June 20, 2024

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Perceptions and drivers of healthcare provider and drug dispenser practices for the treatment of malaria in pregnancy in the context of multiple first-line therapies in western Kenya: a qualitative study | Malaria Journal

Participant characteristics

Thirty healthcare providers and three health managers were interviewed; 18 (55%) were women. There were no refusals. Of 21 healthcare providers from health facilities, 13 were from government-owned facilities, 4 were from private facilities, and 4 were from faith-based facilities. Nine providers were from drug outlets. Of 21 health facility respondents, 16 were from facilities involved in both the MFT pilot and MiMBa project; two were involved in MiMBa, one was involved in the MFT pilot, and two were involved in neither. None of the drug outlet providers were involved in either project. All providers held two-year diploma certificates except for three degree holders (one nurse, one clinical officer, and one health manager), one with a high school diploma, and one with a one-year nursing certificate. One provider had a diploma in education. Respondents had varying lengths of service at their facilities ranging from a few weeks to ten years (Table 1).

Table 1 Characteristics of health facilities and drug outlet respondents

Themes

The key emergent themes on the management of malaria in pregnancy are presented here by each WHO building block. They are summarized in Table 2, together with the implications of each theme for the national programme.

Table 2 Implications of findings for malaria control programmes

Health workforce

Perceptions on malaria treatment in pregnancy

Healthcare providers in health facilities and drug outlets generally had no reservations about giving anti-malarials to pregnant women. Factors considered in prescribing anti-malarials were trimester, the severity of illness and regimen, i.e., mode of administration, number of tablets, and number of days. The national guidelines recommending different drugs for treatment in the first vs. other trimesters were considered impractical by some providers in health facilities and drug outlets. Providers in both health facilities and drug outlets reported using artemether-lumefantrine instead of quinine in the first trimester. This issue was also identified by a health manager who felt that having quinine as a first-line anti-malarial in the first trimester was ineffective as it was usually out-of-stock.

“The guideline says the first line of management is quinine to pregnant mothers. But you would hardly find quinine in the facilities. So the guideline can say it’s quinine, but we have other drugs that we can give. So it is a challenge. Following the guideline but on the ground, things are different.(R7, Health management team).

Knowledge of malaria in pregnancy

All but one respondent, a drug outlet provider, could name at least one complication of malaria in pregnancy. Complications mentioned were maternal anaemia and death, preterm labour, decreased appetite, fever, fatigue and infant outcomes including miscarriages, stillbirths, intrauterine growth retardation, preterm and low birth weight babies, and malaria in newborns.

Training in the last 12 months

Only a few healthcare providers reported having received malaria in pregnancy training in the twelve months preceding the interview. Except for facilities involved in MFT or MiMBa, none of the private health facilities or drug outlet providers had received training.

Leadership/governance

Knowledge of national malaria treatment guidelines

Unlike drug outlets, most health facility providers demonstrated knowledge of the national malaria management guidelines. They also had greater awareness that trimester should be considered when prescribing anti-malarials to pregnant women. None of the respondents from the private health facilities that were not involved in either MFT or MiMBa demonstrated any knowledge of the national guidelines.

Monitoring health worker compliance with malaria management guidelines

Health managers reported continuous supervision of health facilities but that this was dependent on the availability of funds. One manager claimed to conduct spot checks at drug outlets, while another explained that monitoring drug outlet practices was only a recent development. The three managers reported challenges with monitoring drug outlets for compliance, citing a lack of funds and the non-receptivity of health providers.

“We assess this through supervision, through on-job training, through mentorship that you conduct like every month, at times quarterly depending on the availability of the funds”. (R7, Health management team)

“So, the question they ask, “Why should you come and do a DQA on me or giving me support supervision; yet you don’t supply me with anything?“ (R21, Health management team).

Service delivery

Diagnosis of malaria

Knowledge of the symptoms of malaria was generally good among providers in health facilities and drug outlets, and both reported using rapid diagnostic tests or microscopy to make a diagnosis. It emerged, however, that some providers in both groups offered presumptive treatment based on clinical symptoms. Reasons for this included a patient’s inability to pay for laboratory testing, refusal to be tested, or a negative test result in a symptomatic patient. A few providers reported cases of needle stick injuries while drawing blood. Another challenge to testing was a lack of gloves.

Some providers had encountered clients who refused a rapid diagnostic test for malaria as they assumed it was a test for HIV or a sexually transmitted infection, one indicating that clients preferred microscopy.

“Because the rapid test kits came sometimes back so they realise that when they see this, someone can think now we are doing a test for HIV. So, majorly the fear of the unknown like now this is HIV I am going to be tested. Someone can say no”. (R19, health facility).

Poor sensitivity of rapid diagnostic tests was widely reported as a disadvantage compared to microscopy. Some providers attributed this to the tests being unable to detect malaria species, and others due to them being unable to show parasite density and, therefore, the severity of malaria.

“it doesn’t indicate the severity of malaria. It only says it is positive, it is negative. But for the microscopy, it will show the number of strains that are there. How many pluses. Now it will help you differentiate the severity of the malaria.“ (R23, health facility).

Availability of malaria rapid diagnostic tests was a challenge across all types of facilities, with one provider reporting encountering an expired rapid test kit.

Assessing for pregnancy

Healthcare providers generally assessed for pregnancy using the last menstrual period date and pregnancy detection tests. Lack of pregnancy tests in drug outlets meant some drug dispensers had to refer clients elsewhere.

