Table of Contents  
Year : 2015  |  Volume : 17  |  Issue : 1  |  Page : 4-11

Effect of primary health care workers training on the knowledge and utilization of intermittent preventive therapy for malaria in pregnancy in Zaria, Nigeria

Department of Community Medicine, ABUTH, Zaria, Nigeria

Date of Web Publication7-Jan-2015

Correspondence Address:
Adegboyega M Oyefabi
Department of Community Medicine, ABUTH, Zaria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2276-7096.148561

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Introduction: Malaria in pregnancy (MIP) is one of the leading causes of maternal deaths and adverse pregnancy outcomes in Nigeria. All pregnant women in the country are at risk of MIP. Since 2001, intermittent preventive therapy (IPTp) using pyrimethamine sulfadoxinewas recommended by the World Health Organization as a strategy for prevention of MIP. Nigeria adopted this policy in 2005. This study was carried out to determine the effects of training primary health care workers on the utilization of IPTp among pregnant women who attend antenatal clinics in Sabon-Gari local government area (LGA) of Kaduna State, Nigeria.
Methodology: Using quasi-experimental pre and post study design. Two LGAs were sampled, SabonGari the intervention LGA and Zaria LGA as the control. One hundred and seventy clients each from the 6 Primary Health Care Centers (PHCs) in Sabon-Gari, the study and 5 PHCs in Zaria LGA, the control were selected. Semi-structured, Pre-tested questionnaires and focused group discussion (FGD) guides were used as an instrument of data collection from the clients' pre- and post-intervention. Data were analyzed with SPSS 17 and STATA 12SE. Relationships between variables were tested using χ2 at P < 0.05 level of significance.
Results: Majority of the clients aged 20-24 years, were married, Hausa Muslims Intermittent preventive therapy had mainly primary education, and earn < 5000/month. During the baseline assessment at the PHCs in Sabon-Gari LGAs, only 20 (11.8%) of the clients had good knowledge of the IPTp. This however increased significantly to 144 (87.4%) clients post intervention (mks 11.12 ± 1.99 P < 0.001). A significant majority of the clients in Zaria still had poor knowledge of the IPTp post study (mean knowledge score = 3.86 ± 2.50, P < 0.001). The poor practice in Zaria also persisted even after the study period, but with a significant decrease from 160 (94.12%) to 142 clients (83.53%), with the mean practice score in Zaria being 2.62 ± 1.72, P < 0.001). More clients (68%) use IPTp - sulfadoxine pyrimethamine at the study LGA postintervention.
Conclusion: This research has demonstrated significant improvement in the knowledge and utilization of the IPTp by the clients in the study LGA when the health care workers were trained compared with where such training was not conducted, in the control LGA.

Keywords: Intermittent preventive therapy, quasi-experimental, training, utilization

How to cite this article:
Oyefabi AM, Sambo MN, Sabitu K. Effect of primary health care workers training on the knowledge and utilization of intermittent preventive therapy for malaria in pregnancy in Zaria, Nigeria. J Med Trop 2015;17:4-11

How to cite this URL:
Oyefabi AM, Sambo MN, Sabitu K. Effect of primary health care workers training on the knowledge and utilization of intermittent preventive therapy for malaria in pregnancy in Zaria, Nigeria. J Med Trop [serial online] 2015 [cited 2023 Oct 2];17:4-11. Available from:

  Introduction Top

Nigeria has one of the highest maternal mortality ratios in the world, 545 maternal deaths/100,000 live births compared with <10 deaths/100,000 live births in the developed countries. [1] Maternal death is the death of a woman, while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental causes. [1]

One of the main causes of maternal mortality in Nigeria is malaria in pregnancy (MIP) which accounts for 11% of the maternal deaths in about 7.5 million Nigerians who are pregnant every year. [2] In addition to the direct health impact of malaria, there are also severe social and economic burdens on communities and the country as a whole, with about 132 billion Naira lost to malaria annually in the form of treatment costs, prevention, and the loss of work time. In the year 2000, an estimated 350-500 million clinical cases of malaria occurred worldwide and >1 million people died from the disease, according to the World Health Organization (WHO). This however reduced to about 225 million cases of clinical malaria and 781,000 deaths by the year 2009. [3]

