Acceptability of coupling Intermittent Preventive Treatment in infants with the Expanded Programme on Immunization in three francophone countries in Africa
Corresponding Author Alexandra de Sousa, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland. E-mail: firstname.lastname@example.org
Objective Intermittent preventive treatment in infants (IPTi) is a malaria control strategy currently recommended by WHO for implementation at scale in Africa, consisting of administration of sulphadoxine-pyrimethamine (SP) coupled with routine immunizations offered to children under 1 year. In this study, we analysed IPTi acceptability by communities and health staff.
Methods Direct observation, in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in Benin, Madagascar and Senegal during IPTi pilot implementation. Villages were stratified by immunization coverage. Data were transcribed and analysed using NVivo7 software.
Results Communities’ knowledge of malaria aetiology and diagnosis was good, although generally villagers did not seek treatment at health centres as their first choice. Perceptions and attitudes towards IPTi were very positive among communities and health workers. A misconception that SP was an antipyretic that prevents post-vaccinal fever contributed to IPTi’s acceptability. No refusals or negative rumours related to IPTi coupling with immunizations were identified, and IPTi did not negatively influence attitudes towards other malaria control strategies. Healthcare decisions about children, normatively made by the father, are starting to shift to educated and financially independent mothers.
Discussion Intermittent preventive treatment in infants is well accepted by providers and communities, showing a synergic acceptability when coupled with routine immunizations. However, a misconception that SP alleviates fever should be addressed when scaling up implementation.
Objectif: Le Traitement Préventif Intermittent des nourrissons (TPIn) est une stratégie de lutte contre le paludisme recommandée actuellement par l’OMS pour être implémentée largement en Afrique, consistant en l’administration de sulfadoxine-pyriméthamine (SP), couplée à la vaccination de routine offerte aux enfants de moins d’un an. Dans cette étude, nous avons analysé l’acceptabilité du TPIn par les communautés et le personnel de santé.
Méthodes: L’observation directe, des entretiens détaillés et des groupes de discussion focalisée ont été menés au Bénin, à Madagascar et au Sénégal lors de l’implémentation pilote du TPIn. Les villages ont été stratifiés par couverture vaccinale. Les données ont été transcrites et analysées en utilisant le logiciel NVivo7.
Résultats: Les connaissances des communautés sur l’étiologie et le diagnostic du paludisme étaient bons, bien qu’en général les villageois ne recourent pas aux centres de santé comme premier choix pour le traitement. Les perceptions et attitudes envers le TPIn étaient très positives dans les communautés et chez les agents de la santé. Une idée erronée que le SP est un antipyrétique qui prévient la fièvre post-vaccinale a contribuéà l’acceptabilité du TPIn. Aucun refus ou rumeurs négatifs liés au couplage du TPIn avec les vaccinations n’ont été identifiés et le TPIn n’a pas une influence négative sur les attitudes envers les autres stratégies de lutte contre le paludisme. Les décisions relatives aux soins de santé des enfants, normalement prises par les pères, commencent à passer aux mères instruites et financièrement indépendantes.
Discussion: Le TPIn est bien accepté par les prestataires et les communautés, montrant une acceptabilité synergique lorsqu’il est couplé aux vaccinations de routine. Toutefois, l’idée erronee que le SP atténue la fièvre doit être corrigée lors du déploiement de l’implémentation.
Objetivo: El Tratamiento Preventivo Intermitente en lactantes (IPTi) es una estrategia de control de la malaria actualmente recomendada por la OMS para su implementación a gran escala en África, y consiste en la administración de Sulfadoxina-Pirimetamina (SP) durante las inmunizaciones rutinarias ofrecidas a niños menores de un año. En este estudio hemos analizado la aceptación del IPTi por parte de las comunidades y del personal sanitario.
Métodos: Durante la implementación piloto del IPTi en Benin, Madagascar y Senegal, se llevaron a cabo observaciones directas, entrevistas en profundidad y grupos de discusión. Los poblados se estratificaron según la cobertura vacunal. Se transcribieron los datos y se analizaron utilizando el software NVivo7.
