Feasibility, acceptability, and effectiveness of community interventions to increase the uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in sub-Saharan Africa

Abstract

Despite global progress in malaria control, the disease continues to endanger millions of pregnancies in sub-Saharan Africa (SSA), especially in areas of moderate-to-high transmission. Malaria during pregnancy can lead to maternal anaemia, low birthweight, and perinatal death. Intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP), recommended by the World Health Organization (WHO), is a safe and effective intervention for preventing these adverse outcomes. However, uptake of the recommended doses of IPTp-SP remains low despite improved antenatal care (ANC) attendance. To address this gap, WHO recommends exploring community-based strategies to supplement ANC IPTp-SP delivery.
This thesis investigates whether community-based strategies are feasible, acceptable, and effective in increasing IPTp-SP uptake in SSA. A mixed-methods approach was used across three interlinked studies. First, a systematic review with meta-analysis, meta-ethnography, and economic assessment was conducted. The meta-analysis showed that CHW involvement significantly increased the uptake of two or more SP doses (pooled risk ratio [pRR] 1.48, 95% CI 1.24–1.75) and three or more SP doses (pRR 1.73, 95% CI 1.19–2.50) without reducing coverage of four or more ANC visits (pRR 1.17, 95% CI 1.00–1.36). The meta-ethnography identified trust in CHWs, supervision, and community engagement as key facilitators, while fear of side effects and lack of knowledge, lack of trust in CHWs, and sociocultural factors were notable barriers. Economic analyses suggested community delivery was cost-effective.
Second, a cross-sectional study nested within an implementation trial of integrated ANC and seasonal malaria chemoprevention (SMC) delivery of IPTp-SP in Mali and Burkina Faso assessed the effectiveness of ANC delivery of IPTp-SP per national guidelines. Data were collected through exit interviews with pregnant women, health facility audits, and an ANC provider survey. Findings showed significantly higher delivery of IPTp-SP by directly observed therapy (DOT) in the intervention arms (Mali: 79.2% vs 68.7%, p=0.006; Burkina Faso: 52.3% vs 28.7%, p<0.0001). Some doses were administered at <28 days intervals. Predictors of receiving IPTp-SP by DOT varied by country. ANC providers generally supported community delivery and believed it increased ANC attendance and reduced malaria cases.
Finally, a qualitative study explored the feasibility and acceptability of delivering IPTp-SP through SMC. In-depth interviews and focus group discussions with CHWs, ANC providers, women, and community leaders found broad support for the integrated approach. CHWs felt capable, and community members appreciated the convenience. Overall, ANC delivery was preferred by women and household heads due to perceptions of provider competence and safety. Key barriers included women’s reluctance to take SP due to side effects and limited coordination between CHWs and ANC providers.
Together, these studies provide robust evidence that community-based strategies are feasible, acceptable, and effective. Findings underscore the importance of tailored community engagement, CHW support, and coordinated health system efforts for successful scale-up. This thesis offers critical guidance for policymakers in Mali and Burkina Faso, as well as for the WHO, in advancing malaria prevention among pregnant women through community-based approaches.

Date of Award	9 Dec 2025
Original language	English
Awarding Institution	Liverpool School of Tropical Medicine
Supervisor	Jenny Hill (Supervisor), Eve Worrall (Supervisor) & Kassoum Kayentao (Supervisor)