Community-based strategies to increase coverage of Intermittent Preventive Treatment of malaria in Pregnancy with Sulfadoxine-Pyrimethamine in sub-Saharan Africa: A systematic review, meta-analysis, meta-ethnography, and economic assessment

Background

Community-based approaches may increase uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). We assessed the effects of community-based approaches on IPTp-SP and antenatal care (ANC) coverage, and barriers and facilitators to implementation in sub-Saharan Africa.

Methods

We undertook a meta-analysis and meta-ethnography. We searched online databases for trials, mixed-method, qualitative and cost-effectiveness studies evaluating community health worker (CHW) promotion of ANC and/or IPTp-SP delivery (c-IPTp) with no language restriction up to March 20, 2024. Information on interventions, IPTp doses, ANC visits, and barriers/facilitators were extracted. Meta-analysis (random effects) was conducted comparing effects on two-or-more (IPTp2+), three-or-more IPTp doses (IPTp3+), one-or-more (ANC1+) and four-or-more ANC visits (ANC4+). We followed Noblit and Hare’s method of meta-ethnography to synthesize qualitative findings, using reciprocal translation and line-of-argument synthesis. A theory for increased c-IPTp uptake was developed. A summary of cost and cost-effectiveness studies was done. (PROSPERO CRD42022364114).

Findings

Of 4753 records screened, 23 reporting on 15 studies were included. CHW involvement was associated with an increase in IPTp2+ (pooled RR [pRR] 1·48, 95% CI 1·24-1·75, 12 sub-studies, I2 94·7%) and IPTp3+ (pRR 1·73, 95% CI 1·19-2·50, 10 sub-studies, I2 97·5%), with no decrease in ANC4+ (pRR 1·17, 95% CI 1·00-1·36, 13 sub-studies, I2 90·3%). Cluster randomized trials showed a lower increase in IPTp3+ coverage (pRR 1.08, 1.00-1.16, I2 0·0%, n=6) compared to ‘before-after’ studies (pRR 2.86, 1.29-6.33, I2 98·9%, n=4, subgroup analysis p=0.0193). Barriers to c-IPTp included women’s fear of side effects, lack of knowledge, lack of trust in CHWs, and sociocultural factors. Community sensitization, engagement of husbands, pre-established CHW networks and trained, and supported CHWs facilitated c-IPTp. Incremental cost-effectiveness ratios ranged from $1·1 to $543 per DALY averted

Interpretation

Community-based approaches increased IPTp coverage and may have a positive impact on ANC visits in addition to being cost-effective, though there was high heterogeneity among studies. Community sensitization and engagement in addition to established, trained, and supported CHWs can facilitate c-IPTp acceptability, delivery and uptake.

Funding

EDCTP-2 supported by the European Union (RIA2020S-3302).