Resultados: Los conocimientos comunitarios sobre la etiología y el diagnóstico de la malaria eran buenos, aunque generalmente los miembros de la comunidad no buscaban tratamiento en los centros sanitarios como primera opción. Las percepciones y actitudes frente al IPTi eran muy positivas, tanto entre la comunidad como entre los trabajadores sanitarios. La falsa idea de que el SP es un antipirético que previene la fiebre post-vacunal, contribuyó a la aceptabilidad del IPTi. No se identificaron rechazos o rumores negativos relacionados con la integración del IPTi dentro del PAI, y el IPTi no ha influenciado de forma negativa las actitudes frente a otras estrategias del control de la malaria. Las decisiones sobre los cuidados sanitarios de los niños, normalmente realizadas por el padre, comienzan a ser tomadas por unas madres con educación e independencia financiera.
Discusión: El IPTi fue bien aceptado por los proveedores y las comunidades, mostrando una aceptación sinérgica al entregarse junto con las inmunizaciones rutinarias. Sin embargo, el error de que el SP alivia la fiebre, debería tenerse en cuenta al llevar a mayor escala su implementación.
Intermittent preventive treatment of malaria in infants (IPTi) is a newly recommended malaria control strategy based on the administration of three doses of an antimalarial to infants, which decreases their incidence of malaria by 30% (Aponte et al. 2009). IPTi is administered alongside routine vaccinations (penta 2 and 3 and measles vaccine) of the Expanded Programme on Immunization (EPI) at 2, 3 and 9 months of age (WHO 2006). This coupling results in logistic advantages, high coverage in settings with well-established EPI programmes and low cost (Manzi et al. 2008). However, there are risks. If IPTi showed low acceptability, it could negatively impact EPI coverage, leading to a resurgence of diseases currently under control. Second, if IPTi were perceived as full protection against malaria, it could encourage the population to skip other malaria prevention measures. Thus, determining inherent IPTi acceptability obstacles and beliefs that could limit its success is critical.
The drug of choice for IPTi is sulphadoxine-pyrimethamine (SP). Although SP has been phased out for malaria treatment because of the emergence of drug resistance, it was chosen because it can be administered in single doses with high compliance, it is inexpensive, is readily available, has a long-lasting shelf life, it is safe to administer jointly with vaccinations (WHO 2006) and the incidence of serious adverse events is low (de Sousa et al. 2011). A vast campaign for the replacement of SP with artemisinin-based combination therapies has generated negative press about SP; therefore, misconceptions about SP and questions regarding its reintroduction could influence acceptability. In addition, because of the absence of a paediatric formulation, SP tablets are crushed and dissolved in water for infants intake, which contradicts public health messages on exclusive breastfeeding for infants younger than 6 months (WHO 2000) and increases IPTi’s administration time.
A health intervention that addresses a high morbidity and mortality disease is more likely to be well received by the affected communities. Strategies for preventing malaria are common throughout sub-Saharan Africa and generally well accepted. Although coverage remains low (Crawley et al. 2007), acceptability of malaria intermittent preventive treatment in pregnancy (IPTp) is high (Mubyazi et al. 2008). Initiatives encouraging pregnant women and children under 5 years of age to sleep under insecticide-treated mosquito nets (ITNs) are met with enthusiasm by village communities (Tsuyuoka et al. 2002; Iyaniwura et al. 2008; Prakash et al. 2008), although ITN usage is considerably less common than ownership (Korenromp et al. 2003). Indoor residual spraying is also well accepted (Brieger et al. 1996). Adoption of such interventions is further eased because they are generally provided without cost and are conveniently brought to communities.
To evaluate deployment of IPTi prior to widespread implementation, we conducted a large study in the context of pilot implementation by Ministries of Health (MoHs) in Benin, Madagascar and Senegal. The primary objective was to capture communities’ and health workers’ perceptions and acceptability of IPTi, along with factors that may facilitate or hinder acceptability such as rumours and relationships between community members and health workers. A secondary objective was to understand the decision-making process regarding young children’s health care in communities to better target communication campaigns.