To combat the problem of the MIP, the Federal Ministry of Health in Nigeria introduced the intermittent preventive therapy (IPTp) strategy in 2001 using sulfadoxine pyrimethamine (SP). This policy recommended that the pregnant women should receive the IPTp-SP for malaria during pregnancy. In accordance with the national protocol, SP is given free of charge to pregnant women through the antenatal care (ANC) services at public health facilities and non-governmental organization facilities. Using an approach of directly observed therapy (DOTs), two doses of SP are given during the second and third trimester. The first dose is given after 16 weeks (after quickening) and the 2 nd dose at least 4 weeks after. The therapy should not be administered in the last 4 weeks of gestation. A third dose is also recommended for pregnant women who are HIV positive. This is administered under the strict supervision of the health workers. Studies have shown that this approach is very effective during pregnancy. [4]

However, there is still low utilization of IPTp in pregnancy in Nigeria despite its efficacy, cost effectiveness and easy accesibility to the SP. [5] During the National Demographic and Health Survey in 2008 information were collected on the number of doses of SP taken by the pregnant women. Overall, only 18% of the pregnant women took any antimalarial drug during their last pregnancy, whereas 11% of the women received at least one dose of SP for malaria prevention in pregnancy. Just 7% received the recommended two doses of the IPTp-SP. More pregnant women (8%) received the complete schedule of SP doses during an ANC visit in urban areas compared with the 4% in rural areas. [6],[7] The uptake in the Northwestern Nigeria was the lowest with only 3.9% utilization of at least one dose of SP in pregnancy while the south-west and the south east had values as high as 14% and 17.9% respectively.

The primary health care workers (PHCWs) play a crucial role in the SP delivery. These roles include health education, initiation of appropriate treatment with SP based on the national guideline, treatment of simple MIP and urgent referral of the severe cases. So the appropriate training of the PHCWs may have a significant effect on client uptake and utilization of this therapy. [6],[7] However, there are no documented research in Zaria, northwestern Nigeria to accept or reject this hypothesis. The general objective of this study, therefore, is to determine the effects of training PHCWs on the utilization of the IPTp among pregnant women who attend antenatal clinic in Sabon-Gari local government area (LGA) of Kaduna state. The scope of this study includes an assessment of the knowledge and practice of the IPTp and also determining the factors affecting the IPTp-SP utilization by the pregnant women. [8]

  Methodology Top

Study Design

This research used quasi-experimental study design consisting of a preintervention, intervention and postintervention components. The study population was the clients whose gestational ages are between 16 and 34 weeks and who attend antenatal clinic at the Primary Health Care Centers (PHC) in Sabon Gari LGA, whereas the control were a similar group of clients from Zaria LGA.

Study Area

The study was conducted in Zaria metropolis consisting of Sabon Gari and Zaria LGA. The Zaria LGA has an estimated population of 495,943. It is bounded by Sabon Gari in the west, Soba LGA in the east and Igabi LGA in the south. The administrative headquarter is Zaria city, and it has 13 political wards 7 in the northern and 6 in the southern division of the LGA namely Kufena, TukurTukur, Tudunwada, Gyellesu, Dambo, Fatika and Kwarabai B in the north, and AngwaJuma, Babandodo, Kaura and Kwarabai A, Dutse Abba and Wucciciri in the southern division of Sabon-Gari LGA was carved out of Zaria LGA in 1996. The LGA is boarded by Giwa on the western part, Soba in the East, Kudan in the North and in the South with Zaria LGAs. The Sabon-Gari LGA has a total population of 322,876 based on the 2006 national census. Both LGAs are in the guinea savannah region with temperature range of 22.7° December to January during the Harmattan to as high as 28-30° in April. Rainfall is between April and October. Maximum rainfall is in August. The LGA is in a hollow endemic malaria zone. The major occupation is farming, and the major language spoken is Hausa. The main religions are Islam and Christianity. The 2 LGAs have one Emir, the Emir of Zazau. The popular Ahmadu Bello University campuses are located in the 2 LGAs. [9]

