Ten health workers (all female) were interviewed, including five research nurses from the research trial team, and two nurse midwives, two nurse midwife technicians and one community nurse from the health facility staff. Seven were located at Mpemba Health Centre, two at Madziabango Health Centre and one divided her time between both facilities. Four FGDs of six to nine women each were conducted at Mpemba and one FGD of eight women at Madziabango. More FGDs were conducted at Mpemba due to the greater number of women recruited in the ISTp trial at this facility which resulted in a greater number of women attending the facility for postpartum visits during the period of this observational study. A total of 38 women took part in the FGDs; all were aged between 16 and 40 years old and most listed their occupation as ‘housewife’.
Health workers
Five main themes were identified amongst health workers relating to the acceptability of ISTp-SP: blood tests, drugs, resources and stock, communication, and workload.
Blood tests
Health worker opinions on the acceptability of blood tests for ISTp consisted of concerns on the method of blood taking, the ability of the test to detect malaria, and rumours within the communities regarding blood taking.
Method of blood taking
Differing opinions were offered by health workers on their own perceptions and those of pregnant women on the alternative methods of blood sampling. In general, both trial and facility health workers perceived that pregnant women found blood tests uncomfortable irrespective of the method of sampling used, but did not believe this to be a barrier to repeat visits.
“Some perceive the finger prick as painful; some perceive that peripheral [venous] is painful. We are told different things.” (SSI 6, trial staff)
“It is not a big deal, they feel uncomfortable but after the whole process is done they forget everything and are able to come again for the next antenatal clinic.” (SSI 1, health facility staff)
A small number of health workers amongst both trial and facility staff felt that venous blood samples were more convenient owing to the multiplicity of tests that could be conducted on a larger blood sample derived from a single blood draw. However, the majority of interviewed health workers had a preference for finger prick tests for RDTs compared to venous samples due to finger pricks being simple and faster to administer. Another reported advantage was that smaller amounts of blood are needed for RDTs, which was more acceptable to pregnant women who worry about their blood “finishing”. The facility staff felt familiar with finger prick tests as they were also used for RDTs to detect HIV and syphilis during routine ANC.
“I think RDTs are simple and it’s easier and even to the mother it’s acceptable… because they think the blood [taken venously] is too much, they say, ‘I’m pregnant and you are taking too much blood from me, how can I cope?’ but the RDTs they are more small and they don’t complain.” (SSI 10, health facility staff)
Perception of RDTs and the influence of blood sampling procedure on the reliability of RDT results
One of the health facility midwifes interviewed reported that she did not trust RDTs because they sometimes gave negative results when clinical symptoms suggested malaria.
“Testing with these RDTs, it may give negative test results yet clinically you are seeing that this patient has the signs typical of malaria. That’s when we say that I think these devices are not so effective.” (SSI 7, health facility staff)
However, all other health workers interviewed (trial and facility staff) felt they could trust RDT results and that pregnant women were also confident in the diagnosis as they could see the results of the RDT. Some health workers expressed doubt over the reliability of microscopy due to human error and suggested that RDTs were more reliable, especially when health workers had less experience.
“They don’t doubt when we are using the RDT process because they see the whole process, unlike when we are using the microscope process.” (SSI 1, health facility staff)
“It is effective because when one is positive it means she is indeed positive, unlike the microscope way because sometimes it’s difficult for the laboratory technician to detect the parasites and the results can come out negative when one is positive.” (SS1, health facility staff)
“I prefer RDTs because in the microscopy, you need experience.” (SSI 9, health facility staff)
Comments made by a small number of health workers/trial staff revealed that the method of blood sampling can influence confidence in the reliability of RDT results; these health workers felt that venous blood samples detected ‘real’ malaria due to drawing directly from the vein.
“Since we go straight into the vein to take the blood, I think we can determine that this is the real malaria in the stream.” (SSI 2, health facility staff)
Community rumours regarding blood draws
Health workers reported that they were aware of rumours and misconceptions within the community regarding blood draws for screening tests in the trial, the most prominent belief being that the blood taken would be sold.
“They come to the clinic and you draw blood maybe to do a certain test, they feel like you’re selling their blood.” (SSI 6, trial staff)
Other beliefs reported were blood being used for reasons other than those explained in the trial and that blood would be finished in the mother, leaving inadequate blood for the baby. Health workers believed these rumours which arose during the trial would remain in the event that ISTp were to be introduced into routine service delivery. However, health workers felt these misconceptions were not necessarily a barrier to implementing ISTp, as evidenced by the continued compliance of women in attending scheduled antenatal visits during the trial where venous blood draws were routinely conducted; they believed that these rumours could be addressed by simple explanation to the women in a way they would understand of the convenience of venous blood draws for conducting several blood tests from a single sample. They also stressed the importance of informing and involving husbands and community leaders who have strong influence on pregnant women’s care seeking.