Six districts in three countries (Benin, Madagascar and Senegal) had been previously selected for pilot implementation of IPTi by countries’ MoHs among UNICEF’s Accelerated Child Survival Districts. Data were collected during the first year of implementation (2007–2008). IPTi pilot districts were predominantly rural. In Benin and Madagascar, the main religion is Christian, whereas in Senegal, it is Muslim. Most communities live on subsidiary agriculture and fishing (Table 1).
Table 1. Characteristics of study sites
|Study population||1 601 732||447 957||821 150||332 625|
|Time frame||8–12 month||Mar 07 to Mar 08||June 07 to Jan 08||Jan 07 to Sep 07|
|# infants receiving IPTi||65 681||15 335||32 846||17 500|
|IPTi/EPI coverage|| ||99%||98%||99%|
|Measles coverage|| ||72%||64%||79%|
|Districts||6||Adjohoun-Bonou-Dangbo, Djidja-Abomey-Agbangnizoun||Amparafaravola, Moramanga||Vélingara, Kédougou|
|Distribution of population|| ||83% rural||100% rural||88% rural|
|Ethnicities represented|| ||Weme, Fon||Sihanaka, Bezanozano||Peulh, Malinke|
|Languages spoken|| ||Weme, Fon, French||Malagasy, French||Peulh, Malinke, French|
|Religions represented (*)|| ||Christian (66%), Traditional (25%) Muslim (9%)||Christian (45%),Traditional (52%),Muslim (7%)||Muslim (95%) Christian (5%) Traditional (1%)|
|Common livelihoods|| ||Agriculture, fishing, handcrafting||Agriculture, commerce, transportation, civil servant||Agriculture, commerce, breeding|
Districts are divided into communes composed of several villages. The communes were allocated into three measles immunization coverage strata (<50%; 50–70% and >70%) (MOH 2007a,b) and in each stratum, two or three villages were sampled randomly, totalling 39 villages (Table 2). All health centres were visited in each selected village. Households with infants were initially pointed at by the village leader followed by selection by proximity (using the itinerary method by visiting the nearest household in clockwise direction) until saturation of answers was obtained. Consent was obtained from the village leader and from the households before interviews were conducted. Health centres’ records of infants who did not attend the previous vaccination session as scheduled allowed researchers to locate and interview their families regarding their absence.
Table 2. Sampling
|Districts implementing IPTi||2||2||2|
|Measles immunization coverage strata in districts (*)||3||2||2|
|Villages selected per stratum||2||2||2–3|
|Villages sampled per country||18||8||13|
|IDIs conducted per country||471||54||80|
|FGDs conducted per country||21||10||20|
|Population represented||190 000||90 000||140 000|
A dozen experienced investigators fluent in the local languages were trained for 3 days before their first visit and 1 day before each additional passage, based on a detailed interview manual. Data were collected through direct observation (DO), in-depth interviews (IDIs) and focus group discussions (FGDs). The investigators were immersed in the communities for a total of 6 months, divided between two and three passages starting at 3 months of the implementation and during a period of 1 year. DO, IDI and FGD topics covered are presented in Table 3.