Sampling Technique

Multistage sampling method was used to select the respondents, and the following stages were followed: Sabon-Gari LGA was the study LGA, while the other urban LGA in Zazzau emirate, Zaria, was selected purposively to allow for comparability of the population (demographic) characteristics and to improve the accuracy of findings. The six PHCs that offer comprehensive maternal and child health (MCH) services were selected from the 11 wards in Sabo LGA. 5 PHCs were selected by simple random sampling technique (balloting) from the 13 health wards in Zaria LGA. There was then a proportional allocation of the number of clients needed per facility based on the average number of clients that attend the antenatal clinic weekly. Systematic random sampling technique was used to select the clients until the required sample size was obtained in each center. The PHCs selected from Sabon Gari LGA were; Samaru, Limi, Abdul Kwari, Chikaji, Kwata and Jama'a. The clients selection was proportionally allocated based on the client load per center using the ratio 4:4:4:2:2:1 respectively. The health centers in Zaria LGA were stratified to the northern and southern divisions of the LGA. Two health centers, Tundu wada and Dambo in the northern division and Babandodo Rimi Doko andWuciciri in the southern division of the LGA by the simple random sampling technique (balloting) from the 36 PHCs in Zaria. The ratio for the distribution of the clients in Zaria LGA per facility was as follow:

Babandodo: Tudunwada: Wuciciri: Dambo: RimiDoko: 4:2:2:1:1.

Sample Size

The sample size for the study was 170 each for pre and post intervention in the study and control LGA using the formula n = 2 (Zα + Z 1-β) 2 Pq/d 2 .

Zα is the standard normal deviate, set at 1.96 (for 95% confidence level),

d is the desired degree of accuracy (taken as 0.05).

p, is the estimate of the proportion of pregnant women who practice IPTp/in Kaduna state = 0.021. [9]

q = Complimentary probability to P = (1 − P) = (97.9%).

The pregnant women who were booked at these centers and the PHC workers who attended to them were included in the study.

Exclusion Criteria

The women who had a history of sulfonamide reactions and those whose gestational ages were <16 weeks or >34 weeks were excluded from this study to avoid the possible in utero side-effects of the SP.

Data Collection

Data were collected from the pregnant women (both the control and study group) about their knowledge of MIP and the utilization of SP for malaria prophylaxis with structured interviewers administered closed (with few open) ended questions on social, demographic features, the fertility pattern, the utilization of the ANC services, knowledge of IPT and utilization of malaria prevention in pregnancy, including the practice of the IPTp by the respondents.

The researcher trained eight research assistants who assisted in data collection and collation.

The Training Intervention

The Intervention was the training for PHCWs on standard guideline for the SP-IPTp. They were expected to disseminate the knowledge to the clients via the routine health education sessions in the clinic. The training was done at each facility because the health workers could not leave their various clinics for a centralized location due mainly to the few number of the health workers per center, but we were able to conduct a joint training for the health workers in Jama'a and Samaru PHCs at the seminar room of the Samaru PHC.

This training lasted for a period of 2 weeks. There were 2 h per session with 1 h lecture and 1 h interactive discussions, questions and answers. There were two sessions of the training per center per week at varied times usually when the workers were less busy. Some time, the research team covered 2-3 PHCs in a day.

Three months after the training intervention, postintervention data were collected in both the study and the control LGAs using the same sample size, sampling technique, study instruments and research team as done at the baseline. The post intervention data were collected from 17 th to 30 th October 2012 in the study and from 1 st to 15 th November 2012 in the control facilities.