Anti-malarial of choice for treatment in pregnancy

When asked for their drug of choice for malaria in pregnancy, regardless of trimester, most providers named intravenous artesunate due to its ease of administration, quick action and short regimen.

“would prefer these mothers being given injectables. That is the Artesunate. It is easy to administer and the duration is also not taking a number of days. You know artesunate is given intravenously so I think it also works faster” (R10, health facility).

Some providers preferred artemether-lumefantrine due to its availability and safety in pregnancy, while a few preferred the newer artemisinin-based combinations, dihydroartemisinin-piperaquine and pyronaridine-artesunate, due to the regimen of once-daily dosing for three days.

Drug stock-outs

Healthcare providers from drug outlets and health facilities mentioned sending clients to buy drugs elsewhere due to stock-outs. To counter this, drugs were redistributed across facilities, or facility improvement funds were used to procure anti-malarials before government sent stock. A common concern amongst providers was the stock-out of quinine. Some providers from drug outlets stated that intravenous and oral quinine were slow-moving commodities and did not see a need to stock them.

“We have not been getting prescriptions for it. That is why the latest stock we had, after selling them, we said no. Because of the low demand. Because when you bring it there, some got expired.“ (R30, drug outlet).

Products and technologies or access to essential medicines

Anti-malarial drug characteristics

Most providers described patients complaining that quinine had a bitter taste and caused ringing of the ears (tinnitus). A few also noted that quinine was associated with premature contractions, and they prescribed salbutamol concurrently to counter this.

Quinine is good when you are monitoring the patient in the hospital because quinine, they cause contractions in women. And when we are monitoring here, we combine quinine with salbutamol to avoid those contractions.“ (R13, health facility).

A few providers explained that AL had a sour taste and smell and caused nausea and vomiting, while some said injectable artesunate had no side effects. On the packaging, providers preferred ACT blister packs over quinine packaging. They felt that dispensing quinine into sachets and envelopes by hand was unhygienic and could lead to losing pills.

You see like for the quinine that we have been using, they are packaged in a cloth. So, you keep on, you pick one, one. Either while dispensing, even when the client is taking the ones, the one, one, some can fall down.“ (R02, health facility).

It emerged that blister packs were easier to dispense and increased adherence as they were well-labelled.

AL. It is nice. The way it is four-four and even they write day one, day two…very nice, the blister pack. So it guides you.“ (R11, health facility).

Providers suggested the oral quinine regimen of three times daily for seven days was too long; this, in addition to side effects, contributed to poor adherence. The counting of drops during the administration of intravenous quinine was considered tedious by one provider. A few providers found injectable artesunate’s three doses in twenty-four hours more favourable. While some providers noted that AL had a significant pill burden, with four tablets taken twice daily for 3 days, most preferred the AL regimen over oral quinine because of the shorter number of treatment days.

Factors considered when prescribing anti-malarials

Drug safety in pregnancy was an important consideration in the prescription of anti-malarials, according to most providers in both health facilities and drug outlets.

One of the things you need to know about the drug is how safe is that drug to this pregnant mother” (R10, health facility).

Most providers cited drug cost as a consideration when prescribing anti-malarials. A unique and worrying perspective from a drug outlet provider was that he would sell half the required dose if the client could afford that.

Some may not be able to buy the whole dose of the antimalarial. So what I do, I tell her to take at least a half of the dose, that is one and a half days. Then after that she comes back and adds another.“ (R33, drug outlet).

It emerged that patient preference was a consideration in anti-malarial prescription in health facilities and drug outlets. Providers explained that patients preferred injectables (artesunate injection) over oral drugs and AL over quinine. A unique perspective from a health facility provider was that some women, to avoid taking quinine, would opt to wait until it was safe to take AL in the second trimester.

Some of them nowadays know, they’ll say, “Ah, I am waiting for that period when you’ll tell me that it’s okay for me to take AL.“ Or they will buy out over the counter.“ (R25, health facility).

A few health facility providers did not think that patient preference was a factor when prescribing anti-malarials.

“It’s me to convince the patient on the choice of drug to take.“ (R16, health facility).

“I will not be swayed by the client preference. I’ll give the correct thing according to the guideline.“ (R19, health facility).

It emerged that patient adherence was another factor considered in anti-malarial prescribing. To increase adherence, one provider reported giving the first dose of AL as directly observed therapy (DOT) and the remaining doses to be taken at home.

Other factors considered were drug availability and expiration dates, drug allergies, patient weight and age, and comorbidities like hypertension, HIV, and diabetes.

Challenges of different drug recommendations in different populations

Some providers noted that, despite the government MFT pilot, there were fewer drugs for use in pregnancy.

I feel that the drugs for those who are not pregnant are more than for the pregnant women. So, the pregnant women feel left behind. So, they should bring more drugs for the pregnant women; so, that they also feel better.(R5, drug outlet).

It emerged that there was confusion about which drug was to be used in which population.

“Most people are confused on what should be given to certain age groups, the pregnant women. So, the information was not a bit clear.“ (R04, health facility).

One provider mentioned a lack of job aids as a challenge in correctly prescribing the MFT drugs.

“The only challenge comes in when the drugs are new in the environment. New in the environment means when the clinicians are not conversant with the new molecules, you have to make sure that they know that this drug exists and you need to have job aids apart from sensitisation. They need to have their job aids besides them. Because basically there’s this phobia of this is a new drug I’ve not prescribed. You have not known much about it. What will happen because it’s my first time prescribing it. The more you practice, the more you get acquainted with the drug, the more you get eager to know what happens.” (R20, health facility).

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