Table 3. Topics addressed by each data collection method
|DO||Households and health centres||Common observations:|
| Perceptions regarding the newborn care|
| Circulating rumours on malaria, immunizations, IPTi, SP medication and undesired side effects.|
|Additional observations in households:|
| Children’s socialization|
| Use of ITNs and other children heath and caretaking behaviours|
| Caregivers attitudes and behaviour regarding health care, and specifically malaria treatment and prevention|
| Healthcare decision making|
|Additional observations in health centres:|
| General interactions provider-beneficiaries|
| Education Information Communication sessions|
| IPTi administration (in fixed and advance clinics)|
|IDI||Households and health centres||Common topics for parents and health workers:|
| Malaria aetiology, diagnosis, treatment and prevention|
| Perceptions about IPTi-EPI coupling|
| Knowledge of IPTi (purpose, mode of administration and time of administration)|
| Concerns/rumours about adverse side effects due to IPTi|
| Perceptions regarding the extended length of immunization sessions|
|Additional topics for parents:|
| Attitudes about modern medical care (including reasons for adhering to or refusing IPTi and other prescribed interventions)|
| Identification of decision maker regarding children’s health (who decided on who paid for children’s vaccination or treatment at the health centres).|
|Additional topics for providers:|
| Concerns regarding SP efficacy and availability|
| SP administration (advantages and disadvantages)|
|FGD||Neutral sheltered places||Common topics for parents and health workers:|
| Malaria prevention|
| Differences between IPTi and vaccination|
| Efficacy of IPTi|
| Side effects and rumours about IPTi|
| Reasons to adhere to or refuse IPTi|
|Additional topics for parents:|
| Changes noticed in caring for their infants after the IPTi-EPI coupling |
Advantages and inconveniences of IPTi
| Impact of IPTi on infants’ health|
|Additional topics for healthcare personnel:|
| Perceptions and support of IPTi|
| Implementation protocols|
| Additional work burden because of IPTi|
| Impact on motivation and quality of care provided to patients|
Six hundred and five IDIs with all selected household caregivers of infants and all health centres workers were conducted in their homes and health centres, respectively, or in alternative convenient locations. Fifty-one FGDs of 1–1.5 h semi-structured discussions with homogeneous groups of 10 persons regarding age, gender, language and education level were conducted guided through open questions by the investigator/moderator. Interviews and FGDs were conducted until reaching saturation when no new information emerged (Glaser & Strauss 1967; Savoie-Zaic 1996; Pires 1997; Cresswell 1998). They were recorded, transcribed and entered in a custom-made Nvivo programme, and analysed. DO targeted observations regarding infant care and perceptions concerning malaria, immunizations, IPTi, SP and adverse effects. Observations in households were made on children’s socialization, general child health care and specific attitudes concerning malaria treatment and prevention. In the health centres, observations targeted healthcare providers’ interactions with parents.
Data were entered into a in-Nvivo7 qualitative analysis computer software (QRS international) database and analysed by themes according to the topics discussed (Strauss & Corbin 1998).
Intermittent preventive treatment in infants was administered to approximately 65 700 infants living in the study sites during the first year of implementation. Results from analysis of 605 IDIs (407 with caregivers 198 with health workers) and 51 FGDs (46 with caregivers, five with health workers) are reported (Table 2).
The average age of community respondents was 27 years (range 18–84), 76% were women and most were illiterate. The average age of health workers respondents was 32 years (range 20–57), 64% were women and had a middle school or a primary school level of education, depending whether they were formal health workers (nurses and midwifes) or community health workers (CHWs).
Among community members, malaria was generally understood as a disease caused by a mosquito bite and humidity (rain and stagnant waters) perceived as favourable for the proliferation of mosquitoes and hence malaria presence all year. A small number attributed malaria to other causes (sun exposure, shyness, evil spirits, witchcraft and curses). Malaria was recognized by fever and convulsions. Other signs quoted were tiredness, anorexia, vomiting and anaemia. Children were considered to be the most threatened by malaria. Families were concerned with preserving children’s health and understood the advantages of prevention compared with care, showing a positive attitude towards seeking prevention options and reporting that children must always sleep under a bed net. Caregivers unanimously indicated that malaria seriously affects the household activities and constitute an important financial burden. ‘When mosquitoes bite or houses are unhealthy, children get malaria and they get warm and feel cold … Malaria shows itself in children by fever, coughing, tiredness, pale eyes. With malaria, children do not play as usual, and they refuse to eat. It becomes serious and can result in convulsions’. FGD, Women, Benin.