Data Analysis

The Statistical Package for Social Sciences (SPSS) version 18, STATA12SE and IBM Microsoft EXCEL 2007 were used for data entry and analysis. The results of the analysis were presented in statistical forms as graphs, charts and tables. Chi-squares were used to test for associations between the knowledge of IPTp pre- and post-intervention among the health workers and the client's socio demographic features, fertility patterns, ever use, never use and the proportion of pregnant women who use IPTp pre- and post-intervention. The researcher also sought to find out if there were any significant associations in the utility rate attributable to the intervention. Statistical significance was set at P < 0.05. The mean knowledge and the mean practice scores for the IPTp were determined, and the odds ratio (OR) was used to determine the factors affecting the utilization of the IPTp.

Ethical Considerations

The Approval to conduct the research was obtained from the Ethical and Scientific Review committees of the Ahmadu Bello University Teaching Hospital, Zaria. Permission was obtained from the Sabon-Gari and the Zaria LGA council and the supervising heads of the selected PHCs. The purpose of the research was fully explained to the participants. Individual consents were also obtained from each participant to conduct the research.

  Results Top

Majority of the respondents were aged 20-24 years, mean ages were 23.35 ± 5.165 and 23.33 ± 4.31 in the study and control LGA respectively before intervention. They were married, Hausa Muslims who had mainly primary education, and earn < 5000/month [Table 1]. The awareness of the IPTp increased from 60% to 68% in the study LGA and significantly from 52% to 74% in the control LGA [Table 2]. The major source of information on the IPTp was through the routine health education given by health workers during scheduled ANC visits [Table 3]. The knowledge of the IPTp increased from 11.8% to 87.4% (mean knowledge score = 3.86 ± 2.50, P < 0.001), while its utilization increased significantly from 51.6% to 68.3%, post intervention in Sabon Gari, but a significant majority of the clients in Zaria still had poor knowledge of the IPTp post study (mean knowledge score = 3.86 ± 2.50, P < 0.001). The poor practice in Zaria also persisted even after the study period, but with a significant decrease from 160 (94.12%) to 142 clients (83.53%), with the mean practice score in Zaria being (2.62 ± 1.72, P < 0.001). The factors influencing the IPTp utilization include the education status, fear of drug reaction, availability of the drug at the ANC facility and the gestational age at booking (P < 0.05).{Table 1}{Table 2}{Table 3}

  Discussion Top

The clients were young reproductive-aged women with a mean age of approximately 23 years. This falls within the reproductive age of 15-49 years. Most of the clients had only primary education, and earn < 5000/month [Table 1]. This is <1 dollar/day, which is an indication of extreme poverty. [9] Many of these women could not therefore, afford to pay for a comprehensive health services at the ANC facilities. They relied on the free health care services provided at the PHCs by the state government and would, therefore, prefer if available to get free SP at the facility. Most of the facilities visited in the course of this study sold the SP between N50.00 and N100. Some clienteles could not afford this 'exorbitant' cost and therefore utilize only the free Folic acid and Fesolate. [10] A Study from Tanzania revealed that no matter how modest or cheap the price of the drug may be, the pregnant women usually get disappointed with paying for ANC services including purchasing of the SP and they may even loose trust in the health care workers (HCWs) in light of their awareness that the IPTp-SP is supposed to be given free. [11] This was also observed in Zaria city in the course of this study where some clients would not want to buy the drug from the HCWs, this is because during their last visit, when the free drug supply was available, the SP was given free. The cost of the SP was a strong determinant of the utilization of the IPTp by the Zaria clients (OR = 5.03, confidence interval [CI] =2.5-10.1, P = 0.001) [Table 4]. The inconsistent supply of the free SP by the state ministry of Health and the National Malaria Control Program (NMCP) to the PHCs is capable of paralyzing the IPTp policy. Concern about costs as a determinant of the utilization of the IPTp, the association between costs of accessing health care services and low utilization of hospital services by the poor is widely documented by previous authors. [12],[13],[14],[15]{Table 1}{Table 4}

