Introducing post-discharge malaria chemoprevention (PMC) for management of severe anemia in Malawian children: a qualitative study of community health workers' perceptions and motivation

Thandile Nkosi-Gondwe, Bjarne Robberstad, Björn Blomberg, Kamija S Phiri, Siri Lange, Thandile Nkosi-Gondwe, Bjarne Robberstad, Björn Blomberg, Kamija S Phiri, Siri Lange

Abstract

Background: Severe malarial anaemia is one of the leading causes of paediatric hospital admissions in Malawi. Post-discharge malaria chemoprevention (PMC) is the intermittent administration of full treatment courses of antimalarial to children recovering from severe anaemia and findings suggest that this intervention significantly reduces readmissions and deaths in these children. Community delivery of health interventions utilizing community health workers (CHWs) has been successful in some programmes and not very positive in others. In Malawi, there is an on-going cluster randomised trial that aims to find the optimum strategy for delivery of dihydroartemesinin-piperaquine (DHP) for PMC in children with severe anaemia. Our qualitative study aimed to explore the feasibility of utilizing CHWs also known as health surveillance assistants (HSAs) to remind caregivers to administer PMC medication in the existing Malawian health system.

Methods: Between December 2016 and March 2018, 20 individual in-depth-interviews (IDIs) and 2 focus group discussions (FGDs) were conducted with 39 HSAs who had the responsibility of conducting home visits to remind caregivers of children who were prescribed PMC medication in the trial. All interviews were conducted in the local language, transcribed verbatim, and translated into English. The transcripts were uploaded to NVIVO 11 and analysed using the thematic framework analysis method.

Results: Although intrinsic motivation was reportedly high, adherence to the required number of home visits was very poor with only 10 HSAs reporting full adherence. Positive factors for adherence were the knowledge and perception of the effectiveness of PMC and the recognition from the community as well as health system. Poor training, lack of supervision, high workload, as well as technical and structural difficulties; were reported barriers to adherence by the HSAs.

Conclusions: Post-discharge malaria chemoprevention with DHP is perceived as a positive approach to manage children recovering from severe anaemia by HSAs in Malawi. However, adherence to home visit reminders was very poor and the involvement of HSAs in a scale up of this intervention may pose a challenge in the existing Malawian health system.

Trial registration: ClinicalTrials.gov identifier NCT02721420 . The trial was registered on 26 March 2016.

Keywords: Anaemia; Community health workers; Malaria; Malawi; Secondary prevention; Social perception.

Conflict of interest statement

Ethics approval and consent to participate

Prior to collection of data ethical clearance for the qualitative research was obtained from the regional committee for medical and health research ethics in Western Norway (REC 2015/537) and from the University of Malawi, College of Medicine Research Ethics Committee (COMREC no.P.2/15/1679). Written and verbal informed consent was obtained in the local language from all the HSAs.