Although communities’ knowledge of malaria’s aetiology and diagnosis was good and attitudes towards modern treatments were generally positive, the therapeutic itinerary choices started with self-medication (with drugs available in the household, or given by a neighbour or friend, or bought in the market) followed by traditional healers, and in most cases, going to health centres was the last resort. The reasons for this were by order of importance: economic difficulties, problems of geographical accessibility, trust in indigenous beliefs, commitment to traditional medicine and/or distrust of the modern health system.
The majority of community members understood that IPTi was used to reduce fever, including malaria, and about a third perceived it to also reduce post-vaccinal fever and as a substitute for paracetamol, an antipyretic often used by parents after vaccinations. Post-vaccinal fever is strongly feared by caregivers who report attending vaccination with healthy children and often returning with feverish children. Since the introduction of IPTi, some caregivers claimed to have noted a post-vaccinal fever reduction, although they understood that IPTi aims to protect against malaria. ‘This medicine that we received during the vaccination acts against fever and malaria.’Woman, houseworker, 36 years old, Benin.
Caregivers were introduced to IPTi during the education, information and communication activities preceding immunization sessions. As young children are generally under the exclusive care of their mothers or other women in the household, women are generally more knowledgeable about IPTI than men. However, most community members knew about IPTi and showed a very positive attitude towards it, including encouraging neighbours to attend health clinics to receive IPTi, a behaviour observed in all countries. When asked what they liked about IPTi, the most frequent answers were its ability to prevent or decrease fever and its gratuity. ‘The health worker told me about IPTi, and I made the decision that my wife would follow all the IPTi sessions. Last session she couldn’t attend because there was a mourning in her family. But from now on she will not miss one single session.’Man, FGD, Senegal.
Although immunizations and IPTi are free, caregivers have to pay for their transportation to the health centres. Therefore decisions concerning the recourse to a medical structure, including children’s vaccination, are usually made by the head of the household, typically the father, in charge of the household expenses. However, women that have gained some financial independence and can afford to cover the expenses as well as those with more education often proceed without consulting the father. ‘When our children fall sick, we bring them to the health center ourselves. Their father deals later with the expenses. Usually it is the father who makes the decision of where we take the children, but many times it is the mother who takes the initiative’. Woman, 25 year old, Benin.
We did not observe cases of refusal for IPTi or detected any negative rumours. The trust in health providers was generally so high that people gladly accepted the measures they were offered. In most study sites, consent to receive IPTi was sought during the education sessions that preceded vaccinations. However, in some areas of Senegal where IPTi was seen as a mandatory measure or ‘law of the hospital’, communities were not always informed on their rights to refuse the intervention. Additionally, women’s desire to receive IPTi was sometimes used by nurses to make them attend immunizations. Therefore, although unlikely due to the wish observed to receive IPTi, it is possible that in some Senegalese communities, high adherence to EPI/IPTi was the result of fear of reprisals by health workers.
Health workers correctly identified IPTi as a strategy for malaria prevention in children that involved offering SP alongside specific vaccinations. Nurses and midwives had a slight better understanding of IPTi than CHWs. For example, a minority of CHWs shared communities’ confusion of SP with paracetamol, and few fully understood the concept of adverse effects. CHWs attributed this difference to the lack of formal training received. Training is highly appreciated because of the possibility of travelling and receiving monetary compensation. At the launching of IPTi, only formal health workers received training and were asked to organize training sessions in the health centres with their assistants. CHWs claimed that this ‘cascade training’ did not always occur and instead knowledge was conveyed through a ‘learn on the job’ technique based on practice and informal discussions during immunization sessions. This technique was effective in conveying a good understanding of IPTi and its administration, but less effective on more complex subjects such as drug safety.
Health workers had a very positive attitude towards IPTi. Some reported seeing an impact on the number of malaria cases seen, including reduced health facility demand for severe malaria treatment, since the onset of IPTi. ‘IPTi is a good policy, because we noticed that there are fewer sick children and malaria rate seems to be in decline’ Man, 28 year old, nurse, Benin.
