by: Joseph C. Okeibunor 1,2,3 , Bright C. Orji 2 , William Brieger 2,4 , Gbenga Ishola 2 , Emmanuel ‘Dipo Otolorin 2 , Barbara Rawlins 2 , Enobong U. Ndekhedehe 5 , Nkechi Onyeneho 1 and Günther Fink 3 Preventing Malaria in Pregnancy through Community-Directed Intervention: Evidence from Akwa Ibom State, Nigeria This project was implemented through a grant from the ExxonMobil Foundation to Jhpiego, an affiliate of The Johns Hopkins University. innovating to save lives Research Question Will CDI increase uptake of the following malaria in pregnancy services? ITN during pregnancy Number of antenatal care visits Taking antimalarial during pregnancy Taking the recommended two doses of SP during the last pregnancy Basic Malaria in Pregnancy (MIP) Interventions and Indicators Roll Back Malaria 2010 targets are 80% coverage of these: Use of insecticide-treated nets (ITNs) during pregnancy Used ITN in the night prior to the interview Number of antenatal care (ANC) visits (where MIP control services provided) Taking appropriate anti-malaria drug for malaria episode during pregnancy Taking the recommended two doses of sulphadoxine pyrimethamine (SP) during the pregnancy as intermittent preventive treatment (IPT) 1 Harvard School of Public Health; 2 Jhpiego; 3 University of Nigeria, Nsukka; 4 Johns Hopkins Bloomberg School of Public Health; and 5 Community Partners for Development 0 2 4 6 8 10 12 Any Net ITN IPTp 2 ACT Rx Pregnant Women Child <5 yrs Percentage 11.8 4.8 4.9 2.4 2008 DHS Results Showing Low Coverage Study area is immersed in year-round malaria transmission Nigeria MIP Community-Clinic Partnership Intervention CLINIC MIP performance standards developed and implemented COMMUNITY MIP skills and responsibilities implemented through community- directed intervention Training, Supervision, Mobilization, Commodities Referrals, Records, Feedback Implementation of Malaria in Pregnancy Control Design: Pre-Post Parallel Group Design Adapting CDI to MIP Prevention Front-line staff conducted community outreach, meetings, mobilization, etc. Kin groups formed basis of community-directed distributor (CDD) selection Community members in 489 kin groups (clans) chose 734 trained CDDs who were trained by front-line staff CDD kits provided – medicine, counseling cards, registers Communities conducted mapping to identify socio- economic structures that will support MIP programming Communities conducted census to estimate quantities of commodities required by each kindred (clan) Evaluation Design Key Findings ANC visits rose in treatment and control groups (estimated coefficient on group differences -0.016, 95% CI [-0.107, 0.074], p= 0.646). However, CDI led to substantial, additional increases in ITN use and in adherence to the prescribed IPTp protocol. Relative to women in the control area, an additional 7.4% of women slept under a net during pregnancy (95% CI [0.035, 0.115], p<0.01). An additional 8.5% of women slept under an ITN after delivery and before the interview (95% CI [0.045, 0.122], p-<0.001). The effects of the CDI program were largest for IPTp adherence, increasing the fraction of pregnant women taking at least two SP doses during pregnancy by 35.3 percentage points (95% CI [0.280, 0.425], p < 0.001) relative to the control group. October 2007 Program Launch February 2010 July 2008 Baseline Survey Females 15-49 183,007 No recent pregnancy 144,322 Recently pregnant 36,685 Not selected 37,405 Interviewed 1,280 Incomplete information 6 Sample analyzed 1,274 Endline Survey Females 15-49 192,613 No recent pregnancy 151,897 Recently pregnant 40,716 Not selected 39,336 Interviewed 1,380 Incomplete information 2 Sample analyzed 1,378 Community-Directed Intervention (CDI) to the Rescue CDI happens when communities plan and implement health interventions with minimal guidance from the health system. For the past 16 years, the African Program for Onchocerciasis Control has used the CDI approach to provide ivermectin successfully in over 100,000 African villages. To meet Millennium Development Goals, lessons are being learned from CDI about the role of the community in health service delivery, including malaria. To reduce malaria-related sicknesses and death during pregnancy, lessons are being learned about the need for and role of the community in health service delivery Multivariate Difference-in-Differences Estimation Program Impact Slept under ITN Regularly Use of ITN and ANC Attendance over Time Robustness Check Conclusions: CDDs Are on Hand to Encourage ITN Use and Provide SP for IPT The results suggest that the inclusion of community-based programs can substantially increase effective access to malaria prevention. Given the relatively modest financial commitments they require, community-directed programs appear to be a cost-effective way to improve malaria prevention. The participatory