Consent for publication

Consent for publication of study findings was obtained from all the HSAs involved.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. Hershey CL, Florey LS, Ali D, Bennett A, Luhanga M, Mathanga DP, et al. Malaria Control Interventions Contributed to Declines in Malaria Parasitemia, Severe Anemia, and All-Cause Mortality in Children Less Than 5 Years of Age in Malawi, 2000–2010. Am J Trop Med Hyg. 2017;97(3_Suppl):76–88.
    1. Calis JC, Phiri KS, Faragher EB, Brabin BJ, Bates I, Cuevas LE, et al. Severe anemia in Malawian children. N Engl J Med. 2008;358(9):888–899.
    1. Phiri KS, Calis JC, Faragher B, Nkhoma E, Ng'oma K, Mangochi B, et al. Long term outcome of severe anaemia in Malawian children. PLoS One. 2008;3(8):e2903.
    1. Esan MO, Phiri KS, Molyneux EM, Mukaka M, Cheema B, Boele van Hensbroek M. High transfusion failure rates in Malawian children with severe anaemia following a standard blood transfusion regimen. Br J Haematol. 2011;154(6):783–785.
    1. Phiri K, Esan M, van Hensbroek MB, Khairallah C, Faragher B, ter Kuile FO. Intermittent preventive therapy for malaria with monthly artemether–lumefantrine for the post-discharge management of severe anaemia in children aged 4–59 months in southern Malawi: a multicentre, randomised, placebo-controlled trial. Lancet Infect Dis. 2012;12(3):191–200.
    1. Bojang KA, Palmer A, van Boele Hensbroek M, Banya WA, Greenwood BM. Management of severe malarial anaemia in Gambian children. Trans R Soc Trop Med Hyg. 1997;91(5):557–561.
    1. Bojang KA, Milligan PJM, Conway DJ, Sisay-Joof F, Jallow M, Nwakanma DC, et al. Prevention of the recurrence of Anaemia in Gambian children following discharge from hospital. PLoS One. 2010;5(6):e11227.
    1. Bojang KA, Van Hensbroek MB, Palmer A, Banya WA, Jaffar S, Greenwood BM. Predictors of mortality in Gambian children with severe malaria anaemia. Ann Trop Paediatr. 1997;17(4):355-9.
    1. Bojang KA, Akor F, Conteh L, Webb E, Bittaye O, Conway DJ, et al. Two strategies for the delivery of IPTc in an area of seasonal malaria transmission in the Gambia: a randomised controlled trial. PLoS Med. 2011;8(2):e1000409.
    1. Verhoef H, West CE, Nzyuko SM, de Vogel S, van der Valk R, Wanga MA, et al. Intermittent administration of iron and sulfadoxine-pyrimethamine to control anaemia in Kenyan children: a randomised controlled trial. Lancet. 2002;360(9337):908–914.
    1. Brabin B, Prinsen-Geerligs P, Verhoeff F, Kazembe P. Anaemia prevention for reduction of mortality in mothers and children. Trans R Soc Trop Med Hyg. 2003;97(1):36–38.
    1. Brabin BJ, Premji Z, Verhoeff F. An analysis of anemia and child mortality. J Nutr. 2001;131(2s-2):636S–645S.
    1. Aponte JJ, Schellenberg D, Egan A, Breckenridge A, Carneiro I, Critchley J, et al. Efficacy and safety of intermittent preventive treatment with sulfadoxine-pyrimethamine for malaria in African infants: a pooled analysis of six randomised, placebo-controlled trials. Lancet. 2009;374(9700):1533–1542.
    1. Menendez C, Kahigwa E, Hirt R, Vounatsou P, Aponte JJ, Font F. Randomised placebo-controlled trial of iron supplementation and malaria chemoprophylaxis for prevention of severe anaemia and malaria in Tanzanian infants. Lancet. 1997;350(9081):844-50.
    1. Schellenberg D, Menendez C, Kahigwa E, Aponte J, Vidal J, Tanner M, et al. Intermittent treatment for malaria and anaemia control at time of routine vaccinations in Tanzanian infants: a randomised, placebo-controlled trial. Lancet. 2001;357.
    1. Athuman M, Kabanywanyi AM, Rohwer AC. Intermittent preventive antimalarial treatment for children with anaemia. Cochrane Database Syst Rev. 2015;1:1–55.
    1. Akech SO, Hassall O, Pamba A, Idro R, Williams TN, Newton CR, et al. Survival and haematological recovery of children with severe malaria transfused in accordance to WHO guidelines in Kilifi, Kenya. Malaria J. 2008;7(1):256.
