Malaria-related ideational factors and other correlates associated with intermittent preventive treatment among pregnant women in Madagascar

In Madagascar, 88% of the population lives in an area of high malaria transmission [1]. Malaria infection is the eighth most frequent cause of morbidity at community health facilities across the country [2]. Madagascar’s malaria burden, particularly among pregnant women, is a health priority because of the health risks malaria infection poses for not only a pregnant woman, but also her fetus and newborn child. In areas of high malaria transmission, Plasmodium falciparum, which causes the vast majority of malaria infections in Madagascar [3], is associated with both maternal anaemia [4] and increased risk of low-birth weight of newborns and contributes to higher risk of infant mortality [5]. The World Health Organization (WHO) recommends that pregnant women in zones of stable transmission receive sulfadoxine–pyrimethamine (SP) as part of intermittent preventive treatment for malaria in pregnancy (IPTp) [6].

Since 2004, the National Malaria Control Programme [Programme National de la Lutte contre le Paludisme (PNLP)] has recommended that pregnant women take at least two doses of SP to prevent malaria (IPTp2) [2]. In 2013, the Malagasy Ministry of Public Health (MOPH) set a national target of achieving 80% coverage of IPTp2 in targeted districts by 2017; these districts being those with stable or seasonal malaria transmission [7]. The MOPH recommended that both doses of SP be administered for free under the supervision of health workers during antenatal care visits (ANC)—the first dose upon the first fetal movement and the second a month later [2]. Although the 2013 Malaria Indicator Survey (MIS) did not estimate ANC coverage, the 2008–2009 Demographic Health Survey (DHS) found that 86.3% of women made two or more ANC visits [8]. The 2013 MIS estimated IPTp2 coverage was lower, at 20.6% [3], among target districts. Health programmes in Madagascar and elsewhere have sought to improve IPTp2 coverage, although their success has not been consistent. Identifying the factors associated with IPTp2 coverage is crucial for designing better programmes to address IPTp2 provision and malaria-related maternal and child mortality and morbidity. Health communication programmes, in particular, can benefit from understanding what factors are associated with pregnant women receiving IPTp to ensure their messaging is relevant and reaching the intended audience.

As national policy recommends the provision of SP during ANC visits [2], these factors would be expected to also play a role in IPTp uptake. Most pregnant women who receive at least one dose of SP in Madagascar obtain the medication during an ANC visit [3]. Subsequently, uptake of IPTp is largely dependent on a woman making ANC visits; as a result, IPTp and ANC attendance share many of the same correlates [9]. The factors associated with IPTp2 uptake occur at various levels: health systems [2, 10], health providers [2, 9], the households in which pregnant women live [11‐13], and individual-level factors [12, 14, 15]. However, the role that psychosocial factors play at the individual level, and their association with IPTp, have been examined less frequently in quantitative studies. In contrast, the effect of a woman’s psychosocial characteristics on ANC attendance has been well documented. A woman’s involvement in the decision that she seek antenatal care, relative to her husband’s involvement, and her need for money or transport [16‐22], often influences whether or not she makes ANC visits. The way a future mother perceives the quality of available health care [15] and the reasons why she may hesitate to disclose her pregnancy early [23, 24] can also impact ANC attendance.

Psychosocial factors that influence a behaviour have been framed using the ideation model. Ideation encompasses social, cognitive, and emotional factors at the community and individual levels [25]. The ideation model draws on various existing behavioural change theories and suggests that ideational factors—such as knowledge attitudes, perceived risk, subjective norms, self-efficacy, personal advocacy, and interpersonal communication—can influence health behaviours [25]. While the ideation model has recently been applied to explain variations in bed net ownership in Tanzania [26, 27], to date, no studies in Madagascar have examined the statistical association between a woman’s ideation and IPTp uptake.

Research from sub-Saharan Africa has indicated that women are often unaware of the benefits of taking IPTp [15] and some perceive it as unsafe [15, 21]. A systematic meta-analysis of data from sub-Saharan Africa found that a woman’s malaria and IPTp knowledge were correlated with her likelihood of taking IPTp2 [15]. Similarly, women who knew that SP was taken to prevent malaria were almost two times more likely to take a dose of SP as instructed by a health provider [28]. The literature offers mixed conclusions as to whether side-effects, either perceived or experienced, affect a woman’s likelihood of taking SP during pregnancy to prevent malaria [28, 29]. Data from Tanzania showed that women who experienced side effects took SP at a similar rate as women who had not [28]. This paper is the first study to take a detailed look at how a woman’s ideational factors, among others, may influence IPTp2 in Madagascar.

This paper has identified several significant correlates of IPTp2 uptake in six districts of Madagascar. These included a woman’s education level, her IPTp/ANC ideation index, the number of ANC visits she completed, her level of education, her district of residence and community-level factors. Although the study sample is not representative of all women of reproductive age in Madagascar or the six districts, it is the most comprehensive multivariate analysis of IPTp correlates in Madagascar to date. Only a few quantitative studies have examined the correlates of IPTp2 in Madagascar [12, 14, 32]. As far as the authors know, it is also the first study to investigate the association between a comprehensive list of ideational factors and IPTp2 in Madagascar’s targeted districts.

Unlike a meta-analysis from sub-Saharan Africa [32], the current study results did not confirm that women in areas of intermediate malaria prevalence were more likely to receive IPTp2 than those in low transmission areas. However, the current study’s sample was too small to make generalized statements about the differences in IPTp2 prevalence across different transmission zones, so the authors could not make conclusive statements about this correlate.