This is a big challenge to the IPTp-SP delivery in Nigeria. The policy on free IPTp is available, but the drugs are not available in many PHCs. The poor, who attend the PHCs in most cases, may have to pay to get the drug either from the HCWs or outside the clinic. The currently introduced SURE-P MCH program of the federal government of Nigeria, coordinated by the National Primary Health Care Development Agency, if well implemented, may address this problem of cost, since the ANC attendees may benefit from the conditional fund transfer after fulfilling the specified criteria. But addressing the problem of unemployment and promotion of women empowerment program by both government and development partners will be a more enduring solution. [16]

It was found in this study also that the facilities in villages located relatively far from the Zaria metropolis such as Wuciciri, RimiDoko, Dambo and Jamaa did not have the IPT-SP supply most of the time compared to PHCs within the city, hence their utilization of the IPTp-SP were very poor. This anomaly needs to be corrected. There is a need for equity in the distribution of the IPTp-SP to every PHC in the LGA to achieve the much-desired reduction in the burden of the MIP in Zaria. [17-18]

A major concern in the utilization of the IPTp-SP in Zaria is that the health workers were not trained on the IPTp prior to this study, and this is reflected in an FGD with the Community Health Officer in charge of the Tudun Wada PHC who told the researcher that we "have never attended any training on the IPTp."" There was also confusion about time of administration of the SP in Samaru PHC among the PHCWs during an FGD, where each of the health workers had different views of the correct time to take the SP in pregnancy. A Health worker believed the drug should be given about the 16 weeks after quickening, but others said "the drug might cause abortion at 16 weeks, it is better given at 24 weeks." If PHCWs could not clearly say the correct time for the administration of the IPTp, can we expect their clients to know? [19] Studies in Kenya and Malawi had revealed similar findings where the PHCWs had poor knowledge of when to start the IPTp and could not identify the gestational fundal heights. This kind of situation might have negative consequences on the ANC attendees and their unborn babies since they were given the therapy at the wrong time. [20] Administration of the IPT-SP at less than the 16 weeks may cause fetal neural tube defect and when given at more than above 34 weeks may lead to neonatal jaundice, or in severe cases kernicterus. This may eventually lead to severe complication such as fetal or neonatal death. [21]

It was also noted in this study that majority of the clients also took the drug at home without supervision as prescribed by the PHCWs [Table 4]. The PHCWs at both LGAs not practicing DOTs IPTp were making this home recommendation because they were not aware of either the national or the WHO guideline stipulating the supervised utilization of the IPTp in the hospital and not at home. [22] The few HCWs who were aware of taking the drug using the Directly observed strategy complained of nonavailability of water, and inadequate number of staff to justify the nonadherence to DOTs. [23] This practice makes it difficult to know if the patients actually takes the drug or takes it correctly. Monitoring and evaluation for proper planning for SP distribution will also be difficult. [24]{Table 4}

Just like in Zaria, a study in Tanzania found out that SP was not always available at the health facility pharmacy; clean cups and water were also not available to administer the drugs. The pregnant women were buying their drugs at an external pharmacy and they took the drugs at home. Allowing pregnant women to take the IPTp drug unsupervised, either at the clinic or home, makes compliance uncertain and undermines the essence of IPT pstrategy. [25]

This study shows that the home utilization of the IPTp-SP significantly reduced in the study sites (P = 0.0001) but significantly increased in the control LGA (P = 0.0145) after the training intervention [Table 4]. This clearly showed that just asking the health workers to give the SP to the clients at the Ante Natal Clinic is not enough but training and retraining of these health workers and provision of an enabling environment can improve this practice in these facilities.{Table 4}

During the baseline assessment at the PHCs in Sabon-Gari LGAs, only 20 (11.8%) of the clients had good knowledge of the IPTp. This however increased significantly to 144 (87.4%) clients post intervention (mks 11.12 ± 1.99 P < 0.001). A significant majority of the clients in Zaria still had poor knowledge of the IPTp post study (mean knowledge score = 3.86 ± 2.50 P < 0.001). These have further corroborated the need for sustained training on the IPTp to ensure correct utilization.