Many health workers indicated that IPTi improved EPI adherence and noted that mothers were coming in more frequently and earlier to immunization sessions. Health workers reported that even caregivers from neighbouring districts were attending immunization at IPTi districts instead of their own, which they attributed to the demand for IPTi, and resulted in the surpassing of 100% immunization coverage reported in the administrative records. ‘The population likes IPTi very much. There are people from Bohicon and Zangnanado that come here on vaccination days because they know we also give a medicine that prevents malaria in children. Everyone wants to immunize their children in Abomey (an IPTi district). People leave Bohicon (at 10 km from Abomey) to do their immunization and IPTi here, so we did not have enough drugs for 1 month of vaccination. The amount of drugs we receive is not sufficient because there are a lot of foreigners coming and we cannot refuse them only because they are not residents in our area’. Man, 34 years old, nurse, Benin.
Health workers reinforced communities’ positive perception and attitudes towards IPTi, and some CHWs also contributed to the communities’ misconceptions, such as the association of IPTi with an antifever medicine, as they believed that fear of fever was the main reason why some parents were reluctant to vaccinate their children. Despite general approval, some complaints regarding the addition of IPTi to EPI activities were collected. Some professional health workers considered IPTi as an intervention in which they had little to gain as there was no extra pay or provision of additional medical equipment or motorcycles. Others had difficulties managing the IPTi-EPi coupling because of the increased workload burden, especially because of the handling of the drug (weighing babies for correct dosage and making a safe drinkable SP solution for infants). As there is no paediatric SP formulation available, the tablets had to be cut to the right dosage and dissolved in boiled water. In Madagascar, some health workers requested mothers to express breast milk to dissolve the SP tablets, a practice abandoned after a few months because it limited the participation of secondary caregivers such as grandmothers and fathers. ‘We usually do not weigh babies during classic immunizations, but with IPTi we must weigh all babies to know which dose of SP to give. It is also necessary to extract the milk from mothers for children younger than 6 months and crush the tablet.’Woman, Nurse, Madagascar.
Importantly, the use of a phased-out drug such as SP did not compromise community’s acceptance of IPTi. Moreover, no negative perceptions related to SP safety were identified in spite of a pharmacovigilance campaign to report adverse events launched during implementation (de Sousa et al. 2011).
Intermittent preventive treatment in infants was well accepted by communities with no cases of refusal observed or reasons why caregivers would not consent. IPTi’s popularity was so high that residents of non-pilot implementing villages often came to the pilot districts requesting IPTi, as well as caregivers of ineligible children. Although its addition to routine immunizations led to additional waiting time at the health facility, this delay was accepted by both health workers and caregivers. The concern that the negative press SP had received to facilitate its replacement with artemisin-based combination therapy could affect communities’ acceptability was not observed. Importantly, community members receiving IPTi maintained the use of other malaria control measures, such as bed nets and environmental sanitation, alleviating concerns that IPTi may reduce compliance with these other measures.
Communities’ acceptance of IPTi was attributed to the high demand for free antimalarials (although caregivers still had to pay for transportation to health centres to receive EPI/IPTi) and the convenience of administration with routine immunizations, SP’s reputation for reducing post-immunization fever was another important incentive. This misconception, probably reinforced by the use of the same word to designate malaria and fever in local languages, contributed to women requesting the drug even when their children were not eligible. Although this misconception has a positive effect on EPI compliance and IPTi acceptability, it could undermine the public’s trust in the healthcare system once its effect is no longer perceived.
A new intervention’s acceptance is more efficient when its social and psychological costs are low and the target disease is felt by the populations (Jaffré 1991). In these sites, malaria burden and child mortality are high, and malaria control interventions are viewed as a priority. Community members placed malaria as the major concern among children illnesses and had a correct understanding of its causes, manifestations and preventive measures. However, care-seeking behaviour often starts by self-medication, and only when the illness worsened in the child brought to health centres.
