SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA FACTORS ASSOCIATED WITH UPTAKE OF INTERMITTENT PREVENTIVE TREATMENT IN PREGNANCY IN ADAKLU DISTRICT IN THE VOLTA REGION BY RAPHAEL WORLANYO AKPAH (10936040) A THESIS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE. APRIL, 2023 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION I declare that with the exception of references to other people’s work, which have been duly acknowledged, this research work is my own work done under supervision. I also declare that this research work, partly or in whole, has not been submitted to any university for the award of any degree. Raphael Worlanyo Akpah …………………… April 15, 2023 (Student) (Signature) (Date) Dr. Priscillia Nortey April 15, 2023 (Supervisor) (Signature) (Date) University of Ghana http://ugspace.ug.edu.gh iii DEDICATION This work is dedicated to my wife Benedicta Dzissah and my good friend Dennis Tabiri for their immense support. I am forever grateful. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT I thank the Almighty God for his protection and guidance which has seen me through this phase and many other phases of my life. My heartfelt gratitude goes to my supervisor, Dr. Priscilla Awo Nortey for her guidance and counselling which extended beyond the scope of this research. I also acknowledge the support of all my friends especially Charles Kafui Agblanya, whose contribution to this research was invaluable. I am also grateful to Mr. Charles Kofi Azagba for his encouragement and support through it all. University of Ghana http://ugspace.ug.edu.gh v TABLE OF CONTENTS DECLARATION ......................................................................................................................... ii DEDICATION ............................................................................................................................ iii ACKNOWLEDGEMENT ......................................................................................................... iv TABLE OF CONTENTS ............................................................................................................ v LIST OF ACRONYMS AND ABBREVIATIONS .................................................................. ix LIST OF TABLES ...................................................................................................................... xi LIST OF FIGURES ................................................................................................................... xii ABSTRACT................................................................................................................................xiii CHAPTER ONE ..........................................................................................................................1 INTRODUCTION .......................................................................................................................1 1.1 Background ............................................................................................................................1 1.2 Problem statement ..................................................................................................................2 1.3 Research questions. ................................................................................................................4 1.4 Objectives ...............................................................................................................................4 1.4.1 General objectives ...........................................................................................................4 1.4.2 Specific objectives ...........................................................................................................4 1.5 Justification of the study ........................................................................................................5 1.6 Conceptual framework for uptake of IPTp. ...........................................................................6 1.6.1 Narration of conceptual framework .................................................................................7 CHAPTER TWO .........................................................................................................................9 LITERATURE REVIEW ...........................................................................................................9 University of Ghana http://ugspace.ug.edu.gh vi 2.1 Malaria in pregnancy burden..................................................................................................9 2.2 Intermittent preventive treatment of malaria in pregnancy ....................................................9 2.3 IPTp coverage in Ghana .......................................................................................................10 2.4 Socio- demographic factors affecting uptake of IPTp. ........................................................11 2.4.1 Age.................................................................................................................................11 2.4.2 Parity ..............................................................................................................................11 2.4.3 Marital status .................................................................................................................12 2.4.4 Educational level ...........................................................................................................12 2.4.5 Occupation .....................................................................................................................12 2.5 Client level factors ...............................................................................................................13 2.5.1 Knowledge about IPTp and MiP ...................................................................................13 2.5.2 Knowledge of pregnant women on Intermittent Preventive Treatment. .......................13 2.5.3 Source of Knowledge ....................................................................................................13 2.5.4 Male partner involvement ..............................................................................................14 2.6 Healthcare worker factors ....................................................................................................14 2.6.1 Healthcare worker attitude and client interaction ..........................................................14 2.6.2 HCW knowledge about MiP and IPTp ..........................................................................15 2.6.3 Training of HCWs .........................................................................................................15 2.6.4 Patient Nurse Ratio ........................................................................................................16 2.7 Health facility factors ...........................................................................................................16 2.7.1 Accessibility to health facilities .....................................................................................16 2.7.2 IPTp and DOT policy ....................................................................................................17 2.7.3 Stock status ....................................................................................................................17 2.8 Client level characteristics influencing uptake of IPTp. ......................................................18 2.8.1 Gestational age at first Antenatal Care visit ..................................................................18 University of Ghana http://ugspace.ug.edu.gh vii 2.8.3 ANC Attendance (Timing and Frequency)....................................................................18 CHAPTER THREE ...................................................................................................................21 METHODS .................................................................................................................................21 3.1 Study Design ........................................................................................................................21 3.2 Study Area ............................................................................................................................21 3.2.1 Adaklu District and Malaria ..........................................................................................22 3.2.2 ANC and IPTp Delivery in Adaklu ...............................................................................23 3.3 Study Variables ....................................................................................................................23 3.3.1 Dependent Variable .......................................................................................................23 3.3.2 Independent Variables ...................................................................................................23 3.4 Study Population ..................................................................................................................27 3.4.1 Inclusion Criteria ...........................................................................................................28 3.4.2 Exclusion Criteria ..........................................................................................................28 3.6 Sampling Technique.............................................................................................................30 3.7 Data Collection Instruments.................................................................................................31 3.7.1 Data Collection Technique. ...........................................................................................31 3.7.2 Quality Control ..............................................................................................................32 3.7.3 Pre-Testing of Questionnaires .......................................................................................32 3.8 Data Processing and Analysis ..............................................................................................32 3.9 Ethical Consideration ...........................................................................................................33 3.10 Sponsorship ........................................................................................................................34 CHAPTER FOUR .....................................................................................................................35 RESULTS ...................................................................................................................................35 4.1 Socio-demographic characteristics of respondents (women at PNC) ..................................35 4.2 Knowledge of Postnatal women on Malaria in Pregnancy and IPTp ..................................37 University of Ghana http://ugspace.ug.edu.gh viii 4.3: Knowledge on IPTp and Malaria in Pregnancy among HCWs. .........................................40 4.4 ANC attendance and uptake of IPTp. ...................................................................................42 4.5 Healthcare facilities and Uptake of IPTp in in Adaklu District, 2022 .................................44 4.6 Association between socio-demographic characteristics