This proportion of the ever use of the IPTp-SP in this study was 64.11% at the baseline, which increased to 72.94% after the intervention at the study LGA. While that of current use was 51.58% and 55% respectively pre intervention, which later increased to 68.2% and 63.53% at the control LGA [Table 5]. This is comparable to previous studies in Africa. [26],[27] It is also a good development that more pregnant women began to take the 2 nd dose of the IPTp within the recommended period of at least 4 weeks after the first dose as observed in this study.{Table 5}

At the baseline assessment, only 2.4% of the clients in the study and 1.76% in the control can be adjudged with good practice based on the selected ten questions that were asked the clients a score of 1-4 was considered poor, 5-6 fair and any score > 6 was good. There was significant increase in the good practice of the IPTp in the study population from four clients (2.4%) at the baseline assessment to 88 (51.8%) post intervention in the Sabo-Gari PHCs with a mean practice score of (5.52 ± 3.17, P < 0.001). The poor practice in Zaria persisted even after the study period, but with a significant decrease from 160 (94.12%) to 142 clients (83.53%), with the mean practice score in Zaria being 2.62 ± 1.72, P < 0.001).

This is similar to a previous study in Nigeria that found out that few health workers adhered to the DOTs IPTp strategy in public and private health facilities. [28] In our FGD in Tudun wada PHC we also learnt some women avoided taking the drug in the clinic by the flimsy excuse that they did not eat from home before coming for the ante natal visit.

The factors that were found to be strongly associated with the utilization of the IPTp in Sabo LGA were clients' educational attainment (OR = 4.71, 95% CI = 1.23-12.4, P = 0.01) and the drug availability at the facility (OR = 4.18, 95% CI = 2.07-8.43, P < 0.0001), while cost of the SP (OR = 5.03, 95% CI = 2.5-12.4, P = 0.001), clients' educational attainment (OR = 3.17, 95% CI = 1.59-6.31) and the booking age (OR = 2.66, 95% CI = 1.25-5.70, P = 0.02) were the determinants for the utilization of the IPTp in Zaria LGA. Other associated factors in Zaria LGA were the number of pregnancies (parity), distance, fear of the reaction and previous failure of the SP (OR > 1) [Table 4]. This is similar to the findings of the National Malaria Indicator Survey, which identified education level, wealth and place of settlement as the possible determinants. Other studies in Nigeria and Africa have also identified knowledge and care seeking behavior of the pregnant women as key determinants of utilization of preventive measures. [29],[30],[31],[32]

Our study has some limitations. This study was conducted at the health facilities in the two LGAs. There might have been selection bias since we do not know about the situation of pregnant women who do not attend the ante natal clinic. Despite these limitations, however, we are confident that our data provide useful information for the predictors of the utilization of the IPTp in Nigeria and will, therefore, inform stakeholders and policy decisions in this LGAs, Kaduna state and the country at large.

  Conclusion Top

From this study, it was found that before intervention the knowledge and the practice of the IPTp by both the health workers and the clients were poor but significantly improved at the study LGAs but not at the control post intervention. The major factors affecting the utilization of the SP at these facilities were the knowledge of the PHCWs, educational status of the client, the cost of the SP, the gestational age at booking, distance of the client home to the PHCs, the availability of the drug in the facility, the fear of the reaction to the drug and the previous experience of the failure of the SP malaria prophylaxis.


  • The study has demonstrated that the training of the health care providers can bring about significant improvement to effective utilization of the IPTp. Therefore, the health department of each LGA in collaboration with the NMCP should ensure the training and retraining of the PHC workers at the ANC on the IPTp-SP
  • The trained HCWs in each facility should also ensure regular health education during the ANC for the pregnant women on the IPTp as an effective malaria prophylaxis in pregnancy

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  [Table 1]JMedTrop_2015_17_1_4_148561_t1.jpg, [Table 2]JMedTrop_2015_17_1_4_148561_t2.jpg, [Table 3]JMedTrop_2015_17_1_4_148561_t3.jpg, [Table 4]JMedTrop_2015_17_1_4_148561_t4.jpg, [Table 5]JMedTrop_2015_17_1_4_148561_t5.jpg

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