Based on relatively high general malaria ideation scores, mothers commonly perceive malaria as a severe disease, have basic knowledge about it, feel they are susceptible to it, are confident they can prevent it, and talk about the risk of malaria. The significant role of IPTp/ANC ideation, but not general malaria ideation, suggests that improving general attitudes and social norms regarding malaria is not sufficient to influence IPTp2 behaviour. Taking two doses of SP during pregnancy requires a sequence of health-seeking behaviours such as going to a health facility, taking medicine, and interaction with ANC providers. Consequently, it makes sense that different ideational factors were found to be associated with IPTp2, such as a woman’s involvement in the decision to seek preventive care and take any medication that she is offered. The significance of IPTp/ANC ideation as a correlate of IPTp2 uptake in the final model speaks to the important role of psychosocial factors, interpersonal communication, a woman’s role in decision making about her health, and her attitude toward ANC and taking medication during pregnancy in influencing IPTp2 uptake in Madagascar.

While this study did not directly investigate the role of supply-side factors, such as SP supply, there were several reasons to suspect that health-facility characteristics and health-provider practice accounted for the observed variation in IPTp2 coverage. First, most women who did not receive SP said it was because their ANC provider did not offer them malaria prophylaxis. Second, this study observed large regional differences in the odds of IPTp2 coverage that could be due to differences in women’s access to ANC, health-provider training, or the availability of SP. Third, community-level factors accounted for some of the variation of IPTp2 coverage, which may have reflected household distances to ANC providers or quality of ANC services. Literature from Madagascar [2, 9, 10] and sub-Saharan Africa [15, 18‐21, 23, 32‐34] indicate the crucial role of supply-side factors in determining IPTp coverage. Factors that reportedly limit IPTp2 coverage include a lack of recent IPTp health-provider training [18, 19, 35, 36], inadequate health-provider knowledge [17, 20], a lack of clear IPTp guidelines at health facilities [36, 37], and inconsistent availability of SP [35]. One qualitative study described a health provider in Madagascar who reported giving pregnant women two doses of SP a month instead of two doses during the entire pregnancy because the health provider felt the medication was “too weak” [10]. In Nigeria, one study found that while most health providers were aware an IPTp policy existed and what drug and how many doses to prescribe, they were not aware the national policy required directly observing women taking SP and did not know during what trimesters they should prescribe SP [17]. Such reports underscore the role of health-provider training and attitudes in ensuring IPTp is given according to national recommendations. In 2013, four out of five pregnant women in Madagascar, made at least two ANC visits but only one in five received IPTp2 [3]. It is plausible that the gap in IPTp2 coverage in Madagascar is not due to low ANC attendance, but is an unfortunate consequence of irregular SP availability or health-provider behaviours [32‐38].

The positive correlation found between a woman making additional ANC visits and her odds of receiving IPTp is unsurprising, and consistent with other literature in sub-Saharan Africa [15, 32, 33]. The more ANC visits a woman attends, the more opportunities she has to receive two doses of SP.

While greater household wealth has been linked to increased odds of receiving IPTp2 in Madagascar [12] and in sub-Saharan Africa data [15, 32], this study found no such relationship after adjusting for a woman’s district of residence, number of ANC visits, malaria message exposure, IPTp/ANC ideation, education level, and community-level characteristics. This finding is similar to that of Kesteman et al. [14] who found no significant relationship between household wealth and a woman’s odds of receiving IPTp2. The absolute variation in wealth level among the rural households sampled may not have been sufficiently large, or household wealth may not influence IPTp2 coverage in Madagascar, at least partly, because of widespread availability of SP.

This study adds to a body of mixed evidence suggesting an association between a woman’s education and her likelihood of receiving IPTp. Like Clouston et al. [12], data showed that women who had completed primary school as their highest level of educational achievement had a significant advantage regarding their odds of receiving IPTp2 compared to women with no formal schooling. This was not a relationship observed in women attending sentinel health facilities across Madagascar [14]. Two meta-analyses of sub-Saharan Africa countries yielded contradictory findings concerning the role of educational achievement in predicting IPTp2 [15, 32].

Not all women in Madagascar make at least two visits to a health provider during pregnancy [3]. To address gaps in IPTp2 coverage, health communication programmes should improve IPTp and ANC-related ideation among women of reproductive age. Health communication programmes seeking to improve IPTp coverage should focus on IPTp-related ideation rather than general malaria ideation, such as one’s risk of malaria or the perceived severity of the disease. For example, programmes could encourage women to talk to their spouses or friends about the risk of malaria in pregnancy and promote early and complete ANC attendance as a community norm. Programmes could encourage families to include women in discussions about their care seeking during pregnancy. As the IPTp/ANC ideation index reflected women’s attitudes toward seeking ANC from health providers and health facilities, health programmes must address supply-side factors while maintaining demand for ANC services and trust in ANC health providers. Both health communication and health policy makers can address gaps in IPTp2 coverage by continuing to address supply-side barriers such as SP supply chain management and training for health providers to increase their IPTp-related knowledge and practices. Further research is needed to identify which health-provider ideational variables—such as knowledge and perceived efficacy of SP—need to be addressed in training and communication efforts. As the MOPH and PNLP continue to work toward higher IPTp2 coverage rates, they will require innovative ways to ensure SP availability at the health-facility level as well new mechanisms to train, supervise, and monitor health-provider provision of SP.

The results of this study suggest both supply-side and demand-side factors influence IPTp2 coverage in Madagascar. A woman’s individual ideational characteristics, such as her attitudes toward IPTp/ANC and her participation in the decision to seek care, are associated with whether or not she receives IPTp2. The authors suspect health-system factors account for much of the variance in IPTp2 coverage, confirming existing literature that points to the importance of health systems in ensuring access to quality IPTp services. Social and behaviour change communication programmes may be able to influence IPTp2 coverage by changing women’s attitudes specific to IPTp/ANC including gender norms that increase her involvement in making decisions about her health within a household and the importance of seeking ANC services regularly during pregnancy.