and uptake of IPTp. ....................46 4.7 Association between knowledge of women attending postnatal care on IPTp, Malaria in Pregnancy and uptake of IPTp. ..................................................................................................48 4.8 Association between ANC attendance and uptake of IPTp .................................................51 4.9 Multivariate analysis of association between independent variables and uptake of IPTp. ..52 CHAPTER FIVE .......................................................................................................................55 DISCUSSION, CONCLUSION, AND RECOMMENDATIONS. ........................................55 5.1 Uptake of IPTp among women attending PNC....................................................................55 5.2 Socio demographic characteristics of mothers attending PNC ............................................56 5.3 Client level factors associated with uptake of IPTp .............................................................57 5.4 Healthcare worker factors associated with uptake of IPTp ..................................................58 5.5 Health facility factors associated with uptake of IPTp ........................................................59 5.6 Strength of the study ............................................................................................................59 5.7 Limitation of the study .........................................................................................................59 5.8 Conclusion............................................................................................................................60 5.9 Recommendations ................................................................................................................60 APPENDIX 1: INFORMED CONSENT FORM....................................................................72 APPENDIX 2: QUESTIONNAIRE .........................................................................................76 APPENDIX 3 – GHANA HEALTH SERVICE ETHICAL CLEARANCE ........................77 University of Ghana http://ugspace.ug.edu.gh file:///C:/Users/rakpah/Desktop/New%20folder%20(3)/Thesis.%20Raphael%20Worlanyo%20Akpah_....docx%23_Toc133521162 ix LIST OF ACRONYMS AND ABBREVIATIONS ACT - Artemisinin-based Combination Therapy ANC - Antenatal care DHS - Demography Health Survey DHIMS - District Health Information Management System DHIS - District Health Information System DOT - Directory Observed Therapy GHS - Ghana Health Service GSS - Ghana Statistical Service HCW - Health care Worker IPTp - Intermittent Preventive Treatment of malaria in pregnancy ITNs - Insecticide Treated Nets MIP - Malaria in Pregnancy NHIS - National Health Insurance Scheme NMCP - National Malaria Control Program OPD - Out Patient Department PMI - President’s Malaria Initiative RBM - Roll Back Malaria SP - Sulfadoxine-Pyrimethamine University of Ghana http://ugspace.ug.edu.gh x SSA - Sub-Sahara Africa USAID - United State Agency for International Development WHO - World Health Organization University of Ghana http://ugspace.ug.edu.gh xi LIST OF TABLES Table 1: Operational definition and scale of measurement for variables. .................................23 Table 2: Operational definition and scale of measurement for variables. .................................25 Table 3: Sample size determination by Sub District. ................................................................30 Table 4: Distribution of Socio-demographic characteristics of study participants, Adaklu District, 2022. .............................................................................................................................36 Table 5: Knowledge of postnatal women on IPTp and Malaria in Pregnancy in Adaklu District, 2022 ..............................................................................................................................38 Table 6: Knowledge on IPTp and Malaria in Pregnancy among Healthcare workers in Adaklu District, 2022 ..............................................................................................................................41 Table 7: Distribution of ANC attendance and IPTp uptake in Adaklu District, 2022 ………..43 Table 8: Healthcare facilities and uptake of IPTp in Adaklu District, 2022 .............................45 Table 9: Association between socio-demographic characteristics of mothers and uptake of IPTp. ...........................................................................................................................................47 Table 10: Association between knowledge of women attending postnatal care on IPTp, Malaria in Pregnancy and uptake of IPTp. .................................................................................49 Table 11: Association between ANC attendance and uptake of IPTp. .....................................51 Table 12: Multivariate analysis of association between independent variables and uptake of IPTp. ...........................................................................................................................................53 University of Ghana http://ugspace.ug.edu.gh xii LIST OF FIGURES Figure 1: Conceptual framework showing factors associated with uptake of IPTp. ...............6 Figure 2: Map of Adaklu district showing health facility distribution (GHS, 2022) ............22 University of Ghana http://ugspace.ug.edu.gh xiii ABSTRACT Introduction: Ghana together with other countries adopted a WHO policy in 2016 that provides Intermittent Preventive Treatment in Pregnancy to protect pregnant women and their unborn babies against malaria. This study aimed at assessing factors associated with uptake of Intermittent Preventive Treatment in Pregnancy (IPTp) within the Adaklu District. Method: The study was a cross-sectional study. A structured questionnaire was administered to women attending postnatal care in December, 2022. Antenatal record books of the women attending postnatal care were reviewed and data collected on number of ANC visits and receipt of SP. Simple random sampling technique was used to select respondents from all facilities in each sub-District. HealthCare Workers who render ANC services in health facilities in Adaklu were interviewed. Logistic regression analysis was done to determine the association between the independent variables and uptake of IPTp. Data was analyzed with STATA version 16 with a statistical significance set at 5%. Results: The uptake of IPTp reduced in increasing doses. Uptake for IPTp 1, IPTp3 and IPTp 5 was 98%, 56.3% and 6.9% respectively. Formal education among women attending postnatal care increased uptake of IPTp (OR-1.47 p = 0.001). Up to 29 (72.5%) of HCWs indicated the first dose of SP is given at 16 weeks. Stock levels of SP was adequate to meet the demands by the pregnant women in all the facilities for the period 2022. Conclusion: IPTp 3 which is used as a proxy in calculating IPTp coverage in Ghana observed in this study did not meet the national target of 80%. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background Malaria, a preventable, curable and a life-threatening disease is caused by Plasmodium parasites. An estimated 229 million malaria cases were recorded in malaria endemic countries throughout the world in 2019. An estimated 215 million cases accounting for 94% of cases was recorded in Africa in 2019 (World Malaria Report, 2020). Malaria is endemic with seasonal variations in Ghana. All Ghanaians are susceptible to malaria infection, however due to decreased immunity, children under five and pregnant women are more likely to have severe malaria. Depending on how long the dry season lasts in Ghana, different geographic regions have different malaria transmission seasons (USAID-PMI, 2016). In Africa, malaria infection in pregnancy is primarily caused by Plasmodium falciparum with associated effects such as maternal morbidity and poor birth outcomes including preterm delivery and low birth weight. Malaria in pregnancy can cause stillbirth and preterm birth. Pregnant women are more susceptible to getting malaria and are more likely to suffer the severe form of the disease. In pregnancy, placenta infected with malaria parasites is a major risk factor for perinatal and neonatal and infant mortality, child growth retardation and poor cognitive outcomes (World Malaria Report, 2020). Pregnant women are more vulnerable to malaria due to increased attraction to mosquito, hormonal factors, and immunological changes (Takem & D’Alessandro, 2013). Intermittent University of Ghana http://ugspace.ug.edu.gh 2 preventive treatment in pregnancy (IPTp) is given to pregnant women at 16 weeks of gestation, then monthly till delivery was recommended by WHO in 2012. In 2016, a policy requiring the administration of three or more doses of IPTp to pregnant women was adopted and put into effect by 36 African nations, including Ghana. Comparing to 2015, when 18% of pregnant women took three doses of IPTp, around 19% did so in 2016 (World Malaria Report, 2017). Ghana reviewed and adopted WHO’s recommended 3 strategic approach for preventive and management of malaria in pregnancy (MiP) in 2015. These are distribution and promoting Insecticide Treated Net (ITN) use at first ANC visit, administration of intermittent preventive treatment (IPTp), and management of malaria in pregnant women (USAID-PMI, 2018). Investigating the variables that affect pregnant women's use of IPTp in Ghana's Adaklu District in the Volta region was the main objective of this research. The results of this study will advance our understanding and serve as a blueprint for developing interventions that will increase pregnant women's uptake of IPTp. 1.2 Problem statement The use of sulfadoxine and pyrimethamine (SP), coupled with the promotion of long-lasting bed nets usage for the prevention of malaria in pregnancy was adopted in Ghana in 2003. Given as a directly observed therapy (DOT) at monthly intervals, pregnant women are served with SP as early as 16 weeks during ANC visit. The National Malaria Control Program (NMCP) reviewed and implemented a policy of three or more doses of SP uptake by pregnant women until delivery in 2017 as recommendation by WHO (“Ghana Malar. Indic. Surv.,” 2019). In Sub-Saharan University of Ghana http://ugspace.ug.edu.gh 3 Africa, SP coverage remains low at an average of 11.77% even though there have been remarkable achievements made with ITN uptake (Odjidja et al., 2017). Pregnant women in Ghana who received one dose of SP improved from 58% in 2008 to 91% in 2019, while those who received two doses went from 46% to 80%. Pregnant women who received three doses of SP increased from 28% to 61% throughout the same time frame. Even though IPTp is given until delivery with a maximum of seven doses, the national target for IPTp coverage is 80%. IPTp 3 is used as the proxy in calculating IPTp coverage (“Ghana Malar. Indic. Surv.,” 2019). The Adaklu District recorded a downward trend in its IPTp coverages since 2013. Adaklu District recorded 67.5%, 61.1%, 54.9%, 35.4% and 18% for IPTp 1, IPTp 2, IPTp 3, IPTp 4 and IPTp 5 respectively in 2021 with a dropout of 18.7%. The achieved coverage of 54.9% in 2021 for IPTp 3 is below the national target of 80% or more (DHIMS 2, 2022). The effect of malaria in pregnancy remains a public health concern as it affects the pregnant woman, the fetus and society. Some of the effects of malaria on the pregnant woman are severe anemia, acute pulmonary edema, acute renal failure and death. Spontaneous abortion, premature delivery, perinatal mortality, intrauterine growth restriction and low birth weight are some of the effects of malaria on the fetus. Malaria in pregnancy also causes low productivity, loss of job, and loss of income and resources on the family. Some factors known to contribute to IPTp uptake are client level factors such as age, occupation, religion, caregiver factors such as knowledge on malaria and IPTp and Healthcare facility factors such as availability of SP. University of Ghana http://ugspace.ug.edu.gh 4 The objective of this study was to identify the variables associated with the low uptake of IPTp in the Adaklu District. 