Drugs
Several opinions regarding drug effectiveness and preferences were expressed by the health workers regarding the decreased effectiveness of SP for prevention of malaria due to SP resistance, the relative effectiveness of SP and DP, prevention versus treatment and drug side effects.
Low effectiveness of SP to prevent malaria due to SP resistance
The majority of health workers felt an alternative drug to SP was required as SP was no longer effective in preventing pregnant women from malaria infection due to SP resistance. They also reported that the vast majority of women attending antenatal care services at the facilities no longer believed SP prevented malaria and regularly asked to enrol into the ISTp trial to benefit from DP which they believed was more effective in treating and preventing malaria.
“They differentiate between SP and DHA [DP]. Most of the women want to be on ISTp because they know that it is a new drug that we are testing.” (SSI 5, trial staff).
DP compared to SP
The overriding opinion of the facility health workers and trial staff interviewed was that DP was more effective than SP as exemplified by the infrequent unscheduled visits made by women who received DP.
“If a woman is on ISTp and is taking DHA [DP], it’s rare that the woman might come to the clinic with malaria, unlike that on IPTp.” (SSI 8, trial staff)
Health workers expressed approval of weight-based dosing of DP as opposed to a set dose for everyone, although some felt that outside a trial setting the correct dose would more likely be taken if only whole tablets were given due to time constraints in cutting tablets.
“I know how hospitals work – we have lots of patients. If the government decide to go with this, are they going to manage giving three and a half tablets to someone? Will they have time maybe to give one half according to the protocol?” (SSI 3, trial staff).
Prevention versus treatment
There was consensus amongst health workers that prevention is better than cure. However, with the wide perception of decreased efficacy of SP and a feeling that women prefer not to take drugs during pregnancy if they are not ill, many placed emphasis on the promotion of ITNs rather than IPTp-SP for prevention. It was also a common opinion that prevention and treatment should work “hand-in-hand” so that if prevention has failed, a woman would receive effective treatment.
“If the woman is not given a bednet then this woman will be coming frequently to the hospital with malaria, so I think to prevent first and we can give treatment if prevention is failed” (SSI 10, health facility staff)
Drug side effects and adherence to treatment
All health workers involved in the trial gave a favourable opinion of DP over SP owing to fewer side effects seen with DP.
“There are few side effects [of DP], if any, I’ve never heard of severe side effects.” (SSI 3, trial staff).
However, acceptance by pregnant women to adhere to a 3-day DP course without DOT was a clear concern by health workers. In the trial, women were provided with transportation reimbursements to enable them to attend supervised dose administration at the clinic, which would not be possible under routine service delivery. As such, health workers feared women would be unable to travel to ANC daily to receive DOT due to long distances, limited transportation and costs.
“These women come from afar, so they just buy drugs from the shops without coming to the hospital.” (SSI 8, trial staff)
Other concerns included the perception that if women vomited a dose of the drug at home, they would not be able to repeat the dose and that some women would not receive permission from their husbands to access treatment. Health workers used what they had heard women say about taking SP to form their opinions of how likely it is they would take DP.
“They will just say, ‘I will take the medicine at home because I am coming from very far so I cannot take SP here, I have to take it home after eating food,’ but then when they go home they just drop the treatment without taking it.” (SSI 8, trial staff)
There was wide agreement amongst trial and facility health workers that women in the trial would not have completed each course of DP if doses two and three had been allowed to be taken at home. However, it was also agreed that if ISTp were to become government policy, adherence to all doses being taken under supervision at the clinic would be high as it would be seen as compulsory.
“If it was a government policy, they will be coming [to ANC to take DP].” (SSI 5, trial staff)
Resources and stock
A key health worker concern was the likelihood of a continuous supply of RDTs and medication were ISTp to be introduced as policy. All of the non-trial health workers interviewed reported that their facility had experienced stock-outs of RDTs outside of the trial. Some maintained that SP is always in stock, while others said government hospitals routinely run short of drugs. However, they noted that the government has been supportive of the study and point to this as evidence of the government’s commitment to ISTp.