approach underlying CDI programs also promises to strengthen ties between the formal health sector and local communities. At least one ANC visit Slept under net during pregnancy Slept under net before interview Took malaria prevention drug Took at least 2 SP doses Panel A : OLS Post 0.177*** 0.0301*** 0.0134 0.139** 0.203*** (0.04) (0.01) (0.01) (0.05) (0.03) Post*CDI -0.0163 0.0731*** 0.0845*** 0.039 0.353*** (0.04) (0.02) (0.02) (0.05) (0.03) Panel B : Logistic Regressions Post 2.357*** 1.225*** 1.192 1.854*** 6.022*** (0.44) (0.03) (0.15) (0.43) (1.17) Post*CDI 1.467* 1.342*** 1.521*** 1.712** 3.159*** (0.30) (0.14) (0.22) (0.42) (0.58) Notes: Results displayed in Panel A reflect coefficients from a linear probability model, while results displayed in Panel B reflect odds ratios based on a logistic regression model. Numbers in parentheses are standard errors clustered at the local government area (LGA) level. Multivariate controls include age, ethnicity, religion, marital status, respondent’s educational attainment, occupational status and household wealth as measured by a principal-component based asset index. Based on a sample of 2,655 observations. At least one ANC visit Slept under net during pregnancy Slept under net before interview Took malaria prevention drug Took at least 2 SP doses Panel A: Bordering LGAs only CDI Effect -0.047 0.0504* 0.0888*** 0.002 0.328*** (0.06) (0.02) (0.02) (0.07) (0.05) Observations 1735 1735 1735 1735 1735 R-squared 0.236 0.078 0.087 0.148 0.318 Panel B: Non-bordering LGAs only CDI Effect 0.0864*** 0.0905*** 0.0478** 0.166*** 0.401*** (0.00) (0.01) (0.01) (0.01) (0.00) Treatment LGA Onna Eket Eket Ikot Abasi Ikot Abasi Control LGA Mbo Mbo Mbo Onna Onna Observations 934 914 914 940 940 R-squared 0.184 0.048 0.041 0.122 0.319 Key References Consulted National Population Commission Nigeria, ICF Macro. Nigeria: DHS, 2008–Final Report (English). Calverton, MD: Macro International; 2009. World Health Organization. Guidelines for the Treatment of Malaria. Geneva: WHO; 2007. Shane B. Malaria Continues to Threaten Pregnant Women and Children. Population Reference Bureau Articles. 2001. Steketee R, Nahlen B, Parise M, Menendez C. The burden of malaria in pregnancy in malaria-endemic Aareas. American Journal of Tropical Medicine and Hygiene. 2001;64(1): 28–35. Centers for Disease Control and Prevention. Alternatives for Pregnant Women and Treatment: Severe Malaria. Atlanta: CDC; 2007 World Health Organization. Technical Expert Group Meeting on Intermittent Preventive Treatment in Pregnancy (IPTp). Geneva: WHO; 2008. Jhpiego. ExxonMobil Supported Malaria in Pregnancy Project Report. Baltimore: Jhpiego Corporation; 2008. Ethical Approval The study was registered with the Federal Ministry of Health in Abuja. Prior to the rollout of the program, a consensus-building meeting was held with senior members of the State Ministry of Health to agree on the services CDDs would provide. In addition, health workers engaged with community stakeholders in local meetings to seek their approval, sensitize them towards the importance of their role in promoting maternal health, encourage shared learning and create a supportive environment for the program. Ethical approval was obtained through the Committee on Human Research at Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, and the National Malaria Control Programme (NMCP), Abuja, approved the study protocol for implementation. A formal MOU was set up between Jhpiego and local as well as State authorities. Informed and written consent was obtained from all persons who voluntarily agreed to be interviewed. 6 LGAs Selected for Intervention A: Control Arm Ikot Abasi, Mbo, Mkpat Enin Train health workers on basic malaria service provision B: Treatment Arm Eket, Esit-Eket, Onna Health workers train and equip CDDs with tools and intervention drugs Supply ITN, SP and malaria case tracking forms to health facilities C C C C C C C Train health workers on basic malaria service provision Supply ITN, SP and malaria case tracking forms to health facilities C Reduce Malaria in pregnancy Communities served by health workers in health clinic or CDDs at home + Two Cluster Parallel Group Design Uptake of IPTp over Time among Pregnant Women
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by: Joseph C. Okeibunor1,2,3, Bright C. Orji2, William Brieger2,4, Gbenga Ishola2, Emmanuel ‘Dipo Otolorin2, Barbara Rawlins2, Enobong U. Ndekhedehe5, Nkechi Onyeneho1 and Günther Fink3
Preventing Malaria in Pregnancy through Community-Directed Intervention:Evidence from Akwa Ibom State, Nigeria
This project was implemented through a grant from the ExxonMobil Foundation to Jhpiego, an affiliate of The Johns Hopkins University.
innovating to save lives
Research QuestionWill CDI increase uptake of the following malaria in pregnancy services?