1.3 Research questions. 1. What was the uptake of IPTp in Adaklu District in 2022? 2. What are the Health Care Worker (HCW) factors associated with uptake of IPTp in Adaklu District? 3. What are the client factors associated with uptake of IPTp in Adaklu District? 4. What are the health facility factors associated with uptake of IPTp in Adaklu District? 1.4 Objectives 1.4.1 General objectives To assess the factors associated with uptake of IPTp among pregnant women in Adaklu District. 1.4.2 Specific objectives 1. To determine the level of uptake of IPTp in Adaklu District. 2. To determine HCW factors associated with uptake of IPTp in Adaklu District. 3. To assess client factors associated with uptake of IPTp in Adaklu District. University of Ghana http://ugspace.ug.edu.gh 5 4. To identify health facility factors associated with uptake of Adaklu District. 1.5 Justification of the study The introduction of IPTp using SP is aimed towards eliminating malaria in pregnancy and its associated effects. This reality of eliminating malaria in pregnancy will not be achieved if eligible mothers due for IPTp in the Adaklu District do not receive SP when they are due. Research is therefore needed in this area to ascertain the factors contributing to uptake of IPTp in Adaklu District. Studies are needed to determine the variables influencing the uptake of IPTp in Adaklu District. Increased uptake of IPTp would aid in the reduction of low birth weight, maternal anemia, stillbirths and as well as maternal and neonatal fatalities in Adaklu District. The study's recommendations may help authorities to implement initiatives to improve care quality and increase IPTp uptake in Adaklu District. Understanding the factors influencing uptake of IPTp in Adaklu District would help the District Health Directorate (DHD) and other Health Directorates in Ghana implement interventions to improve and sustain uptake of IPTp. University of Ghana http://ugspace.ug.edu.gh 6 1.6 Conceptual framework for uptake of IPTp. Figure 1: Conceptual framework showing factors associated with uptake of IPTp. Client Level Characteristics  Gestational age at first ANC  Gestational age at first IPTp uptake  Number of ANC visits Health System Factors  Accessibility of Health Facility/ANC.  Cost of ANC services.  Quality of care  Stockout of SP  Availability of water at ANC unit  Availability of protocols and job aids on IPTp at ANC unit Client/Caregiver Factors Socio-demographic factors  Age  Educational Level  Occupation  Religion  Marital status  Parity Client Factors  Knowledge on IPTp  Perceptions towards IPTp  Experienced side effects of IPTp  Male Involvement  Distance from home to the Health facility Caregiver Factors  Health Care Worker level of education  Number of Health Care Workers who conduct ANC services at ANC unit  Health Care Worker attitude towards clients  Health Care Worker knowledge on IPTp  IPTp DOT practice by Health Care Workers Uptake of IPTp University of Ghana http://ugspace.ug.edu.gh 7 1.6.1 Narration of conceptual framework Figure 1 is a conceptual framework that shows relationships between and among factors that influences the uptake of IPTp. Newman and Andersen healthcare model serves as the foundation for this concept. The model was developed in the 1960’s and has undergone four phases with the final phase proffered in 1990. The model characterizes an individual's access to health care utilization into 3 main factors; predisposing, enabling and need factors. The predisposing factors refers to the sociocultural and demography factors that exist prior to an individual falling sick. Some of these factors are age, occupation, health beliefs etc. Enabling factors are the factors that promote access to acquiring health care which includes family and social support, availability of health personnel and facilities etc. Immediate cause of using health services is a need factor, such as health issues that create a need for medical care (Andersen, 1995). Client level characteristics like age of pregnancy at first antenatal clinic, gestational age at first uptake of IPTp, number of antenatal clinic visits and G6PD status can influence the uptake of IPTp. Client factors are the factors that positively or negatively affects the uptake of IPTp. Socio- demographic factors such as age, level of education, occupation, religion, income, and parity. Client’s knowledge, perceptions, past experienced side effects of IPTp, male involvement also influences the uptake of IPTp. Caregiver/Health worker factors such as level of education, number of healthcare workers conducting ANC services at the ANC unit, IPTp given as DOT, healthcare worker knowledge on SP and healthcare workers attitude towards clients also contributes to the uptake of IPTp. University of Ghana http://ugspace.ug.edu.gh 8 Health system factors are the factors that makes available IPTp to the eligible pregnant women. These factors are accessibility of ANC, cost of ANC services, quality of care, stock out of SP and availability of water at ANC. University of Ghana http://ugspace.ug.edu.gh 9 CHAPTER TWO LITERATURE REVIEW 2.1 Malaria in pregnancy burden In 2016, 216 million malaria cases were reported globally. About 445,000 people died as a result of this in 2016 (WHO, 2017a). Africa accounts for more than 80% of the world's malaria cases, particularly children under five years of age and among pregnant women (Prasad, Rai, & Hussain, 2018; WHO, 2017a). It is estimated that, 125 million pregnant women globally reside in places where they have a high risk of getting malaria in pregnancy (Dellicour, Tatem, Guerra, Snow, & Ter Kuile, 2010). When compared to non-pregnant women, pregnant women have a threefold increased chance of developing severe malaria (Kovacs, Rijken, & Stergachis, 2015; WHO, 2015). Malaria in pregnancy is responsible for 200,000 neonatal deaths per year (WHO, 2019). Due to this, malaria in pregnancy is a prioritized area. An estimated 399,736 suspected malaria in pregnancy cases were reported in 2017 against 383,034 reported in 2016 (NMCP, 2018). 2.2 Intermittent preventive treatment of malaria in pregnancy Nations with high malaria transmission rates, the WHO advises IPTp using SP to prevent malaria in pregnancy (World Malaria Report, 2013). SP has been confirmed to be safe to use during pregnancy and has no negative effects on the fetus (WHO, 2012). SP, a very cost-effective medicine in preventing malaria during pregnancy and lowering infant mortality in regions with moderate to high malaria transmission rates. It also protects the pregnant women and their University of Ghana http://ugspace.ug.edu.gh 10 unborn children from some harmful effects of malaria such as maternal anemia and neonatal death (Sicuri et al., 2010). A meta-analysis of seven studies in sub-Saharan Africa on IPTp revealed that, three or more doses were linked to a greater mean birth weight than two doses. Placental malaria was less common in the three plus dose group (Kayentao, Garner, Macarthur, & Luntamo, 2013). WHO recommends that, every effort should be made to increase the use of IPTp throughout Africa, particularly in regions with a high malaria infection rate. This need to be covered by antenatal care, which calls for roughly 8 visits from pregnant women and the medicine (SP) served as a Directly Observed Therapy (DOTS). Folic acid at 0.4mg daily can be safely taken in combination with SP to maintain its antimalarial activity. It can be taken with or without food. (WHO, 2012). 2.3 IPTp coverage in Ghana In 2003, Ghana began implementing the IPTp strategy in a few Districts. (Ghana Demographic Health [DHS], 2008). In order to comply with WHO's new guidelines in 2012 which mandated that all pregnant women get at least five doses of SP beginning at sixteen weeks' gestation and continuing until delivery, NMCP amended its policy in 2014 (PMI, 2016). In order to receive the necessary doses of SP, it was crucial that pregnant women begin their ANC visits very early. (Oppong et al., 2019). During the same time period, the proportion of pregnant women who received three or more doses of SP increased from 28% to 61%. Even though IPTp is given until University of Ghana http://ugspace.ug.edu.gh 11 delivery with a maximum of seven doses, the nationwide target for IPTp is 80% using IPTp 3 as the proxy in calculating the coverage (“Ghana Malar. Indic. Surv.,” 2019). 2.4 Socio- demographic factors affecting uptake of IPTp. 2.4.1 Age WHO reported in 2014 that a key risk factor for pregnant women not receiving IPTp is being 20 years of age or younger. In Tanzania, pregnant women aged 30-34 and 35-39 were more likely than others to complete the recommended IPTp dose according to Kibusi et al., (2015). Pregnant women older than 34 had a decreased likelihood of taking the required doses of IPTp, according to research by Okethwangu et al. (2019). Women's age, however, was not substantially connected with their uptake of IPTp, according to Bajaria et al. (2019) in a study in Tanzania. 2.4.2 Parity There was no correlation between taking the recommended three or more IPTp dosages and having a history of pregnancy in Kintampo (Oppong et al., 2019). In Ghana, people who have three or four children may have taken SP before and may not want to go through similar experiences with the side effect, which could result in them taking less SP (Owusu-Boateng & Anto, 2017). Bajaria et al., (2019) stated concluded that parity and uptake of IPTp were unrelated. Participants who had more than 3 children reported a low uptake of IPTp in Tanzania (Kisibu et al. 2015). University of Ghana http://ugspace.ug.edu.gh 12 2.4.3 Marital status A Tanzanian research by Kibusi et al. in 2015 showed a strong correlation between increased IPTp uptake among married or cohabiting women compared to single or divorced women. Married women in Kenya were more likely than single women to take the prescribed IPTp dosages (Choonara et al., 2015). 2.4.4 Educational level A study by Kibusi et al. (2015) in Tanzania indicated there was a substantial correlation between educational level and uptake of IPTp. When compared to pregnant women who had never attended school, pregnant women with a second education in Chókwè district, southern Mozambique were nearly twice as likely to receive higher IPTp doses (Arnaldo et al., 2018). Promoting formal education beyond primary school may increase the acceptance of IPTp (Arnaldo et al., 2018). 