Barriers to IPTp uptake: access vs. quality
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1 Innovative approaches to identify and apply context-specific interventions Barriers to IPTp uptake: access vs. quality Marcia Castro & Jesse Heitner Harvard School of Public Health
2 Aims What are the impediments for achieving better IPTp coverage, in the context of Kenya? IPTp correctly administered? Are there significant spatial patterns in the IPTp intake? Individual characteristics Quality (HF) Access (District) Evidence for interventions?
3 Angola MIS Burkina Faso DHS 2003 Cameroon DHS 2004 Congo (Brazz.) DHS 2005 Ethiopia DHS 2005 Kenya DHS Kenya DHS 2003 Liberia MIS 2009 Madagascar DHS Malawi DHS 2010 Malawi DHS 2004 Niger DHS 2006 Nigeria DHS 2008 Nigeria DHS 2003 Rwanda Int.DHS Rwanda DHS 2005 S.T. Principe DHS Senegal DHS Senegal DHS 2005 Sierra Leone DHS 2008 Tanzania DHS 2010 Tanzania DHS Uganda DHS 2006 Zambia DHS 2007 Zambia DHS Zimbabwe DHS Zimbabwe DHS % who took any anti-malarial drug
4 Angola MIS Burkina Faso DHS 2003 Cameroon DHS 2004 Congo (Brazz.) DHS 2005 Ethiopia DHS 2005 Kenya DHS Kenya DHS 2003 Liberia MIS 2009 Madagascar DHS Malawi DHS 2010 Malawi DHS 2004 Niger DHS 2006 Nigeria DHS 2008 Nigeria DHS 2003 Rwanda Int.DHS Rwanda DHS 2005 S.T. Principe DHS Senegal DHS Senegal DHS 2005 Sierra Leone DHS 2008 Tanzania DHS 2010 Tanzania DHS Uganda DHS 2006 Zambia DHS 2007 Zambia DHS Zimbabwe DHS Zimbabwe DHS % who took 2+ doses (SP/Fansidar)
5 IPTp in Kenya First introduced in 1998 The 1 st dose given at 16 weeks of gestation; subsequent doses with each ANC scheduled visit as long as they are 1 month apart. IPTp coverage below the target Providing clear directions on when to give IPTp in a memo from the MOH, and the review of this memo during routine supervisory visit, resulted in a twofold increase in coverage of the recommended 2 doses of IPTp.
6 IPTp in Kenya - coverage 60% 50% 40% 92% of women in Kenya receive antenatal care from a medical professional: doctors (29%), nurses/midwives (63%) 2008/9 30% 20% 10% 0% Any drug One dose of SP/Fansidar 2+ doses of SP/Fansidar 2+ doses of SP/Fansidar, at least one during ANC
7 IPTp in Kenya spatial patterns
8 IPTp in Kenya spatial patterns
9 IPTp uptake - framework District Individual/HH Education, Income, Bednet ownership Health Facility Cluster Access Quality Characteristics Proportion of district area covered by roads ANC facilities per 1000 women of childbearing age in the district
10 Modeling approach Multilevel model Individual/HH Health Facility/DHS Cluster District Data: DHS 2008/2009 DHS 2010 Service Provision Assessment Access variables created with the aid of GIS
11 IPTp in Kenya - Individual characteristics Individual Any Drug 2 SP doses 2 SP ANC Odds Odds Odds Household Owns a bednet *** *** *** Married * Age * More than Secondary Ed ** ** ** Complete Secondary Ed *** ** ** Some Secondary Ed *** ** ** Complete Primary Ed ** * * Some Primary Ed ** ** Wealth Quintile ** *** p 0.001; ** p 0.05; * p 0.1
12 IPTp in Kenya - HF HF/Cluster *** p 0.001; ** p 0.05; * p 0.1 Any Drug 2 SP doses 2 SP ANC Odds Odds Odds Access: Distance to nearest HC (Km) ** ** * Prob. experiencing minor cost problems ** Quality: Prob. Recommeding Facility ** Major problems with waiting times * The average wait is 1-3 hours ** Provider explains how to take IPTP * HF gives counseling about 4 visits ** ** The average wait is minutes ** Characteristics: Midwives work at HC * Midwives refer women to HC **
13 IPTp in Kenya - District District Any Drug 2 SP doses 2 SP ANC Odds Odds Odds Km 2 of roads per 1000 Km ** Km 2 of roads per 1000 Km *** # ANC facilities / 1000 women (15-45) ** ** *** p 0.001; ** p 0.05; * p 0.1
14 More roads, better coverage?
15 IPTp in Kenya all levels Any Drug 2 SP doses 2 SP ANC Proportion of total variance explained at facility level Proportion of total variance explained at district level Proportion of total variance explained at individual 3.64% 0.00% 3.32% 12.05% 5.35% 5.93% 19.67% 22.08% 21.17%
16 IPTp in Kenya what s next? Training
17 IPTp in Kenya what s next?
18 IPTp in Kenya what s next? Optimizing the spatial distr. of HFs with ANC
19 IPTp in Kenya what s next?
20 IPTp in Kenya what s next? mhealth Mobile technology to increase ANC attendance and IPTp uptake Uganda Ghana Tanzania/Zanzibar Send text reminders of appointments based on date of 1 st visit and gestational age
21 IPTp in Kenya what s next? Tracking pregnant women Small area estimation Demand Women in reproductive age Pregnant women Under coverage (?) Expected number of pregnant women CHWs CHW & mhealth Surveillance
22 Intermittent Screening and Treatment (IST) Active detection and case management process using ANC as a platform Rwanda - completed a study using RDTs and treatment of those with parasitemia during first ANC visit and is in the process of setting guidelines for formalizing this as part of ANC UNICEF in collaboration with USAID is piloting IST in selected regions of Indonesia Low transmission areas - IPTp or IST?
23 ANC & IPTp: bridging the gap Information Quality/Access Surveillance mhealth/chw???
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