ITN during pregnancy Number of antenatal care visitsTaking antimalarial during pregnancyTaking the recommended two doses of SP during the last
pregnancy
Basic Malaria in Pregnancy (MIP) Interventions
and IndicatorsRoll Back Malaria 2010 targets are 80% coverage of these:
Use of insecticide-treated nets (ITNs) during pregnancy Used ITN in the night prior to the interviewNumber of antenatal care (ANC) visits (where MIP control services
provided)Taking appropriate anti-malaria drug for malaria episode during
pregnancyTaking the recommended two doses of sulphadoxine
pyrimethamine (SP) during the pregnancy as intermittent preventive treatment (IPT)
1Harvard School of Public Health; 2Jhpiego; 3 University of Nigeria, Nsukka; 4Johns Hopkins Bloomberg School of Public Health; and 5Community Partners for Development
0
2
4
6
8
10
12
Any Net
ITN IPTp 2
ACT Rx
Pregnant Women Child <5 yrs
Per
cent
age
11.8
4.8 4.9
2.4
2008 DHS Results Showing Low Coverage
Study area is immersed in year-round
malaria transmission
Nigeria MIP Community-Clinic Partnership
Intervention
CLINIC
MIP
performance
standards
developed and
implemented
COMMUNITY
MIP skills and
responsibilities
implemented
through
community-
directed
intervention
Training, Supervision,
Mobilization, Commodities
Referrals, Records, Feedback
Implementation of Malaria in Pregnancy Control
Design: Pre-Post Parallel Group DesignAdapting CDI to MIP Prevention
Front-line staff conducted community outreach, meetings, mobilization, etc.
Kin groups formed basis of community-directed distributor (CDD) selection
Community members in 489 kin groups (clans) chose 734 trained CDDs who were trained by front-line staff
CDD kits provided – medicine, counseling cards, registers
Communities
conducted mapping to identify socio-economic structures that will support MIP programming
Communities conducted census to estimate quantities of commodities required by each kindred (clan)
Evaluation Design
Key FindingsANC visits rose in treatment and control groups (estimated
coefficient on group differences -0.016, 95% CI [-0.107, 0.074], p= 0.646).
However, CDI led to substantial, additional increases in ITN use and in adherence to the prescribed IPTp protocol.
Relative to women in the control area, an additional 7.4% of women slept under a net during pregnancy (95% CI [0.035, 0.115], p<0.01).
An additional 8.5% of women slept under an ITN after delivery and before the interview (95% CI [0.045, 0.122], p-<0.001).
The effects of the CDI program were largest for IPTp adherence, increasing the fraction of pregnant women taking at least two SP doses during pregnancy by 35.3 percentage points (95% CI [0.280, 0.425], p < 0.001) relative to the control group.
October 2007 Program Launch February 2010
July 2008Baseline Survey
Females 15-49
183,007
No recent pregnancy
144,322
Recently pregnant
36,685
Not selected
37,405
Interviewed
1,280
Incomplete information
6
Sample analyzed
1,274
Endline Survey
Females 15-49
192,613
No recent pregnancy
151,897
Recently pregnant
40,716
Not selected
39,336
Interviewed
1,380
Incomplete information
2
Sample analyzed
1,378
Community-Directed Intervention (CDI) to the
RescueCDI happens when communities plan and implement health interventions with minimal guidance from the health system.For the past 16 years, the African Program for Onchocerciasis Control has used the CDI approach to provide ivermectin successfully in over 100,000 African villages. To meet Millennium Development Goals, lessons are being learned from CDI about the role of the community in health service delivery, including malaria.
To reduce malaria-related sicknesses and death during pregnancy, lessons are being learned about the need for and role of the community in health service delivery
Multivariate Difference-in-Differences Estimation
Program ImpactSlept under ITN Regularly
Use of ITN and ANC Attendance
over Time
Robustness Check
Conclusions: CDDs Are on Hand to Encourage
ITN Use and Provide SP for IPTThe results suggest that the inclusion of community-based
programs can substantially increase effective access to malaria prevention.