2.4.5 Occupation Compared to other occupational classes, self-employed individuals took less IPTp (Choonara et al., 2015). University of Ghana http://ugspace.ug.edu.gh 13 2.5 Client level factors 2.5.1 Knowledge about IPTp and MiP Uptake of IPTp was found to be significantly influenced by knowledge on MiP and IPTp. Educating pregnant women on the importance of IPTp and MiP could increase IPTp uptake (Amaron et al., 2012). A study conducted in East African revealed IPTp uptake was significantly influenced by IPTp awareness (Exavery et al., 2014a; Odongo, Bisaso, Byamugisha, & Obua, 2014). Gulema & Berhane, (2017); Njim, (2016), stated lack of knowledge of the indicated ANC schedule have a negative impact on uptake of IPTp. 2.5.2 Knowledge of pregnant women on IPTp. In Western Nigeria, the knowledge of IPTp use was a major determinant for uptake of IPTp. Health education on the advantages of taking SP and the problems associated with malaria in pregnancy can help greatly increase the uptake of IPTp. (Amoran et al., 12). 2.5.3 Source of Knowledge In a study in Kenya's Bungoma East District, pregnant women who relied on radio for information were 3 times likely to obtain IPTp dosages than pregnant women who relied solely on community healthcare workers for information (Chepkemoi Ng’etich-Mutulei & Odhiambo, 2014). University of Ghana http://ugspace.ug.edu.gh 14 A study by Sabin et al in 2018, found that pregnant women in villages in Eastern India have a near universal respect for physicians, as has been shown in other countries in Uganda (Rassi et al., 2016). Even when women are hesitant about a preventive or treatment plan, they expressed a readiness to follow any advice given by a doctor, believing it to be more reliable than other sources of information and assistance. 2.5.4 Male partner involvement In Ghana Boateng et al. (2018) found male partner involvement in the clinic was one of the most important factors influencing IPTp uptake. An increase in the number of men participating in ANC increased adoption of IPT2 by 0.5% and IPT3 by 0.7%. Because most remote area women rely heavily on their partners for support while seeking healthcare, male partner engagement can affect uptake of IPTp. 2.6 Healthcare worker factors 2.6.1 Healthcare worker attitude and client interaction Amankwah and Anto (2019) found the quality of contact between the HCW and clients was critical in uptake of IPTp at private health facilities in Ghana's Tema Metropolis, as pregnant mothers would often adopt IPTp if the HCW encouraged them to do so. Both (Bajaria et al., 2019; Exavery et al., 2014b) concurred on what other studies had found that there exists a favorable relationship between uptake of IPTp and provider advise on the effectiveness of malaria treatments, the threat of malaria during pregnancy, and patient re-visitation to the same facility, resulting in patients taking more IPTp doses as recommended during visits. Ibrahim et University of Ghana http://ugspace.ug.edu.gh 15 al.'s (2017) findings showed that the Sunyani Metropolis's health care employees' negative attitudes hindered the implementation of the IPTp. Women may decide to use ANC based on perceived treatment quality as well as facility readiness, according to Bajaria et al. (2019), therefore it is important to send them clearer and more authoritative messages. 2.6.2 HCW knowledge about MiP and IPTp Almost all ANC clinic staff in Ghana, according to Antwi (2010), knew when to start the pregnant patient's SP operation. However, only 36.7% of the staff were aware of the SP's frequent adverse effects that pregnant women are likely to encounter, and 56.7% were aware of the SP administration contraindication. Sabin et al., (2018) revealed that HCWs were generally unaware of the suggested malaria prevention techniques in international standards. This highlighted the need for increased HCW education and a better use of them to spread knowledge of alternatives for practical malaria prevention strategies for expecting mothers. This was especially important for those working in ANC clinics or in communities. 2.6.3 Training of HCWs Regular training and supervision of ANC service providers was critical in increasing SP uptake (Amankwah & Anto, 2019 and Rassi et al., 2016). In Uganda Nankwanga & Gorette, (2008) regular training and supervision on IPTp guidelines helps to improve Health care workers confidence and knowledge on SP’s effectiveness. University of Ghana http://ugspace.ug.edu.gh 16 2.6.4 Patient Nurse Ratio According to the Ministry of Health's Holistic Evaluation 2015, Ghana exceeded the WHO recommended ratio of one nurse per 1,000 people. Ghana exceeded the WHO-recommended ratio of one nurse per 1,000 persons, according to the MOH Holistic Evaluation report, 2015. One nurse was needed for every 959 individuals in the country in 2014, and that number decreased to 739 in 2015 (PMI, 2016). 2.7 Health facility factors No connection with IPTp uptake was found for any of the person or facility-level variables examined in private facilities in the Tema Metropolis (Amankwah & Anto, 2019). 2.7.1 Accessibility to health facilities Ghana Health Service developed CHPS compounds to improve access to underserved communities. The basis of operations for a community health nurse is a CHPS compound, which comprises of at least a two-room building outfitted with essential curative and preventive care tools. When the CHPS program was introduced, more than 70% of Ghanaians were more than eight kilometers away from the closest healthcare facility, which was an issue brought on by shoddy roads. In Ghana, MIP prevention was primarily implemented through the districts, subdistricts, and CHPS zones (PMI, 2016). University of Ghana http://ugspace.ug.edu.gh 17 2.7.2 IPTp and DOT policy A study by Amankwah & Anto, (2019) revealed Midwives attending to pregnant women in Ghana admitted during an in-depth interview. 29% of the women who claimed they had ever taken the SP home provided evidence that compliance with this aspect of the guidelines was quite low. Additionally, many private midwives did not think DOT should be used because they anticipate people taking their medications at home. Some midwives in Kenya argued that because they work in private institutions, they cannot force women to take the medication under monitoring. (Hill, Dellicour, et al., 2013). It was reported that issues such as a scarcity of water and glasses at ANC units also posed as roadblocks to the successful implementation of DOT. A cross-sectional study in Enugu State that provide ANC services Onoka, Onwujekwe et al., (2012) discovered that lack of water in health facility had no effect on the provision of optimal IPTp services to pregnant women. 2.7.3 Stock status Detailed discussions with some midwives in Ghana revealed there was no shortage of SP. (Owusu Boateng & Anto, 2017). Amankwah & Anto, (2019) agreed by noting supplies from the NMCP were readily available and could be obtained with the timely submission of requisitions, there was a consistent supply of SP. It is likely that women were not always given SP during ANC visits, as indicated in earlier Sub Sahara Africa studies, even though the MoH of Mozambique has not reported any SP stockouts since 2013 (Arnaldo et al., 2018; Florey, 2013; Hurley et al., (2016). Two supply-side obstacles to the uptake of IPTp for pregnant women were found in a qualitative study conducted in Uganda (Chepkemoi Ng’etich Mutulei, 2013). University of Ghana http://ugspace.ug.edu.gh 18 2.8 Client level characteristics influencing uptake of IPTp. 2.8.1 Gestational age at first Antenatal Care visit The gestational age at which pregnant women receive their initial IPTp dose varies by nation according to guidance from their national regulations. In Tanzania, the first dose of IPTp is given between 20 and 24 weeks of gestation, but the national guidelines on IPTp dosing in Ghana recommends taking IPTp from sixteen weeks of gestation. Taking the first dosage of SP at sixteen weeks is also advised by Mali and Kenya. The first dose of SP should be administered at twenty weeks, according to Mozambique's national guidelines. (Gomez et al., 2014). Anders et al., (2008) in North East of Tanzania, reveals issues like limited SP medication stockpiles or women's personal choices hindered the early use of IPTp. An unexpectedly high percentage of pregnant women visiting prenatal clinics before to the recommended gestation for the administration of the first dosage of IPTp may possibly be a contributing cause. 2.8.3 ANC Attendance (Timing and Frequency) The provision of antenatal care (ANC) by qualified healthcare professionals is crucial for ensuring a healthy pregnancy and improving pregnancy outcomes by identifying any difficulties early on, promoting healthy lifestyle choices, and providing opportunity for patients to communicate effectively with healthcare professionals. Although rates vary by country, ANC coverage has increased over time in sub-Saharan African nations (World demographics health survey, 2016). University of Ghana http://ugspace.ug.edu.gh 19 In Ghana, 83% of rural and 92% of urban pregnant women got four or more ANC visits (Statistical Service Accra, 2015). Compared to a recent study conducted at Ghana's private medical institutions, where five ANC visits were on the average (Amankwah & Anto, 2019). As stated in the new guideline, the WHO (2016) advises a minimum of eight contacts. 15.2% of women in another facility-based study in Accra made the necessary eight or more visits. Although very important, the gestational age at which a pregnant woman attended her first ANC visit was not the primary determinant in obtaining additional doses of SP, but rather the quantity of pre-delivery visits, as observed in several earlier research (Owusu-Boateng & Anto, 2017). According to Exavery et al. (2014), early ANC initiation was associated with a higher likelihood of IPTp uptake, and the time of ANC initiation was found to be highly useful in determining the degree of IPTp uptake among expecting mothers in Tanzania. Late registration will reduce the number of IPTp that can be administered. In a study by Anchang-Kimbi et al. (2014) conducted in Cameroon to evaluate the factors that influence ANC clinic attendance and IPTp intake among pregnant women, it was found that women who had their first visit during the third trimester were more likely to only receive one dose (p=0.001), whereas women who had their first ANC attendance earlier were more likely to receive two or more doses (OR = 0.4; 95% CI = 0.2 - 0.7). In a previous study, Bouyou-Akotet et al. (2013) found that early SP initial dose uptake and the overall number of ANC visits made were the two main factors influencing the uptake of higher IPTp doses. University of Ghana http://ugspace.ug.edu.gh 20 The ideal uptake of IPTp in Ghana, according to Odjidja, Kwanin, and Saha (2017), is influenced by a number of factors, including frequent visits to ANC clinics, health information, governance of the health staff, finances, products, and service delivery. University of Ghana http://ugspace.ug.edu.gh 21 CHAPTER THREE METHODS 3.1 Study Design This study was a cross-sectional study employing a quantitative approach. Structured questionnaires and an observation checklist were used to collect data on uptake of IPTp and related factors. Data was collected from women attending postnatal care, healthcare workers and health facilities in Adaklu District in December 2022. 