    1. Price RN, Simpson JA, Nosten F, Luxemburger C, Hkirjaroen L, ter Kuile F, et al. Factors contributing to anemia after uncomplicated falciparum malaria. Am J Trop Med Hyg. 2001;65(5):614–622.
    1. van Boele Hensbroek M, Calis JC, Phiri KS, Vet R, Munthali F, Kraaijenhagen R, et al. Pathophysiological mechanisms of severe anaemia in Malawian children. PLoS One. 2010;5(9):e12589.
    1. Hill J, Hoyt J, van Eijk AM, D’Mello-Guyett L, ter Kuile FO, Steketee R, et al. Factors affecting the delivery, access, and use of interventions to prevent malaria in pregnancy in sub-Saharan Africa: a systematic review and meta-analysis. PLoS Med. 2013;10(7):e1001488.
    1. Kweku M, Webster J, Adjuik M, Abudey S, Greenwood B, Chandramohan D. Options for the delivery of intermittent preventive treatment for malaria to children: a community randomised trial. PLoS One. 2009;4(9):e7256.
    1. Mbonye AK, Bygbjerg IC, Magnussen P. A community-based delivery system of intermittent preventive treatment of malaria in pregnancy and its effect on use of essential maternity care at health units in Uganda. Trans R Soc Trop Med Hyg. 2007;101(11):1088-95.
    1. Patouillard E, Conteh L, Webster J, Kweku M, Chandramohan D, Greenwood B. Coverage, adherence and costs of intermittent preventive treatment of malaria in children employing different delivery strategies in Jasikan, Ghana. PLoS ONE. 2011;6(11):e24871.
    1. Kolaczinski JH, Kolaczinski K, Kyabayinze D, Strachan D, Temperley M, Wijayanandana N, et al. Research costs and effects of two public sector delivery channels for long-lasting insecticidal nets in Uganda. Malar J. 2010;9:102.
    1. Das A, Friedman J, Kandpal E, Ramana GN, Gupta RK, Pradhan MM. Strengthening malaria service delivery through supportive supervision and community mobilization in an endemic Indian setting: an evaluation of nested delivery models. Malar J. 2014;13:482.
    1. Mukanga D, Babirye R, Peterson S, Pariyo GW, Ojiambo G, Tibenderana JK. Can lay community health workers be trained to use diagnostics to distinguish and treat malaria and pneumonia in children? Lessons from rural Uganda. Tropical Med Int Health. 2011;16(10):1234-42.
    1. Mukanga D, Tibenderana JK, Kiguli J, Pariyo GW, Waiswa P, Bajunirwe F. Community acceptability of use of rapid diagnostic tests for malaria by community health workers in Uganda. Malar J. 2010;9:203.
    1. Shaw BI, Asadhi E, Owuor K, Okoth P, Abdi M, Cohen CR, et al. Perceived quality of Care of Community Health Worker and Facility-Based Health Worker Management of pneumonia in children under 5 years in Western Kenya: a cross-sectional multidimensional study. Am J Trop Med Hyg. 2016;94(5):1170–1176.
    1. Callaghan-Koru JA, Nonyane BA, Guenther T, Sitrin D, Ligowe R, Chimbalanga E, et al. Contribution of community-based newborn health promotion to reducing inequities in healthy newborn care practices and knowledge: evidence of improvement from a three-district pilot program in Malawi. BMC Public Health. 2013;13(1):1052.
    1. Mbonye AK, Bygbjerg IC, Magnussen P. Intermittent preventive treatment of malaria in pregnancy: a new delivery system and its effect on maternal health and pregnancy outcomes in Uganda. Bull World Health Organ. 2008;86(2):93-100.
    1. Mbonye AK, Hansen KS, Bygbjerg IC, Magnussen P. Effect of a community-based delivery of intermittent preventive treatment of malaria in pregnancy on treatment seeking for malaria at health units in Uganda.(Report) Public Health. 2008;122(5):516.
    1. Gilmore B, McAuliffe E. Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review. BMC Public Health. 2013;13(1):847.
    1. Ngasala BE, Malmberg M, Carlsson AM, Ferreira PE, Petzold MG, Blessborn D. Effectiveness of artemether-lumefantrine provided by community health workers in under-five children with uncomplicated malaria in rural Tanzania: an open label prospective study. Malar J. 2011;10:64.
