Research

Community response to intermittent preventive treatment of malaria in infants (IPTi) delivered through the expanded programme of immunization in five African settings

Marjolein Gysels¹ , Christopher Pell¹ , Don P Mathanga² , Philip Adongo³ , Frank Odhiambo⁴ , Roly Gosling⁵ , Patricia Akweongo³ , Rose Mwangi⁶ , George Okello⁴ , Peter Mangesho⁷ , Lawrence Slutsker⁸ , Peter G Kremsner^9,10 , Martin P Grobusch^9,11 , Mary J Hamel^4,8 , Robert D Newman⁸ and Robert Pool^1,5

¹  Centre for International Health Research (CRESIB), University of Barcelona, Spain

²  Malaria Alert Centre, College of Medicine, Blantyre, Malawi

³  Navrongo Health Research Centre, Navrongo, Ghana

⁴  Kenya Medical Research Institute, Kisumu, Kenya

⁵  London School of Hygiene and Tropical Medicine, London, UK

⁶  Joint Malaria Program, Kilimanjaro Christian Medical Centre, Moshi, Tanzania

⁷  National Institute for Medical Research-Amani Research Centre, Muheza, Tanzania

⁸  Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA

⁹  Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon

¹⁰  Institute of Tropical Medicine, University of Tübingen, Tübengen, Germany

¹¹  Infectious Diseases Unit, Division of Clinical Microbiology and Infectious Diseases, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

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Malaria Journal 2009, 8:191doi:10.1186/1475-2875-8-191

Published:	10 August 2009

Abstract

Background

IPTi delivered through EPI has been shown to reduce the incidence of clinical malaria by 20–59%. However, new health interventions can only be effective if they are also socially and culturally acceptable. It is also crucial to ensure that attitudes to IPTi do not negatively influence attitudes to and uptake of immunization, or that people do not misunderstand IPTi as immunization against malaria and neglect other preventive measures or delay treatment seeking.

Methods

These issues were studied in five African countries in the context of clinical trials and implementation studies of IPTi. Mixed methods were used, including structured questionnaires (1,296), semi-structured interviews (168), in-depth interviews (748) and focus group discussions (95) with mothers, fathers, health workers, community members, opinion leaders, and traditional healers. Participant observation was also carried out in the clinics.

Results

IPTi was widely acceptable because it resonated with existing traditional preventive practices and a general concern about infant health and good motherhood. It also fit neatly within already widely accepted routine vaccination. Acceptance and adherence were further facilitated by the hierarchical relationship between health staff and mothers and by the fact that clinic attendance had a social function for women beyond acquiring health care. Type of drug and regimen were important, with newer drugs being seen as more effective, but potentially also more dangerous. Single dose infant formulations delivered in the clinic seem to be the most likely to be both acceptable and adhered to. There was little evidence that IPTi per se had a negative impact on attitudes to EPI or that it had any affect on EPI adherence. There was also little evidence of IPTi having a negative impact on health seeking for infants with febrile illness or existing preventive practices.

Conclusion

IPTi is generally acceptable across a wide range of settings in Africa and involving different drugs and regimens, though there is a strong preference for a single dose infant formulation. IPTi does not appear to have any negative effect on attitudes to EPI, and it is not interpreted as immunization against malaria.