3.2 Study Area Adaklu District is one of the eighteen districts in Volta Region of Ghana. Adaklu Waya serves as the capital of the District Assembly. It has an estimated population of 39,461 for 2021. It lies between Latitudes 6º41’N and 6 ° 1’N, and Longitudes 0º20’E and 0º1’E. It shares boundaries with Ho Municipal to the north, Central Tongu District to the south, Agortime Ziope district to the east, and Ho West District to the west. The District has a total land area of 4000 square kilometres. Two thirds of the total land area are not inhabited or cultivated. The main occupation of the indigenes is subsistence farming and cattle rearing. Health Administration in the District is under the control of the District Health Directorate (DHD). There are 8 Health Centres and 9 Community-based Health Planning and Service (CHPS) Compounds that provide healthcare services to inhabitants in the District. Two of the Health Centres located in Waya and Sofa are owned by the Salvation Army and Evangelical University of Ghana http://ugspace.ug.edu.gh 22 Presbyterian church. The rest are Government owned. The District is zoned into 5 Sub Districts. The Sub-Districts are Ahunda, Helekpe, Sofa Torda, Waya and Wumenu. Figure 2: Map of Adaklu District showing Health Facility Distribution (GHS, 2022) 3.2.1 Adaklu District and Malaria Adaklu is located in the nation's moist semi-deciduous forest zone. This renders the region conducive to Anopheles mosquito breeding, which in turn facilitates the spread of malaria (Adaklu District Health Directorate, 2022). Adaklu District Directorate recorded 2356 confirmed University of Ghana http://ugspace.ug.edu.gh 23 cases of malaria in 2021 out of which 101 of these cases occurred in pregnant women (DHIS 2, 2022) 3.2.2 ANC and IPTp Delivery in Adaklu Antenatal care services are delivered in all the Health Centres and CHPS Compounds in the district by Midwives and trained Community Health Officers. 3.3 Study Variables 3.3.1 Dependent Variable The dependent variable was uptake of IPTp. Uptake was measured as the number of doses of SP taken by a pregnant woman at ANC. It was obtained from the mother’s antenatal record booklet by counting the number of doses of SP taken during pregnancy. Table 1. Operational definition and scale of measurement for variables. Variables Operational definition Scale of measurement Source of data Uptake of IPTp Number of Doses of SP received during pregnancy. Ordinal ANC booklets 3.3.2 Independent Variables 1. Socio-demographic characteristics of women attending postnatal clinic (marital status, age, parity, occupation, education level) was obtained by auditing ANC booklet and postnatal mother questionnaires. University of Ghana http://ugspace.ug.edu.gh 24 2. Client-level factors such as gestational age at first ANC, ANC attendance, gestational age at first intake of SP dose, knowledge on MiP and IPTp, side effects of SP, perceived attitude about staff, and involvement of male partners were obtained from postnatal mother questionnaires and ANC book audit. 3. HCW questionnaire, postnatal mother questionnaires and facility checklist was used to obtain information on Health Facility factors such as health facility readiness to provide IPTp (average health provider patient ratio at the ANC clinic, availability of drinking water at the ANC clinic, distance from home to the health facility, availability of SP in the month of data collection, training schedule). 4. Health care worker factors like knowledge level on MiP and IPTp, educational level, DOT policy practice was obtained from observing and interviewing HCW using a structured questionnaire. University of Ghana http://ugspace.ug.edu.gh 25 Table 2: Operational definition and scale of measurement for variables. Variables Operational definition Scale of measurement Source of data Sociodemographic factors Age Age in completed years Interval Interview Educational level Highest formal Education level attained Ordinal  None  Primary  Senior High/Vocational  Tertiary Interview Marital status Legal status of relationship with partner Nominal  Single  Married  Divorced  Widow  Cohabiting Interview Occupation What the individual does for a living (brings him/her regular income) Nominal  Formal worker  Farming  Trading  Unemployed Interview Parity Number of Children one had given birth to Ratio Interview Client level factors Awareness of SP Respondent awareness of SP. Ordinal  Aware  Not aware Interview ANC Attendance Number of ANC visits Ratio ANC booklet Male partners Involvement Number of times client was escorted by their partner for the ANC visits Ratio ANC booklet University of Ghana http://ugspace.ug.edu.gh 26 Variables Operational definition Scale of measurement Source of data SP side effects Have client experienced any adverse drug reaction following SP administration Nominal  Headache  Itching  Dizziness  Vomiting  General weakness  Others Interview Knowledge about Malaria in Pregnancy (MIP) Respondent knowledge on malaria Ordinal  Poor  Moderate  High Interview Knowledge about IPTp Respondent knowledge on IPTp Ordinal  Poor  Moderate  High Interview Gestational age at first ANC Number of months at which the clients visited the hospital Ratio ANC booklet Gestation age at first SP dose Number of months which client received first SP dose. Ratio ANC booklet Health care worker factors Cadre of staff Cadre of Health care worker Ordinal  Enrolled Nurse  Community Health Nurse  Midwife,  Others Interview Level of knowledge about IPTp. Knowledge of health care workers on IPTp Ordinal  Low  Moderate  High Interview Perception towards IPTp DOTS policy Do they think IPTp is effective or not. Nominal  Yes  No Interview Do you observe as clients swallow the medication? Nominal  Yes  No Interview University of Ghana http://ugspace.ug.edu.gh 27 Variables Operational definition Scale of measurement Source of data Do you record in the clients ANC book? Nominal  Yes  No Interview Drinking water availability Availability of water dispenser or drinking water at the ANC Nominal  Yes  No Interview/Observation Distance to the health facility Accessibility of the health facility Ratio Interview/Observation Availability of SP Stock status in the last 3 months Nominal  Yes  No Observation Training status for practitioners IPTp training for ANC staff Nominal  Trained  Not trained Interview The place where SP is dispersed Pharmacy/ANC Nominal  Pharmacy  ANC Interview 3.4 Study Population In order to reduce recall bias within the study population, only women who attended Postnatal Clinics from the first day after delivery until six weeks in December 2022 were included. Health care workers who provided routine ANC services at Ahunda Health Centre, Nutifafa Health centre, Mimi Clinic, Salvation Army Health centre, Waya Health Centre, Wumenu Health centre, Helekpe Health centre, Anfoe CHPS, Ablornu CHPS, Amuzudeve CHPS, Have CHPS, Hlihave CHPS, Kordiabe CHPS Kodzobi CHPS, Kpetsu CHPS, Tsrefe and Torda CHPS will be included in the studies. To ensure HCW selected for the study are conversant with the practices at the ANC unit, only HCWs who had worked at the health facility for at least six months were included in the study. University of Ghana http://ugspace.ug.edu.gh 28 3.4.1 Inclusion Criteria 1. Health facilities which provides ANC services in the Adaklu District. These includes Ahunda Health Centre, Dave Health Centre, Nutifafa Health Centre, Helekpe Health Centre, Mimi Clinic, Salvation Army Health Centre, Waya Health Centre, Wumenu Health centre, Anfoe CHPS Compound, Ablornu CHPS Compound, Amuzudeve CHPS Compound, Have CHPS Compound, Hlihave CHPS Compound, Kodzobi CHPS Compound, Kpetsu CHPS Compound, Tsrefe and Torda CHPS Compound. 2. All women attending PNC from the first day after delivery until six weeks in December 2022 within any of the study health facilities. 3.4.2 Exclusion Criteria 1. All women who attended postnatal clinic without their ANC record booklets. 3.5 Sample Size Calculation for women attending PNC. Cochrane’s formula was used to calculate the sample size for this study. n= (Z²pq)/d² Where n = Sample size Z = Standard normal variate for margin of error University of Ghana http://ugspace.ug.edu.gh 29 p = proportion of pregnant women who took IPTp 3 or more q = 1-p d = margin of error Using a confidence interval of 95%, a margin of error (α) = 5%. An assumed proportion of annual coverage of 61% for IPTp 3 in the 2019 Ghana demographic health survey was used in calculate the sample size because the prevalence of IPTp was unknown in all the health facilities that provide ANC services in the Adaklu district. This ensured that findings from the study were as close to the population estimates as possible. The sample size was calculated thus: d = the margin of error (5% = [0.05]). n = 1.96² ∗ 0.61(1 – 0.61) 0.05² n = 366 Adjusted for a potential non-response rate of 2%, n = 366 + (0.02 x 366) n= 373 All healthcare workers who found conducting ANC services at the study facilities on the day of data collection and had worked in that facility for at least six months were included in the study. University of Ghana http://ugspace.ug.edu.gh 30 3.6 Sampling Technique The study participants were chosen using a stratified sampling procedure appropriate to size. The Table below shows the WIFA target of each of the five Sub-Districts in Adaklu for 2021. Table 3: Sample size determination by Sub District. Sub Districts WIFA Target(x) Ahunda 2462 Helekpe 1799 Sofa 1232 Waya 1989 Wumenu 1989 The sample size was distributed among the health institutions within each Sub District using proportionate sampling, taking into account the average number of women seen at PNC. Women attending PNC were selected by the use of Simple random sampling by writing yes and no on pieces of papers folded and mixed up in a bowl. Each participant was made to select one piece of paper from the bowl. All women who selected yes were used for this study. Subsequent samples were drawn until the number required for each facility was reached. The Principal Investigator (PI) did the sampling at each of the various facilities. All healthcare workers who conducted ANC at the study facilities on the day of data collection and had been working at the facility for at least six months were also part of the study. University of Ghana http://ugspace.ug.edu.gh 31 3.7 Data Collection Instruments Data was collected by the use of questionnaires and an observational checklist (Appendix 2: questionnaire). The questionnaires were on variables associated with uptake of IPTp. The observational checklist centered on uptake of IPTp. ANC record booklet of women attending postnatal care provided information on the uptake of IPTp. 3.7.1 Data Collection Technique. After seeking the consent of women attending PNC, structured questionnaires were administered via interviews to collect data from them (Appendix 1: consent form). Samples of SP were displayed while interviewing respondents. Questions with detailed explanations was read to each of the women to choose options they deemed best, their ANC booklet were crosschecked to confirm some of the answers. Data collection took 15 minutes on a respondent. A face mask was given to every participant involved in the study to wear for the study. Data was collected from all HCWs who conducts ANC at the facilities after seeking their consent. This lasted for 7 minutes. Observation and record review were done at the health facilities using the checklist (Appendix 1: questionnaire). To ascertain the availability of training manual, ANC attendance register, daily health talk schedule and IPTp protocols, the PI reviewed records in the health facilities. Monthly stock levels of SP was also reviewed using SP bin cards. University of Ghana http://ugspace.ug.edu.gh 32 Four research assistants collected data in the field and the principal researcher supervised the process throughout the period. 