Community-directed distributor training
The intervention included advocacy visits and stakeholder engagements with stakeholders in the community such as Ward Development Committee (WDC) chairmen and members, community and opinion leaders (traditional heads, women group leaders, market leaders, religious leaders, PHC officer-in-charge (OIC), town union leaders, youth leaders, opinion leaders). The community leaders were encouraged to select two trusted and acceptable female volunteer Community Directed Distributors (CDD) of IPTp-SP per settlement in the community. The CDDs were selected based on being trustworthy and well-motivated individuals with at least junior secondary school education who lived and worked in the community. They should also live and/or work in easily accessible sites where pregnant women can access them for IPTp-SP and other concerns. Priority in the selection of CDDs was given to women with prior childbearing experience in order to ensure the selection of CDDs acceptable to the women.
The CDDs were trained on basic information about pregnancy, malaria, malaria in pregnancy, estimation of gestational age, eligibility for IPTp-SP administration and side effects, proper use of insecticide-treated nets (ITN), counselling of pregnant women, referral to the PHC, interviewing technique, and documentation using summary forms. The training module was adapted from the National Guidelines and Strategies for Malaria Prevention and Control during Pregnancy . The training was held for 3 days in the community after which the CDDs were given tool-kit bags containing client visitation forms, registers, ANC referral forms, and IPTp drugs. The training was conducted by the principal investigator and the OIC of the PHC. Before the training, the OIC received refresher training on current WHO recommendations for ANC attendance and frequency of IPTp administration. Weekly and two-weekly supportive supervision of the CDDs was conducted by the OIC and research team, respectively.
The CDDs identified the pregnant women in the community, provided general counselling on pregnancy care, including use of ITN and health-seeking for malaria symptoms to pregnant women and their family members available during the visits, administered IPTp-SP to eligible women, and referred them for ANC for prenatal care and receipt of ITNs over a 5-month period. They also followed up the pregnant women using home visits in order to encourage ANC attendance and ITN use. The CDDs carried out community distribution dressed in branded T-shirts, caps, and bags with educative pictures and write-ups on prevention of malaria in pregnancy. The CDDs received monthly financial token stipends for their transportation and meals. The drug supply to CDDs was linked to the PHC in the community and was only obtained from the facility. For the period of the intervention, the CDDs issued referral forms to pregnant women who received IPTp but were either not enrolled or poorly adherent to ANC. On accessing services in the health facility, the pregnant women were instructed to present the referral forms in addition to verbally communicating that they had been referred by CDDs in the community. With or without the referral forms, the facility health workers also directly enquired from the pregnant women who utilized the health facility whether they had been encouraged to do so through the intervention and if the response was in the affirmative, they indicated this by a tick beside the details of the women in the ANC register. Verbal confirmation was strongly emphasized because the feedback from the CDDs was that some of the women forgot to go along with their referral forms to the health facility.
Review meetings were held on a two-weekly basis with the CDDs. During the review meetings, drug stock and data collection documents were reviewed, field experiences and challenges shared and addressed. Every woman who received IPT from the CDDs was given a card on which doses and the dates the IPT were given was marked and this was presented whenever she visited a health facility for ANC or was due for another dose, in order to avoid inappropriate multiple dosing. The CDDs also visited with their records of IPT administration and verified that pregnant women had not received IPTp in the 4 weeks preceding the current administration.
A community awareness campaign was used to sensitize community members on general malaria prevention and specifically the prevention of malaria in pregnancy. The sensitization was held in the community hall and involved brief health talks, question and answer sessions, and distribution of information and education fliers on prevention of malaria. The leaflets contained pictures and short write-ups in English and Ibo languages conveying information on the prevention of malaria in pregnancy and other preventive practices. The health talks were given in the local dialect by the principal investigator and OIC of the PHC. Additionally, platforms and meetings of social groups in the community and church-based women’s groups and community political groups (tradtional cabinet, consultation meetings) were utilized to educate community members. The community town criers were also engaged to disseminate specific messages on the prevention of malaria in pregnancy.
Post-implementation of the intervention
Over the 5 months of the intervention, a monthly implementation evaluation was conducted starting from the first month of the intervention to assess the proportion of women who received various doses of IPTp-SP using records from CDDs and ANC registers. Change in ANC attendance following the intervention was also computed from the PHC. Satisfaction with the community-directed distribution of IPTp and the CDD services was also assessed.
Sample size determination
The estimated annual population of pregnant women in the Ebiriogu community calculated as 5% of the total population in the community was 303, as obtained from the Ebonyi State Primary Health Care Development Agency. Since the study was conducted over 5 months, about half of this number (152 pregnant women) was used as the minimum target population for the IPTp-SP distribution.