    1. Gies S, Coulibaly SO, Ouattara FT, Ky C, Brabin BJ, D'Alessandro U. A community effectiveness trial of strategies promoting intermittent preventive treatment with sulphadoxine-pyrimethamine in pregnant women in rural Burkina Faso. Malar J. 2008;7(1):180.
    1. Vaughan K, Kok MC, Witter S, Dieleman M. Costs and cost-effectiveness of community health workers: evidence from a literature review. Hum Resour Health. 2015;13.
    1. Lwin MM, Sudhinaraset M, San AK, Aung T. Improving malaria knowledge and practices in rural Myanmar through a village health worker intervention: a cross-sectional study. Malar J. 2014;13:5.
    1. WHO, GHWA . Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country cases studies, and recommendation for integration into national health system. Geneva: World health Organization; 2010.
    1. Mwai GW, Mburu G, Torpey K, Frost P, Ford N, Seeley J. Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review. J Int AIDS Soc. 2013;16(1):18586.
    1. Christopher JB, Le May A, Lewin S, Ross DA. Thirty years after Alma-Ata: a systematic review of the impact of community health workers delivering curative interventions against malaria, pneumonia and diarrhoea on child mortality and morbidity in sub-Saharan Africa. Hum Resour Health. 2011;9(1):27.
    1. Mutamba BB, van Ginneken N, Smith Paintain L, Wandiembe S, Schellenberg D. Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review. BMC Health Serv Res. 2013;13(1):412.
    1. McDermott RA, Schmidt B, Preece C, Owens V, Taylor S, Li M, et al. Community health workers improve diabetes care in remote Australian indigenous communities: results of a pragmatic cluster randomized controlled trial. BMC Health Serv Res. 2015;15(1):68.
    1. Medhanyie A, Spigt M, Kifle Y, Schaay N, Sanders D, Blanco R, et al. The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study. BMC Health Serv Res. 2012;12(1):352.
    1. Chikaphupha KR, Kok MC, Nyirenda L, Namakhoma I, Theobald S. Motivation of health surveillance assistants in Malawi: a qualitative study. Malawi Med J. 2016;28(2):37–42.
    1. Kadzandira JM, Chilowa W, Unicef. The role of health surveillance assistants (HSAs) in the delivery of health services and immunisation in Malawi. Lilongwe: University of Malawi, Centre for Social Research; 2001.
    1. Kok MC, Muula AS. Motivation and job satisfaction of health surveillance assistants in Mwanza, Malawi: an explorative study. Malawi Med J. 2013;25(1):5–11.
    1. Krüger C, Heinzel-Gutenbrunner M, Ali M. Adherence to the integrated management of childhood illness guidelines in Namibia, Kenya, Tanzania and Uganda: evidence from the national service provision assessment surveys. BMC Health Serv Res. 2017;17(1):822.
    1. Vareilles G, Marchal B, Kane S, et al. Understanding the motivation and performance of community health volunteers involved in the delivery of health programmes in Kampala, Uganda: a realist evaluation. BMJ Open. 2015;5:e008614.
    1. Bonenberger M, Aikins M, Akweongo P, Wyss K. The effects of health worker motivation and job satisfaction on turnover intention in Ghana: a cross-sectional study. Hum Resour Health. 2014;12:43.
    1. Greenspan JA, McMahon SA, Chebet JJ, Mpunga M, Urassa DP, Winch PJ. Sources of community health worker motivation: a qualitative study in Morogoro Region, Tanzania. Hum Resour Health. 2013;11:52.
    1. Kalyango JN, Rutebemberwa E, Alfven T, Ssali S, Peterson S, Karamagi C. Performance of community health workers under integrated community case management of childhood illnesses in eastern Uganda. Malar J. 2012;11:282.
    1. Antwi GD, Bates LA, King R, Mahama PR, Tagbor H, Cairns M, et al. Facilitators and barriers to uptake of an extended seasonal malaria chemoprevention Programme in Ghana: a qualitative study of caregivers and community health workers. PLoS One. 2016;11(11):e0166951.
    1. Fogarty L, Kim YM, Juon H-S, Tappis H, Noh JW, Zainullah P, et al. Job satisfaction and retention of health-care providers in Afghanistan and Malawi. Hum Resour Health. 2014;12(1):11.