3.7.2 Quality Control Research assistants were trained on data collection. The PI supported the research assistants in collecting data. The training was on ethics of data collection, field expectations and how to manage them. The PI was part of the data collection teams that went to facilities to pick data. Research assistants communicated via phone calls to the principal investigator in instances where the principal investigator was not with the teams. The PI took delivery of data from the research assistants after each day’s work. 3.7.3 Pre-Testing of Questionnaires Pre-testing of the questionnaires was done at Kpetoe health Centre, located in the capital of Agotime Ziope District. Based on the results of the pre-testing, changes were made to the questionnaire and observation checklist. When necessary, questions were translated into the participants' native tongue to make sure they understood them and could respond appropriately. 3.8 Data Processing and Analysis Microsoft excel was used to clean the data. Data was analyzed with STATA version 16. Sociodemographic factors like marital status, age, religion, sex and occupation were presented in frequencies and percentages. The continuous variables which was not normally distributed were presented in quartiles, ranges and medians. University of Ghana http://ugspace.ug.edu.gh 33 To determine the association between uptake of IPTp and the independent variables, logistic regression analysis was done. Independent variables at the univariate level with significant p- values was used at the multivariable level of analysis and the model with the best Akaike’s Information Criterion (AIC) and Bayesian’s Information Criterion (BIC) were selected. The significance level was set at 5% for the analysis. Tables indicating odds ratio (crude or adjusted), percentages, confidence intervals and p-values were used to present the results. Relevant literature was to discuss the findings. The PI processed and analyzed all of the data. 3.9 Ethical Consideration Ethical approval was sought from Ghana Health Service Ethics Review Committee with ref number GHS-ERC: 047109122 on October 31, 2022. Approval was also sought from the Volta Regional Health Directorate and Adaklu Health Directorate before the start of the study. Each participant's informed consent was sought prior to collection of data to ensure their voluntary involvement in the study. Each participant received thorough explanations of the study's risks, benefits and objective. Additionally, they were informed of their right to discontinue the study at any time. The informed consent form was required to be signed or thumb printed by participants who accepted to participate in the study. In order to maintain confidentiality, participant names were not recorded. In order to protect each interviewee's privacy, each interview was done in a space free from outside distractions. Checklists and questionnaires completed were kept away from outside parties. Participants did not receive any compensation for their participation in the study. University of Ghana http://ugspace.ug.edu.gh 34 3.10 Sponsorship This study was funded by the principal investigator. The PI completed all additional study- related tasks with assistance from the school of public health at the University of Ghana. University of Ghana http://ugspace.ug.edu.gh 35 CHAPTER FOUR RESULTS 4.1 Socio-demographic characteristics of respondents (women at PNC) The study was done in 2022 among women attending PNC in the Adaklu District of the Volta region of Ghana. Respondents were drawn from the 5 sub- Districts in Adaklu District and were interviewed at all the 17 health facilities that conduct PNC. A total of 375 women attending PNC was used for this study due to the convenience of calculation. The ages of the women attending PNC ranged from 15 years to 42 years, with a median age of 23 years (1st quartile: 28 years, 3rd quartile: 33 years). Most of them 277 (73.9%) fell within the age range of 20 years to 34 years. Up to 210 (56%) of women attending postnatal clinic were educated to the primary level, with only 24 (6.4%) being educated up to tertiary level. Majority of the respondents were married 220 (58.7%). Up to 171 (46%) of respondents were engaged in trading with 90 (24%) being unemployed. Christianity was the dominant religion observed among respondents 307 (81.9%). Table 4 shows the distribution of socio-demographic characteristics of women interviewed at the Postnatal clinic. University of Ghana http://ugspace.ug.edu.gh 36 Table 4: Distribution of Socio-demographic characteristics of study participants, Adaklu District, 2022 Characteristics (n=375) Frequency Percentage (%) Sub – District Ahunda 97 25.9 Helekpe 70 18.7 Waya 79 21.1 Wumenu 79 21.1 Sofa – Torda 50 13.2 Age of women (years) 15-19 37 9.9 20-24 78 20.8 25-29 103 27.5 30-34 96 25.6 35-39 59 15.7 40 or more 2 0.5 Educational Level No Formal Education 87 23.2 Primary Education 210 56 Secondary/Vocational 54 14.4 Tertiary Education 24 6.4 Marital Status Single 64 17.1 Married 220 58.7 Cohabiting 84 22.4 Divorced 4 1.1 Widowed 3 0.8 Occupation Unemployed 90 24.0 Formal worker 23 6.1 Farming 91 24.3 Trading 171 45.6 Religion Christianity 307 81.9 Islam 62 16.5 Traditionalist 6 1.6 University of Ghana http://ugspace.ug.edu.gh 37 Characteristics (n=375) Frequency Percentage (%) Partners Educational Level No formal Education 83 22.1 Primary Education 193 52.8 Secondary/Vocational 66 17.6 Tertiary Education 28 7.5 Partners Religion Christianity 307 81.9 Islam 62 16.5 Traditionalist 6 1.6 4.2 Knowledge of Postnatal women on Malaria in Pregnancy and IPTp Forty-three (43) out of the 375 women were confirmed to have had malaria in the course of their pregnancy. Most 324 (86.4%) of the respondents did not experience any undesirable side effect after being given the IPTp medication (SP). However, nausea, general malaise, dizziness and vomiting were reported by 51 (13.6%) as side effects experienced after taking the medication. Out of the 375 women interviewed at the PNC, 304 (81.1%) indicated they spent less than 30 minutes to travel to a health facility for PNC. Majority of respondents 194 (51.7%) walked to the health facility for PNC with only 7.5% travelling by car. Though 205 (54.7%) of respondents spent nothing in terms of money to get to the health facility, 59 (15.7%) spent 20 Ghana cedis or more. Only 9 (2.4%) of the women attending postnatal clinic had their partners accompanying them to ANC for more than 3 times when they were pregnant. Up to 244 (65.1%) did not have their partners accompanying them for any ANC visit. University of Ghana http://ugspace.ug.edu.gh 38 Table 5 shows the results of knowledge of postnatal women on IPTp and Malaria in Pregnancy Adaklu District in 2022. Table 5: Knowledge of postnatal women on IPTp and Malaria in Pregnancy in Adaklu District, 2022 Characteristics (n=375) Frequency Percentage (%) Time Spent to get to PNC Less than 30 minutes 304 81.1 30 minutes to 1 hour 63 16.8 1 hour to 1.5 hours 5 1.3 1.5 hours to 2 hours 3 0.8 Mode of Transportation to PNC Walking 194 51.7 Motorcycle 153 40.8 Car 28 7.5 Cost of Travel for PNC Zero 205 54.7 Less than 10 cedis 36 9.6 10 – 19 cedis 75 20.0 20 or more cedis 59 15.7 Perception of attitude of ANC staff Poor 1 0.3 Good 58 15.5 Very Good 272 72.5 Excellent 44 11.7 Number of times accompanied by partner to ANC None 244 65.1 1-3 times 122 32.4 More than 3 times 9 2.4 Heard about SP No 19 5.1 Yes 356 94.9 Given SP to swallow at ANC No 3 0.8 Yes 372 99.2 University of Ghana http://ugspace.ug.edu.gh 39 Characteristics (n=375) Frequency Percentage (%) Experienced any side effect after taking SP No 324 86.4 Yes 51 13.6 Side effect experienced (n=51) Nausea 21 41.1 General malaise 24 47.1 Dizziness 4 7.8 Vomiting 2 3.9 Did side effect prevent you from taking subsequent doses No 17 33.3 Yes 34 66.7 Required to pay any money for SP No 374 99.7 Yes 1 0.3 Provided water at ANC No 310 82.7 Yes 65 17.3 How much paid for water (Ghc) Nothing 302 80.5 0.20 pesewas 72 19.2 0.40 pesewas 1 0.3 Reported feverish symptoms during ANC No 328 87.5 Yes 47 12.5 Confirmed to have malaria (n=47) No 4 8.5 Yes 43 91.5 Number of times confirmed to have malaria (n=43) Once 33 76.7 Twice 8 18.6 Thrice 2 4.7 Knowledge of effects of malaria on a pregnant woman Anemia 55 14.7 Miscarriage 285 76.0 Death 35 9.3 University of Ghana http://ugspace.ug.edu.gh 40 Characteristics (n=375) Frequency Percentage (%) Knowledge of effects of malaria on a pregnant woman Low birth weight 28 7.5 Deformity 12 3.2 Death 335 89.3 4.3: Knowledge on IPTp and Malaria in Pregnancy among HCWs. A total of 40 healthcare workers providing ANC services in all the 17 health facilities were interviewed in the 5 sub-Districts of Adaklu. Midwives interviewed were 19 (47.5%). Up to 23 (57.5%) had practiced for one to three years. All the healthcare workers interviewed knew IPTp as a prophylactic drug against malaria in pregnancy. Up to 29 (72.5%) of respondents interviewed indicated the first dose of SP is given at 16 weeks. The remaining 11 (27.5%) said the first dose of SP is given when a pregnant woman experiences quickening (first movement of fetus). University of Ghana http://ugspace.ug.edu.gh 41 Table 6 shows the results of knowledge on IPTp and Malaria in Pregnancy among HCWs. Table 6: Knowledge on IPTp and Malaria in Pregnancy among HCWs in Adaklu District, 2022 Characteristics (n=40) Frequency Percentage (%) Sub- District Ahunda 9 22.5 Helekpe 10 25.0 Waya 9 22.5 Wumenu 8 20.0 Sofa – Torda 4 10.0 Cadre of Healthcare worker Midwives 19 47.5 Community Health Nurse 14 36.0 Enrolled Nurse 5 12.5 Registered General Nurse 2 5.0 Years of Practice 1 -3 years 23 57.5 4 – 6 years 14 35.0 More than 6 years 3 7.5 Knowledge on IPTp What is IPTp Prophylaxis against malaria in pregnancy 40 100.00 When first dose of SP given At quickening 11 27.5 At 16 weeks 29 72.5 How often SP is given Monthly 40 100.00 Number of times IPTp is given 4 times 8 20.00 5 times 32 80.00 Effectiveness of IPTp in preventing malaria Yes 40 100.00 Trained on IPTp Yes 40 100.00 University of Ghana http://ugspace.ug.edu.gh 42 Characteristics (n=40) Frequency Percentage (%) Number of health workers who conduct ANC 2 8 47.1 3 8 47.1 5 1 5.8 Average number of ANC clients seen daily 5 13 76.5 10 4 23.5 4.4 ANC attendance and uptake of IPTp. Observation from the maternal and child health record booklet of women attending postnatal clinic indicated 70 (18.67%) attended ANC six times before they delivered. Up to 53 (14.13%) of respondents reported for ANC services at week 4 of gestation with only 1 (0.27%) reporting at 32 weeks. Out of the 375 women, 114 (56.3%) received 3 doses of IPTp before they delivered whiles 7 (1.8%) did not