Regarding child healthcare decisions, a discrepancy was identified between the responses obtained and the observations made. By norm, the decision-making process is attributed to the father, although decisions rest progressively more on women as they acquire financial autonomy and can support expenses related to child health. Women with paid work and with education were more likely to be involved in household decisions including children’s health as previously reported (DHS 2005, 2006, 2007) and more likely to spend resources on children’s health and nutrition (UNIFEM 2000; Feumetio 2007), but it is difficult for them to transform their work into income, and their unpaid work time is greater than that of men (PNUD 1997). Although with the empowerment of women’s financial and educational levels family decisions concerning child health in rural Africa may be starting to shift from men to women, quantitative surveys may not capture this because of the normative discourse.
Health workers had a positive attitude towards IPTi because it prevents a high disease burden and it was perceived as an incentive for immunization resulting in increased EPI compliance (Dicko et al. 2011). While some health workers expressed concern about the extra time and work required to provide SP-IPTi, reactivation of other medical practices such as systematic weighing of the child and sharing child welfare information with the mother were observed. Concerns were mostly related to the lack of a SP infant formulation that required more than half of the extra time imposed by the addition of IPTi to routine immunizations (de Sousa et al. 2010).
Community health workers knew slightly less about IPTi than professional health staff, a difference attributed to less training received by CHWs, although they were highly motivated and instrumental in the search of children lost to immunization and in social mobilization for IPTi/EPI as part of their regular EPI practice. Because of their bridging role between health centres and communities, CHWs’ perceptions and attitudes were important for the success of the intervention.
The involvement of nurses trusted in matters related to childcare induced consistently positive behaviour. When the nurse offered a drug, the likelihood of acceptance was very high even when people lacked other information. Indeed, IPTi was well accepted even though not always understood by beneficiaries as only malaria control. Therefore, acceptability could not be measured in terms of knowledge but of attitudes and practices (Olivier de Sardan 1991), contradicting the traditional assumption that there is a unidirectional link between knowledge and practice (Haddad & Fournier 1995).
In our sites, IPTi’s acceptability was not affected by the village immunization coverage or by ethnic differences. Despite the geographical, cultural and demographic differences between the three countries included in this study, responses identified were remarkably similar, possibly because of their similar immunization and IPTi programmes. A study in Southern Tanzania (Pool et al. 2008) also found high acceptability of IPTi, attributed to its effect on general health and well-being and some respondents’ belief, as found here, that IPTi was given to ‘cool down’ post-vaccinal fever, although the study found a higher number of complaints regarding the lack of information on EPI-IPTi as well as unfriendly health workers. In Mozambique, IPTi was initially rejected because of negative rumours related to the clinical trial; however, after an information campaign and revised procedures were implemented, acceptance was achieved (Pool et al. 2006). While our study was conducted exclusively in Francophone countries, the addition of IPTi to EPI was also perceived as positive in a multicountry acceptability study conducted in five Anglophone countries (Kenya, Tanzania, Gabon, Ghana and Malawi) (Gysels et al. 2009). Together these results highlight the importance of training activities and communication campaigns addressed to health staff and communities and suggest that IPTi is a strategy with potential for universal acceptability in malaria endemic countries.
In conclusion, IPTi was well accepted by both health workers and community members across different geographical areas and cultural backgrounds indicating that scaled up implementation in Africa has potential for high acceptability. Coupling of IPTi with existing EPI programmes showed favourable synergic acceptability, although misperceptions about its objectives should be corrected during training and communication programmes.
We especially thank the people of Benin, Madagascar and Senegal IPTi implementing districts for their valuable time and support throughout this study. We thank Didier Dupont for training in Nvivo7. We thank the Bill and Melinda Gates Foundation for their financial support. This study was undertaken as part of a large Implementation Research project. Alexandra de Sousa is a staff member of the World Health Organization. The authors of this article alone are responsible for the views expressed in this publication, which do not necessarily represent the decisions or policies of the World Health Organization or UNICEF.