHWs can learn to keep community records on IPTp, make appointments, and easily contact pregnant women in their communities to ensure they receive the next IPTp dose, but need support [31]. Monthly meetings provided an opportunity to review and summarize CHW data at the health centre and helped ensure quality of the data collected by CHWs; the meetings enabled regular supervision when health centres lacked adequate transportation resources.

While the consensus among health staff and CHWs was that both male and female CHWs could be trained to perform and carry out the same tasks, some tasks were more comfortable for either males or females. While male CHWs were in a better position to provide communication and education about the programme specifically and health generally to other males in the village, including the husbands of the pregnant women, there were some cultural limitations to their interactions with pregnant women whose husbands may not be comfortable with a male health worker making home visits. Female CHWs were reported to have better rapport with pregnant women, but less influence on male villagers, similar to a study in Kenya which found that female CHWs were perceived to provide higher quality counseling related to maternal and newborn issues [41]. The original model of the Burkina Faso community-based health promotion effort of having one female and one male CHW in each village clearly has benefits in ensuring that the total population is reached. Pairing female and male CHWs have been shown to overcome potential gender issues [42]. Reaching the husband is important. One study in Burkina Faso affirmed that husbands, having ‘‘caused’’ a pregnancy, feel a shared responsibility for their wives’ related healthcare above what they might from illnesses [43] and another study noted that spousal support for taking IPTp was attributed to effective community sensitization, emphasizing the importance of CHW efforts [44].

One limitation of this study was that it was conducted in three limited geographical areas and may not reflect the perspectives of CHWs and facility HCWs in other localities. In addition, the focused attention on IPTp and attention to availability of commodities may not reflect standard programme conditions. Additionally, the individuals interviewed at baseline were not necessarily the same as those interviewed at endline, thus some comparisons were not possible. However, it is important to note that the intervention was designed to build upon the existing CHW job description and the broader CHW training and activities reflecting the current “standard of care” of service delivery in the country. Full sustainably of this approach would require continuous training of new CHWs, as well ongoing supervision.

Following this study, the Burkina Faso Ministry of Health committed to maintaining implementation of the intervention in the communities that participated in the pilot intervention, simplifying the c-IPTp tools used by CHWs, advocating for at least one female CHW to every one male CHW in the recruitment of CHWs for each village, and advocating to make SP available at all times so that there are no missed opportunities to provide SP to pregnant women.

IPTp is a long-standing intervention to reduce malaria morbidity and more broadly further safe motherhood initiatives [45]. One of the ongoing challenges in IPTp has been bringing the intervention to nationwide scale and sustainability [5, 31, 46]. Though engagement of CHWs is broadly endorsed by WHO for primary healthcare [47], it has not been directly incorporated into malaria-specific guidance for IPTp. An update of WHO IPTp Guidelines may be helpful to clearly indicate support for community-based delivery of IPTp to stakeholders in countries with a high-burden of malaria implementing IPTp. This study demonstrates the acceptability of c- IPTp to facility HCWs and CHWs. In order to see maximum impact, it will be important to determine ways for the intervention to occur more broadly and be sustained over time.

This c-IPTp study has shown that it is feasible and acceptable for CHWs, once trained, equipped, and supervised by front-line health staff to reach pregnant women and distribute multiple doses of IPTp. Ensuring regular supplies of SP and having the involvement of both female and male CHWs were facilitating factors to success. C-IPTp can increase IPTp coverage and provide more of the WHO recommended ANC contacts. This intervention could be considered as an additional approach to complement facility-based delivery of IPTp in settings with a strong CHW presence.