receive IPTp before delivery. Table 7 shows the distribution of ANC attendance and uptake of IPTp among postnatal women. University of Ghana http://ugspace.ug.edu.gh 43 Table 7: Distribution of ANC attendance and IPTp uptake in Adaklu District, 2022 Characteristics (n= 375) Frequency Percentage (%) ANC attendance 1 1 0.27 2 25 6.67 3 52 13.87 4 55 14.67 5 61 16.27 6 70 18.67 ANC attendance 7 38 10.13 8 41 10.93 9 22 5.87 10 4 1.07 11 5 1.33 12 1 0.27 Age of pregnancy at first ANC attendance (weeks) First trimester 191 50.9 Second trimester 173 46.1 Third trimester 11 2.9 Age of pregnancy at first ANC attendance (weeks) 4 53 14.13 6 1 0.27 8 74 19.73 9 1 0.27 12 61 16.27 14 15 4.00 16 60 16.00 17 1 0.27 18 8 2.13 20 55 14.67 21 3 0.80 22 1 0.27 24 30 8.00 26 2 0.53 28 8 2.13 32 1 0.27 *These were the observed results of the data collected in the field University of Ghana http://ugspace.ug.edu.gh 44 Characteristics (n= 375) Frequency Percentage (%) When first dose of SP was taken Before 16 weeks 11 3.0 At 16 weeks 171 46.5 17-24 weeks 160 43.5 25 weeks or more 26 7.1 Total number of SP doses taken 0 7 1.87 IPTp 1 58 98.1 IPTp 2 99 82.7 IPTp 3 114 56.3 IPTp 4 71 25.9 IPTp 5 26 6.9 Less than 3 164 43.7 3 or more doses 211 56.3 IPTp 3 uptake No 164 43.7 Yes 211 56.3 4.5 Healthcare facilities and uptake of IPTp in in Adaklu District, 2022 The 17 health facilities visited in Adaklu district in November 2022 showed availability of SP, job aids on IPTp and Malaria in Pregnancy in the ANC. There was no shortage of SP within the past 6 months in any of the facilities. IPTp administration to pregnant women at the ANC was served as DOT in all the 17 facilities. Healthcare facilities and uptake of IPTp in Adaklu District are shown in Table 8. University of Ghana http://ugspace.ug.edu.gh 45 Table 8: Healthcare facilities and uptake of IPTp in Adaklu District, 2022 Characteristics (n= 17) Frequency Percentage (%) IPTp served to pregnant women recorded in MCHRB at ANC No 0 0 Yes 17 100 IPTp served to pregnant mothers recorded in the ANC register in the ANC unit? No 0 0 Yes 17 100 Job aids on IPTp pasted on the walls in the antenatal unit No 0 0 Yes 17 100 Job aids on malaria in pregnancy pasted on the walls in the antenatal unit No 0 0 Yes 17 100 Availability of adverse event forms for SP at the antenatal unit No 0 0 Yes 17 100 SP currently available at the antenatal unit? No 0 0 Yes 17 100 IPTp observed as DOT in the antenatal clinic? No 0 0 Yes 17 100 University of Ghana http://ugspace.ug.edu.gh 46 4.6 Association between socio-demographic characteristics and uptake of IPTp. The Sub-District of residence of women attending postnatal clinic in Adaklu District was found to have a statistically significant association with uptake of IPTp. Residents of Waya Sub- District had 6.11 increased odds of uptake of IPTp. Similarly, Sofa Torda residents had 4.42 increased odds of uptake. Age of mothers was not found to be statistically associated with uptake of IPTp, however their educational level was. Having up to primary level education was associated with 3.29 (p <0.001) increased odds of uptake as compared to having no formal education. Additionally, those educated up to secondary/vocational level and tertiary level had 2.99 (p =0.002) and 4.44 (p =0.002) increased odds on uptake respectively when compared with those with no formal education. Occupation was significantly associated with uptake of IPTp. Being a farmer (OR: 1.82, p =0.046) or engaging in trading (OR:2.03, p =0.007) had statistically significant increased odds of uptake as compared to being unemployed. Being a Muslim (OR:0.10, p<0.001) was associated with 81% reduced odds of uptake as compared to being a Christian. However, being a traditionalist was not significantly associated with uptake when compared to being a Christian. Table 9 Provides the odds ratios, 95% confidence intervals and p-values of association between socio-demographic characteristics of mothers and uptake of IPTp. University of Ghana http://ugspace.ug.edu.gh 47 Table 9: Association between socio-demographic characteristics of mothers and uptake of IPTp. Characteristic Odds ratio 95% Confidence Interval P-value Sub-District Ahunda (base) 1.00 Helekpe 1.23 0.66 – 2.30 0.508 Waya 6.11 3.09 – 12.11 <0.001 Wumenu 1.76 1.00 – 3.22 0.065 Sofa Torda 4.42 2.08 – 9.37 <0.001 Age of women (years) 15-19 (base) 1.00 20-24 1.36 0.61 – 3.00 0.446 25-29 0.90 0.42 – 1.91 0.786 30-34 1.00 0.47 – 2.15 0.991 35-39 1.43 0.62 – 3.29 0.401 40 or more 0.85 0.05 – 14.64 0.911 Educational level No formal education (base) 1.00 Primary education 3.29 1.69 – 6.41 <0.001 Secondary/vocational 2.99 1.48 – 6.68 0.002 Tertiary 4.44 1.70 – 11.64 0.002 Marital status Single (base) 1.00 Married 0.37 0.20 – 0.68 0.001 Cohabiting 0.70 0.35 – 1.42 0.329 Divorced 1.17 0.11 – 12.04 0.893 Widowed 1.96 0.02 – 2.29 0.194 Occupation Unemployed (base) 1.00 Formal worker 2.45 0.94 – 6.37 0.065 Farming 1.82 1.01 – 3.29 0.046 Trading 2.03 1.21 – 3.41 0.007 Religion Christian (base) 1.00 Islam 0.19 0.10 – 0.36 <0.001 Traditionalist 3.04 0.35 – 26.31 0.313 University of Ghana http://ugspace.ug.edu.gh 48 Characteristic Odds ratio 95% Confidence Interval P-value Partner’s educational level No formal education (base) 1.00 Primary education 3.55 1.74 – 7.25 0.001 Secondary/vocational 2.80 1.43 – 5.48 0.003 Tertiary 4.63 1.85 – 11.80 0.001 Partner’s religion Christian (base) 1.00 Islam 0.19 0.10 – 0.36 <0.001 Traditionalist 3.04 0.35 – 26.3 0.313 4.7 Association between knowledge of women attending postnatal care on IPTp, Malaria in Pregnancy and uptake of IPTp. Time spent in getting to the health facility to access ANC services was not found to be associated with uptake of IPTp, however the mode of transportation was. Using motorcycle as mode of transportation was associated with 66% (p<0.001) reduced odds of uptake as compared to walking. When mothers were educated on SP during ANC, it resulted in 7.5 (p=0.002) increased odds of uptake compared to when they are not. However, experiencing undesirable side effects from the medication was associated with 70% (p<0.001) reduced odds of uptake. Knowing miscarriage as an effect of malaria on pregnancy was associated with 2.65 (p=0.001) increased odds of uptake of IPTp. The statistical association between knowledge of women attending postnatal care on IPTp, Malaria in Pregnancy and uptake of IPTp are shown in Table 10. University of Ghana http://ugspace.ug.edu.gh 49 Table 10: Association between knowledge of women attending postnatal care on IPTp, Malaria in Pregnancy and uptake of IPTp. Characteristic Odds ratio 95% Confidence interval P-value Time spent to get to ANC Less than 30 minutes (base) 1.00 30 minutes to 1 hour 0.60 0.35 – 1.04 0.070 1 hour to 1.5 hours 0.41 0.08 – 2.89 0.414 1.5 hours to 2 hours 1.42 0.13 – 15.78 0.778 Mode of transportation to ANC Walking 1.00 Motor bicycle 0.34 0.22 – 0.52 <0.001 Car 0.54 0.24 – 1.21 0.134 Cost of travel to ANC (Ghc) Zero (base) 1.00 Less than 10 0.65 0.32 – 1.33 0.237 10 – 19 0.45 0.26 – 0.78 0.004 20 or more 0.29 0.16 – 0.53 <0.001 Perception of attitude of ANC staff Poor (base) 1.00 Good 0.76 0.35 – 1.67 0.495 Very good 1.04 0.55 – 1.97 0.911 Number of times accompanied by partner to ANC None (base) 1-3 times 1.05 0.68 – 1.63 0.823 Number of times accompanied by partner to ANC More than 3 times 2.83 0.58 – 13.88 0.201 Where first heard about SP ANC (base) 1.00 Friends/Family 1.15 0.19 – 6.99 0.876 Educated on SP No (base) 1.00 Yes 7.50 2.15 – 26.19 0.002 University of Ghana http://ugspace.ug.edu.gh 50 Characteristic Odds ratio 95% Confidence interval P-value Experienced any side effect after taking SP No (base) 1.00 Yes 0.30 0.16 – 0.57 <0.001 Side effect experienced Nausea (base) 1.00 General malaise 0.18 0.05 – 0.72 0.015 Vomiting 0.91 0.05 – 16.54 0.949 Did side effect prevent you from taking subsequent doses No (base) 1.00 Yes 0.06 0.01 – 0.24 <0.001 Provided water at ANC No (base) 1.00 Yes 1.62 0.94 – 2.89 0.079 Reported feverish symptoms during ANC No (base) 1.00 Yes 0.65 0.35 – 1.20 0.164 Confirmed to have malaria No (base) 1.00 Yes 0.87 0.11 – 6.75 0.894 Knowledge of effects of malaria on a pregnant woman Anemia (base) 1.00 Miscarriage 2.65 1.46 – 4.81 0.001 Death 0.96 0.40 – 2.30 0.921 Knowledge of effects of malaria on a pregnant woman Low birth weight (base) 1.00 Deformity 3.00 0.67 – 13.47 0.152 Death 1.28 0.59 – 2.77 0.532 University of Ghana http://ugspace.ug.edu.gh 51 4.8 Association between ANC attendance and uptake of IPTp ANC attendance of 5 or more was associated with 9.55 (p<0.001) increased odds of uptake as compared with ANC attendance between 1 and 4. Reporting for ANC between 17 and 24 weeks of gestation was associated with 59% (p<0.001) reduced odd of uptake as compared to reporting before 17 weeks. Additionally, reporting after 24 weeks was associated with 94% (p=0.007) reduced odds uptake when compared to reporting before 17 weeks. Furthermore, when the first dose of IPTp was taken at 25 weeks or more gestation, it resulted in 99% (p<0.001) reduced uptake when compared with taking the first dose at 16 weeks. Details of association between ANC attendance and uptake of IPTp are given in table 11 below. Table 11: Association between ANC attendance and uptake of IPTp. Characteristic Odds ratio 95% Confidence interval P-value ANC attendance 1-4 (base) 1.00 5 or more 9.55 5.82 – 15.68 <0.001 Age of pregnancy at first ANC attendance (weeks) First trimester 1.00 Second trimester 0.61 0.40 – 0.93 0.022 Third trimester 0.06 0.01 – 0.46 0.007 Age of pregnancy at first ANC attendance (weeks) At 17 weeks (base) 1.00 17-24 weeks 0.41 0.26 – 0.66 <0.001 25 weeks or more 0.06 0.01 – 0.46 0.007 When first dose of SP was taken Before 16 weeks At 16 weeks 0.17 0.02 – 1.37 0.096 17-24 weeks 0.13 0.02 – 1.05 0.056 25 weeks or more 0.01 0.00 – 0.10 <0.001 University of Ghana http://ugspace.ug.edu.gh 52 4.9 Multivariable analysis of association between independent variables and uptake of IPTp. The Sub-District of residence of women attending Postnatal Clinic was significantly associated with uptake of IPTp at both the univariate and multivariable level. At the multivariable level; Helekpe (AOR: 3.68, p=0.002), Waya (AOR: 4.72, p=0.001), Wumenu (AOR: 5.26, p=0.001) and Sofa Torda (AOR: 4.95, p=0.006) sub-districts had increased odds of uptake of IPTp. Being educated on IPTp was associated with 6.04 (p=0.017) increased odds of uptake at the multivariabe level. Additionally, experiencing undesirable side effects after taking SP was associated with 90% (AOR: 0.10, p<0.001) reduced odds of uptake at the multivariable level. ANC attendance of 5 or more was associated with 6.35 (p<0.001) increased odds of uptake as compared to ANC attendance of less than 5. Reporting for ANC between 17 and 24 weeks was associated with 64% (AOR: 0.36, p=0.005) reduced odds of uptake as compared to reporting before 17 weeks. Similarly, reporting after 24 weeks was associated with 95% (AOR: 0.05, p=0.017) reduced odds of uptake compared with reporting before 17 weeks. Details of multivariable analysis between independent variables and uptake of IPTp are shown in Table 12. University of Ghana http://ugspace.ug.edu.gh 53 Table 12: Multivariable analysis of association between independent variables and uptake of IPTp Characteristic Crud e odds ratio 95% CI P- value Adjusted odds ratio 95% CI P- value Sub-district Ahunda (base) 1.00 Helekpe 1.23 0.66 – 2.30 0.508 3.68 1.60 – 8.50 0.002 Waya 6.11 3.09 – 12.11 <0.001 4.72 1.91 – 11.69 0.001 Wumenu 1.76 1.00 – 3.22 0.065 5.26 1.94 – 14.25 0.001 Sofa Torda 4.42 2.08 – 9.37 <0.001 4.95 1.58 – 15.50 0.006 Educational level No formal education (base) 1.00 Primary education 3.29 1.69 – 6.41 <0.001 1.55 0.62 – 3.93 0.351 Secondary/vocational 2.99 1.48 – 6.68 0.002 1.54 0.56 – 4.20 0.399 Tertiary 4.44 1.70 – 11.64 0.002 2.29 0.57 – 9.17 0.241 Religion Christian (base) 1.00 Islam 0.19 0.10 – 0.36 <0.001 0.46 0.18 – 1.20 0.112 Traditionalist 3.04 0.35 – 26.31 0.313 7.62 0.38–154.25 0.185 Educated on SP No (base) 1.00 Yes 7.50 2.15 – 26.19 0.002 4.37 0.89 – 21.40 0.069 University of Ghana http://ugspace.ug.edu.gh 54 Characteristic Crud e odds ratio 95% CI P- value Adjusted odds ratio 95% CI P- value Knowledge of effects of malaria on a pregnant woman Anemia (base) 1.00 Miscarriage 2.65 1.46 – 4.81 0.001 1.40 0.61 – 3.18 0.428 Death 0.96 0.40 – 2.30 0.921 0.91 0.31 – 2.70 0.867 ANC attendance 1-4 (base) 1.00 4 or more 9.55 5.82 – 15.68 <0.001 6.68 3.49 – 12.76 <0.001 Age of pregnancy at first ANC attendance (weeks) At 16 weeks(base) 1.00 17-24 weeks 0.41 0.26 – 0.66 <0.001 0.36 0.18 – 0.74 0.005 25 weeks or more 0.06 0.01 – 0.46 0.007 0.05 0.00 – 0.59 0.017 AIC = 369.60, BIC = 440.29 University of Ghana http://ugspace.ug.edu.gh 55 CHAPTER FIVE DISCUSSION, CONCLUSION, AND RECOMMENDATIONS. 