    1. Abbey M, Bartholomew LK, Nonvignon J, Chinbuah MA, Pappoe M, Gyapong M. Factors related to retention of community health workers in a trial on community-based management of fever in children under 5 years in the Dangme West District of Ghana. Int Health. 2014;6(2):99-105.
    1. Blanas DA, Ndiaye Y, Nichols K, Jensen A, Siddiqui A, Hennig N. Barriers to community case management of malaria in Saraya, Senegal: training, and supply-chains. Malar J. 2013;12:95.
    1. Mpembeni RNM, Bhatnagar A, LeFevre A, Chitama D, Urassa DP, Kilewo C, et al. Motivation and satisfaction among community health workers in Morogoro Region Tanzania: nuanced needs and varied ambitions. Hum Resour Health. 2015;13:44.
    1. Svege S, Kaunda B, Robberstad B, Nkosi-Gondwe T, Phiri KS, Lange S. Post-discharge malaria chemoprevention (PMC) in Malawi: caregivers’ acceptance and preferences with regard to delivery methods. BMC Health Serv Res. 2018;18(1):544.
    1. Gondwe T, Robberstad B, Mukaka M, Lange S, Blomberg B, Phiri K. Delivery strategies for malaria chemoprevention with monthly dihydroartemisinin-piperaquine for the post-discharge management of severe anaemia in children aged less than 5 years old in Malawi: a protocol for a cluster randomized trial. BMC Pediatr. 2018;18(1):238.
    1. Creswell JW, Fetters MD, Ivankova NV. Designing a mixed methods study in primary care. Ann Fam Med. 2004;2(1):7–12.
    1. Smith J, Firth J. Qualitative data analysis: the framework approach. Nurse Res. 2011;18(2):52–62.
    1. Houghton C, Murphy K, Shaw D, Casey D. Qualitative case study data analysis: an example from practice. Nurse Res. 2015;22(5):8–12.
    1. Lohfeld L, Kangombe-Ngwenya T, Winters AM, Chisha Z, Hamainza B, Kamuliwo M, et al. A qualitative review of implementer perceptions of the national community-level malaria surveillance system in Southern Province, Zambia. Malaria J. 2016;15(1):400.
    1. Winn LK, Lesser A, Menya D, Baumgartner JN, Kipkoech Kirui J, Saran I, et al. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health. 2018;8(1):010401.
    1. Gilroy KE, Callaghan-Koru JA, Cardemil CV, Nsona H, Amouzou A, Mtimuni A, et al. Quality of sick child care delivered by health surveillance assistants in Malawi. Health Policy Plan. 2013;28(6):573–585.
    1. Prytherch H, Kagoné M, Aninanya GA, Williams JE, Kakoko DC, Leshabari MT, et al. Motivation and incentives of rural maternal and neonatal health care providers: a comparison of qualitative findings from Burkina Faso, Ghana and Tanzania. BMC Health Serv Res. 2013;13(1):149.
    1. Abdel-All M, Putica B, Praveen D, Abimbola S, Joshi R. Effectiveness of community health worker training programmes for cardiovascular disease management in low-income and middle-income countries: a systematic review. BMJ Open. 2017;7(11):e015529.
    1. Busza J, Dauya E, Bandason T, Simms V, Chikwari CD, Makamba M, et al. The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe. Health Policy Plan. 2018;33(3):328–334.
    1. George M, Pant S, Devasenapathy N, Ghosh-Jerath S, Zodpey S. Motivating and demotivating factors for community health workers: a qualitative study in urban slums of Delhi, India. WHO South-East Asia Journal of Public Health. 2017;6(1):82–89.
    1. Pallas SW, Minhas D, Pérez-Escamilla R, Taylor L, Curry L, Bradley EH. Community health Workers in low- and Middle-Income Countries: what do we know about scaling up and sustainability? Am J Public Health. 2013;103(7):e74–e82.
    1. Shelley D, Nguyen L, Pham H, VanDevanter N, Nguyen N. Barriers and facilitators to expanding the role of community health workers to include smoking cessation services in Vietnam: a qualitative analysis. BMC Health Serv Res. 2014;14(1):606.
    1. Brunie A, Wamala-Mucheri P, Otterness C, Akol A, Chen M, Bufumbo L, et al. Keeping community health workers in Uganda motivated: key challenges, facilitators, and preferred program inputs. Glob Health Sci Pract. 2014;2(1):103–116.

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