Although presence of stock is a feasibility issue regarding implementation of ISTp, it also has implications for health workers’ acceptance of the intervention, which appeared to be conditional on a reliable supply of RDTs, medicines and other supplies:
“…If we adopt the ISTp then we are relying on RDT, then [if RDTs are out of stock] we are going back to IPTp – which is very confusing [for the pregnant women] … If we have the continuous supply of RDT then ISTp will be a success.” (SSI 9, health facility staff)
Communication
Health workers were unanimous in saying there was good communication between both nurse and patient and between themselves and their colleagues. They felt ANC attendance was very good with women only occasionally missing their appointments, adding that they felt confident women would attend scheduled screening visits. The need for efficient communication and understanding between health workers and between health workers and their clients and communities was deemed essential in acceptance of ISTp by these groups.
“… The problems are not that big that we cannot overcome them. We can explain to those people who are involved like the village head committee in assisting us in explaining to the patients and people in the village because it has to start in the community so that when they come here, they should not be surprised with what’s happening at the hospital. So just involving these people I think everything can go on well.” (SSI 7, health facility staff)
Work load
Some health workers expressed concern that ISTp would increase their work load as there is “more to be done” compared to IPTp.
“I think that there can be challenges in areas where workers are few. There can be difficulties with follow up of patients… and also just doing malaria tests.” (SSI 7, health facility staff)
There were suggestions that ISTp could be made more acceptable to health workers as far as additional workload was concerned by incorporating the screening component into tasks already carried out at ANC with task shifting to lower cadre staff such as health surveillance assistants.
“It can be done after they do the antenatal clinic at the booking; they train the HSAs [Health Surveillance Assistants] doing the RDTs for HIV and syphilis, so it can be done at the same time, with the HIV and syphilis test and the Hb, so it can be done.” (SSI 4, trial staff)
Trial participants
Three main themes were identified amongst pregnant women relating to the acceptability of ISTp-SP, relating to blood tests, drugs and reasons for repeat visits.
Blood tests
Several sub-themes around blood tests emerged that influenced the acceptability of ISTp with DP compared to IPTp-SP, including: information dissemination by health workers of the importance of blood tests; blood sampling methods; the relation of blood sampling methods to reliability of test results; the interpretation of the importance of blood tests; and social rumours about blood sampling.
Communication by health workers regarding blood tests
Communication between health providers and pregnant women was described as being good overall. Some women expressed disappointment that reasons for their blood tests were not explained to them by the facility health workers but this was not a shared opinion by the majority of the women. Most women believed blood tests to be very beneficial. When told the results, women reported to have felt more knowledgeable of their wellbeing and that of their unborn babies and empowered to ensure their continued health.
“We saw this as a great and good thing to know how our body is functioning because we used to walk without knowing.” (FGD 1)
Blood collection methods
The sentiments expressed by most women regarding blood sampling revolved around the pain that accompanied the sampling procedure. Opinions were however divided on which method was the more painful.
“Finger pricks are painful. It’s much better from the vein.” (FGD 5)
“I think that finger pricks are good because it’s not like they take a lot of blood.” (FGD 1)
Despite the pain, the overriding opinion was that any pain felt was quickly forgotten.
“You feel pain and you forget it, it’s not like you stop coming for antenatal clinic just because of that.” (FGD 5)
Many expressed a preference for the venous method as the same blood sample could be used for multiple RDTs.
“I like my blood being taken from the arm because the blood taken is used to find so many diseases.” (FGD 2)
Purpose and reliability of screening test results based on blood sampling method
There was some confusion between the belief that the test could detect malaria and the method of taking blood. For some there appeared to be an intrinsic link between the method of taking blood and the disease being tested.
“Most of the time when they are using the finger prick tests it means they want to test the blood for HIV.” (FGD 2)
“I prefer peripheral tests to RDTs because when they do peripheral tests they test us for a lot of infections like syphilis, gonorrhoea, AIDS. They can diagnose us, unlike doing finger prick tests, they only test for one infection.” (FGD 5)
Sentiments were expressed that venous blood samples provided more reliable results on malaria than finger-pick blood samples though there were also contrary opinions that the ability for a screening test to diagnose infection was not dependent on the method used to collect the blood.
“When they are doing the finger prick test they don’t take a lot of blood, as a result sometimes it’s difficult for them to detect the parasite that causes malaria, unlike when they are taking the blood from the arm.” (FGD 2)
“If they use the finger prick test, they would say that I don’t have any disease when in actual fact, I have it. I don’t trust it.” (FGD 2)
“I think they can take blood from anywhere in the body and still test it, it’s the same blood.” (FGD 2)
Health decision making empowerment
The act of taking a finger prick test was seen as empowering for pregnant women to be able to make informed decisions to ensure the health of themselves and their unborn babies. The benefits of blood tests were deemed to outweigh the discomfort experienced during the sampling procedure.