5.1 Uptake of IPTp among women attending PNC Findings from this study in 2022 in Adaklu District indicated a decreasing uptake of IPTp from 98% to 6.9% for IPTp 1 and IPTp 5. Although the uptake of IPTp 1 was high at 98%, it still fell below the NMCP national target of 100%. Not all the ANC units within all the Health facilities are managed by midwives who are authorized to administer the first dose of IPTp to pregnant women. There was also a reduction in uptake of subsequent doses of IPTp. This observed reduction in IPTp doses is consistent to what was observed by (Diengou et al., 2020) in Bamenda Health Districts in Cameroon. In their study, IPTp doses reduced from 95.3% to 54.9% for IPTp 1 and IPTp 3 whiles 4.8% did not receive any dose of IPTp. Similar trend in IPTp uptake was also observed by (Owusu-Boateng & Anto, 2017) in Ghana where 87.5%, 55.7% and 14.5% were recorded for IPTp 3, IPTp 4 and IPTp 5. The observed 56.3% coverage of IPTp 3 in the District did not meet the national target of 80%. In Cameroon and Ghana, Diengou et al., 2020 and Oppong et al., 2019 observed a lower dose of 54.9% and 32.4% for IPTp 3. In Sierra Leone, Amos Buh, 2019 observed 93.24% in IPTp 3 coverage which is higher than what was observed in Adaklu. These differences in the coverages of IPTp dose may be due to different geographical settings. It may also be due to the study population used in the studies i.e. pregnant women and postnatal women. Results from table 6 indicates 40.7% of mothers attending postnatal clinic relied on motorcycle to access ANC University of Ghana http://ugspace.ug.edu.gh 56 services. An amount of 10 cedis or more is spent to access PNC services as transportation fare. The reduction in IPTp 3 coverage could be due to mothers unable to afford 10 cedis or more to access ANC services as a result of low economic activities in the District. This could be due to the poor nature of road network within the District making 40.7% of respondent rely on motorcycle. 5.2 Socio demographic characteristics of mothers attending PNC Educational levels of women attending postnatal clinic was found to be statistically significant to uptake of IPTp (OR-1.47 p=0.001). Formal education (primary, secondary and tertiary level) increases uptake as compared to having no formal education. This is consistent with findings from a study by (Arnaldo et al., 2018). When compared to pregnant women who had never attended school, pregnant women with at least a formal education in Chokwe district, southern Mozambique were nearly twice as likely to receive higher IPTp doses. This is expected given that education might enable women to make better decisions regarding their health issues. A research conducted in Nigeria by Buh et al. (2019) found that women with greater education had a reduced likelihood of obtaining IPTp than women without education. Occupation was significantly associated with uptake of IPTp. Being a farmer (OR: 1.82, p=0.046) or engaging in trading (OR:2.03, p=0.007) had statistically significant increased odds of uptake as compared to being unemployed. Being employed could make one financially independent, thus easily cover ANC related expenses when the need arises. University of Ghana http://ugspace.ug.edu.gh 57 Findings from the study revealed that, Muslims have a reduced odd of 81% uptake of IPTp. This is consistent with a study by Oppong et al., 2019 in Ghana which indicated that, being a Muslim has a reduced odd of 17% uptake of IPTp. 5.3 Client level factors associated with uptake of IPTp Usage of motorcycle as mode of transportation to health facilities for ANC services was associated with 66% (p<0.001) reduced odds of uptake as compared to walking. This may be due the inconvenience of traveling on a motorcycle coupled with the discomfort associated with pregnancy could be the reason for this. Additionally, spending 10 to 19 Ghana cedis (OR: 0.45, p=0.004) and 20 Ghana cedis or more (OR: 0.29, p<0.001) on transportation to ANC had a statistically significant association with uptake as compared to spending zero Ghana cedis. Due to the complications and discomfort associated with pregnancy, most mothers are not able to work regularly to fend for their needs hence resulting in their inability to afford transportation fare of 10 cedis or more to the ANC clinic. Education of pregnant mothers on SP resulted in 7.5 (p=0.002) increased odds of uptake of IPTp compared to when they are not. The source of information for pregnant mothers on SP was from Health care workers at the ANC unit. Pregnant mothers are more likelihood to receive more doses of IPTp in the Bunoma East District in Kenya, with their main source of information on SP for pregnant women being radio compared to pregnant mothers with sole dependence on community healthcare workers at the ANC unit as their main source of information (Chepkemoi et al, 2014). University of Ghana http://ugspace.ug.edu.gh 58 Women attending postnatal care who made 5 or more visits to the ANC when pregnant was associated with 9.55 (p<0.001) increased odds of uptake of IPTp compared to women who made ANC between 1 and 4 visits. This affirms the claim made by Odjidja, Kwanin, and Saha (2017) that the optimal uptake of IPTp in Ghana was influenced by frequent visits to ANC clinics, products and finances. Pregnant women whose first first dose of SP was at 25 weeks or more, resulted in 99% (p<0.001) reduced uptake when compared with taking the first dose at 16 weeks. The total number of IPTp doses that can be given out is reduced by late ANC registration. In a study conducted in Cameroon by Anchang-Kimbi et al. (2014), it was shown that a greater percentage of women with their first visit occurring in the third trimester only received one dose (p< 0.001), while women who attended their first ANC appointment earlier were more likely to receive two or more doses (OR = 0.4; 95% CI = 0.2 - 0.7). 5.4 Healthcare worker factors associated with uptake of IPTp Whiles 72.5% indicated that the first dose of SP is given at 16 weeks, the rest indicated that it is given when the woman experiences quickening (first movements of fetus). The new policy by NMCP on IPTp proposes the first dose be given at 16 weeks of gestation (“Ghana Malar. Indic. Surv.,” 2019). Healthcare workers who rely solely on quickening before administering IPTp might issue the drug late (after 16 weeks) which may reduce the number of the number of doses a pregnant woman can receive. Table 5 revealed 98.6% of mothers have heard of SP at the ANC and its importance which proves that health workers educate mothers on SP at the facility level. University of Ghana http://ugspace.ug.edu.gh 59 This may be due to all healthcare workers (100%) trained in IPTp and malaria hence are well resourced to educate mothers on IPTp and malaria. 5.5 Health facility factors associated with uptake of IPTp All the 17 health facilities visited had job aids on IPTp and malaria pasted at the ANC unit, observed the DOT policy, recorded IPTp administered to pregnant women in the ANC registers and maternal and child booklet, had adverse reaction forms in the ANC unit, had not experienced any shortage of SP within the past 6 months. This may have been the reason for health workers having high level of knowledge on IPTp and malaria as shown in table 7 since they have access to job aids and protocols to aid in their work delivery. 5.6 Strength of the study This study seems to be the first to be conducted the Adaklu District since its inception in 2013 per the literatures reviewed. It therefore sets the platform for similar studies to be conducted in the District. This gives the Adaklu District Health Directorate the opportunity to implement measures to increase uptake of IPTp depending on the issues identified. Additionally, the study provides GHS and its implementing partners with the opportunity to address nationwide challenges with uptake of IPTp. 5.7 Limitation of the study A qualitative aspect would have enhanced the study. This would have thrown additional insight on the aspects of the healthcare system influencing uptake of IPTp. The experiences and University of Ghana http://ugspace.ug.edu.gh 60 difficulties women attending PNC encountered when accessing ANC services when they were pregnant would have also been helpful. 5.8 Conclusion The observed 56.3% uptake for IPTp 3 did not meet the national target of 80%. Postnatal women who used motorcycle as mode of transportation to health facilities for ANC services during pregnancy was associated with 66% (p < 0.001) reduced odds of uptake of IPTp. Formal education (primary, secondary and tertiary level) increased uptake of IPTp (OR-1.47 p = 0.001). Women attending PNC who made 5 or more visits to the ANC when pregnant was associated with 9.55 (p < 0.001) increased odds of uptake of IPTp. All the HCWs involved in rendering ANC services interviewed in ANC facilities had been trained in IPTp. The 17 health facilities visited had job aids on IPTp and malaria pasted at the ANC unit, observed the DOT policy, recorded IPTp administered to pregnant women in the ANC registers and maternal and child booklet, had adverse reaction forms in the ANC unit and had not experienced any shortage of SP within the past 6 months. 5.9 Recommendations The following recommendations are made based on the findings of the study. The Adaklu District Health Directorate should: 1. Support HCWs to intensify education on Malaria in Pregnancy, IPTp and the importance of attending ANC to pregnant women in health facilities and communities. University of Ghana http://ugspace.ug.edu.gh 61 2. Conduct periodic supervisions to Health facilities to ensure HCWs are adhering to ANC and IPTp protocols. University of Ghana http://ugspace.ug.edu.gh 62 REFERENCES Andersen, R. M. (1995). Andersen and Newman Framework of Health Services Utilization. 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