Given the relatively modest fi nancial commitments they require, community-directed programs appear to be a cost-effective way to improve malaria prevention.
The participatory approach underlying CDI programs also promises to strengthen ties between the formal health sector and local communities.
At least one ANC
visit
Slept under net during pregnancy
Slept under net before interview
Took malaria
prevention drug
Took at least 2 SP
doses
Panel A : OLSPost 0.177*** 0.0301*** 0.0134 0.139** 0.203***
(0.04) (0.01) (0.01) (0.05) (0.03)Post*CDI -0.0163 0.0731*** 0.0845*** 0.039 0.353***
(0.04) (0.02) (0.02) (0.05) (0.03)Panel B : Logistic Regressions Post 2.357*** 1.225*** 1.192 1.854*** 6.022***
(0.44) (0.03) (0.15) (0.43) (1.17)Post*CDI 1.467* 1.342*** 1.521*** 1.712** 3.159***
(0.30) (0.14) (0.22) (0.42) (0.58)
Notes: Results displayed in Panel A reflect coefficients from a linear probability model, while results displayed in Panel B reflect odds ratios based on a logistic regression model. Numbers in parentheses are standard errors clustered at the local government area (LGA) level. Multivariate controls include age, ethnicity, religion, marital status, respondent’s educational attainment, occupational status and household wealth as measured by a principal-component based asset index. Based on a sample of 2,655 observations.
At least one ANC visit
Slept under net during
pregnancy
Slept under net before interview
Took malaria prevention drug
Took at least 2 SP doses
Panel A: Bordering LGAs onlyCDI Effect -0.047 0.0504* 0.0888*** 0.002 0.328***
(0.06) (0.02) (0.02) (0.07) (0.05)
Observations 1735 1735 1735 1735 1735R-squared 0.236 0.078 0.087 0.148 0.318
Panel B: Non-bordering LGAs only
CDI Effect 0.0864*** 0.0905*** 0.0478** 0.166*** 0.401***(0.00) (0.01) (0.01) (0.01) (0.00)
Treatment LGA Onna Eket Eket Ikot Abasi Ikot AbasiControl LGA Mbo Mbo Mbo Onna Onna
Observations 934 914 914 940 940R-squared 0.184 0.048 0.041 0.122 0.319
Key References ConsultedNational Population Commission Nigeria, ICF Macro. Nigeria: DHS, 2008–Final Report (English). Calverton, MD: Macro International; 2009.
World Health Organization. Guidelines for the Treatment of Malaria. Geneva: WHO; 2007.
Shane B. Malaria Continues to Threaten Pregnant Women and Children. Population Reference Bureau Articles. 2001.
Steketee R, Nahlen B, Parise M, Menendez C. The burden of malaria in pregnancy in malaria-endemic Aareas. American Journal of Tropical Medicine and Hygiene. 2001;64(1): 28–35.
Centers for Disease Control and Prevention. Alternatives for Pregnant Women and Treatment: Severe Malaria. Atlanta: CDC; 2007
World Health Organization. Technical Expert Group Meeting on Intermittent Preventive Treatment in Pregnancy (IPTp). Geneva: WHO; 2008.
Jhpiego. ExxonMobil Supported Malaria in Pregnancy Project Report. Baltimore: Jhpiego Corporation; 2008.
Ethical ApprovalThe study was registered with the Federal Ministry of Health in Abuja.
Prior to the rollout of the program, a consensus-building meeting was held with senior members of the State Ministry of Health to agree on the services CDDs would provide.
In addition, health workers engaged with community stakeholders in local meetings to seek their approval, sensitize them towards the importance of their role in promoting maternal health, encourage shared learning and create a supportive environment for the program.
Ethical approval was obtained through the Committee on Human Research at Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, and the National Malaria Control Programme (NMCP), Abuja, approved the study protocol for implementation.
A formal MOU was set up between Jhpiego and local as well as State authorities. Informed and written consent was obtained from all persons who voluntarily agreed to be interviewed.
6 LGAs Selected for Intervention
A: Control ArmIkot Abasi, Mbo, Mkpat Enin
Train health workers on basic malaria service provision
B: Treatment ArmEket, Esit-Eket, Onna
Health workers train and equip
CDDs with tools and intervention
drugs
Supply ITN, SP and malaria case tracking
forms to health facilities
C C C C C C C
Train health workers on basic malaria service provision
Supply ITN, SP and malaria case tracking
forms to health facilities
C
Reduce Malaria in
pregnancy
Communities served by health workers in health clinic or CDDs at home
+
Two Cluster Parallel Group Design Uptake of IPTp over Time among Pregnant Women
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