“We know [after having the test] how we are in our body and if we are not okay, we are able to protect ourselves before the problems arises.” (FGD 4)
Rumours regarding the purpose of blood samples
Participants reported social rumours regarding blood samples as their own opinions, the beliefs of their community or as both, and it was often difficult to differentiate between these viewpoints. As similarly reported by health workers, some FGD participants thought blood taken during the trial was being sold, with community perceptions that women enrolled in the trial were selling their blood for the value of the incentives provided.
“Some said that they are taking your blood in exchange for soap or anything that you are given there and yet they are making profits out of your blood.” (FGD 4)
Some FGD participants reported community perceptions that blood samples were kept or taken for occult practices. Another belief mentioned during the FGDs was that the failure by a woman to attend ANC visits would require repayment of a debt by giving blood.
“Others were saying that if you didn’t go for antenatal clinic, they would follow you home so that you should repay the debt.” (FGD 4)
However, there were no indications that these rumours would be sustained if similar volumes of blood were to be drawn as part of a screening policy in routine service provision which would not be accompanied by any incentives, or follow up visits at home.
By agreeing to have their blood tested, some FGD participants believed they were helping their friends who have a “shortage of blood”. Others said blood tests would lead to the birth of a small baby. Although such rumours emerged spontaneously in each FGD and were not prompted by the facilitator, in the discussions that followed many women said they did not believe the rumours and that they are wrong.
Drugs
The effectiveness and replacement of drugs to treat and prevent malaria, perceptions of prevention versus treatment, and opinions between DOT and continued unsupervised medication at home were sub-themes that emerged from the FGDs.
Drug effectiveness and replacement for prevention and treatment
Some women within the FGDs remained satisfied with SP, stating it still offered protection from malaria infection. However, other FGD participants believed SP no longer served its purpose and instead left them feeling weak, causing them to visit ANC again.
“Sometimes when you took the Fansidar [SP] it wasn’t serving its purpose in the body and you could go again to be given another one.” (FGD 1)
DP was commonly considered as “the new SP” and received positive views by the women, including that it gave women strength, was very effective and made malaria disappear. Women said DP tablets were slightly bigger and a different shape, but that they had no problems taking them.
“Because when we were given this drug, we were protected and we never got sick again. Before I started antenatal clinic visits I used to get sick and when I came here and was given this new drug, I got some strength and I was able to work but I wouldn’t work beforehand.” (FGD 1)
None of the women reported having experienced side effects with DP. In contrast, there were several reports that SP sometimes led to dizziness or nausea. This was especially associated with receiving SP as IPTp without a confirmed diagnosis of malaria.
“Others when they were given Fansidar [SP], they were experiencing nausea, so when they were given this new drug they were able to differentiate because they did not experience any side effects.” (FGD 4)
“When we used to receive Fansidar [SP] without being tested…since you take the drug when not sick, you started feeling some odd things in the body.” (FGD 1).
Prevention versus treatment
SP was strongly associated with prevention, providing relief for a short period of time rather than treatment, whereas DP was seen exclusively as treatment.
“There is a difference between these two drugs; Fansidar [SP] protects one from malaria, but then after some time malaria symptoms resurfaces again while this new drug [DP] heals or rather cures so it’s good to go for the new drug because it cures.” (FGD 2)
DOT versus continued medication at home
Only a few women in each FGD engaged with the issue of adherence, but those who did conceded it was sometimes difficult to take the full DP course. When asked about likely adherence to completing the full course of DP at home outside a trial setting, it was suggested that there may be laziness by some women to comply with required adherence and a risk that tablets may be misplaced by children in the home.
“They give you the medication, you take it and because sometimes us women we may be lazy to take the medication, we may not properly take it [at home].” (FGD 1)
Opinion was equally divided as to whether it would be better to take DP at the ANC or at home due to difficulty in daily travel or getting permission from their husbands. No opinions were expressed about adherence to SP as SP was routinely administered as DOT both in the trial and as experienced by the women in previous routine healthcare.
Reasons for repeat visits
Expectations and previous experiences at prior antenatal visits were major influences amongst pregnant women to attend subsequent antenatal care visits. Being well received and respectfully handled by health workers, informed about the wellbeing of their unborn baby and reassured of their own health by being tested for HIV and other infections, and receipt of medications and LLINs were expectations and experiences cited to have promoted high attendance of subsequent visits.