Knowledge, attitudes, practices, and future intentions to use intermittent preventive treatment with sulfadoxine-pyrimethamine among pregnant women in southern Ghana

Knowledge, attitudes, practices, and future intentions to use intermittent preventive treatment with sulfadoxine-pyrimethamine among pregnant women in southern Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Knowledge, attitudes, practices, and future intentions to use intermittent preventive treatment with sulfadoxine-pyrimethamine among pregnant women in southern Ghana Matilda Aberese-Ako, Wisdom Eberlin, Pascal Magnussen, Kingsford Norshie, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6482390/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Malaria in pregnancy is a significant public health concern in sub-Saharan Africa, affecting an estimated 32 million pregnant women annually. One of WHO’s recommendations for malaria prevention is the use of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). However, reports indicate that less than 100% of women in Ghana access IPTp service. This study explored knowledge, attitudes, uptake and future intentions to take IPTp-SP among pregnant women in southern Ghana. Methodology: An ethnographic study design was used. In-depth interviews were carried out among 70 pregnant women in Ghana. The interviews were recorded digitally, transcribed, and uploaded into NVivo Version 11 for coding and thematic analysis. All ethical procedures were followed. Results: Majority of the study participants received three or more doses of SP, suggesting that healthcare facilities were implementing the revised national guidelines. Most particpants were aware of the benefits of SP in malaria prevention and expressed trust in the guidance provided by healthcare providers. Participants lacked knowledge on the exact timing and number of SP doses required during pregnancy and they expressed their desire to receive information from healthcare providers. Despite some women experiencing side effects such as nausea and dizziness in taking SP, most of them continued to adhere to the prescribed SP regimen and indicated their intention to continue taking it due to its benefits. Conclusion: Strengthening communication between healthcare providers and pregnant women regarding dosing schedules, potential side effects, and follow-up doses could improve adherence and optimize the effectiveness of malaria prevention strategies. IPTp-SP pregnant women Ghana healthcare providers qualitative study knowledge attitudes practices Background Malaria in pregnancy is a significant public health concern. The WHO African Region accounted for 233 million cases (94%) of global cases of malaria in 2022 [ 1 ]. Additionally, the prevalence of exposure to malaria during pregnancy in 2022 was highest in west Africa, where about 6.4 million (39.3%) of an estimated 16.2 million pregnant women had malaria infections [ 2 ]. The World Health Organization (WHO) recommends several malaria prevention strategies for pregnant women in areas with moderate to high malaria transmission in Africa [ 1 ]. These include the use of long-lasting insecticidal nets (LLINs), case management of malaria in pregnancy through prompt diagnosis and treatment as well as intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) under directly observed therapy (DOT), as part of ANC in areas with moderate to high malaria transmission in Africa [ 3 , 4 ]. Intermittent preventive treatment of malaria in pregnancy involves administering a full therapeutic course of sulfadoxine-pyrimethamine (SP) to pregnant women at each routine ANC visit, starting in the second trimester, with doses given at least one month apart [ 1 ]. In 2017, 34% of outpatient department (OPD) cases were suspected to be malaria-related, with malaria accounting for about 19% of total hospital admission and 2% of total deaths [ 5 ]. In that same year, 399,736 suspected cases of malaria in pregnancy were recorded at OPDs, of which 133,687 (33.4%) were confirmed [ 5 ]. In Ghana, Malaria infection during pregnancy significantly contributes to both maternal and fetal health complications, including illness and death [ 6 ]. Although Ghana has made progress in reducing malaria infections, a significant number of cases still occur among pregnant women each year [ 7 ]. To improve malaria prevention, Ghana revised its IPTp policy from the recommended three dose regime to a minimum of three doses and a maximum of seven, offering SP every month from the second trimester till delivery [ 8 ]. Ghana has incorporated the IPTp intervention into the free maternal health delivery through ANC services [ 9 ]. However, in 2023 an estimated 78% and 60% of pregnant women received at least two and three doses of SP/Fansidar respectively for malaria prevention [ 10 ]. These figures fall short of the National Malaria Elimination Programme’s target of 85% set in 2011 [ 11 ]. Despite various malaria prevention efforts, key questions remain unanswered, such as why the targets are not being met, how women perceive SP, their experiences in taking SP and their future intentions regarding uptake. Earlier studies attempted to address such questions [ 12 , 13 , 14 ]. A study conducted in the Volta Region of Ghana, found that while majority of nursing mothers had heard of IPTp-SP, only half of them had knowledge of IPTp-SP, and most had a poor perception of the intervention [ 14 ]. The study also found that women with higher IPTp-SP uptake were those with tertiary education. Other studies on pregnant women in southern Ghana found that majority or all had heard of IPTp-SP, recognized its benefits during pregnancy and identified healthcare providers as their main source of information [ 15 , 16 ]. However, a study conducted in Ghana reported low levels of knowledge about IPTp-SP and above average attitude towards it among postpartum women in the Volta Region [ 16 ]. Similarly, another study conducted in Ghana found that less than half of postpartum women in the Asunafo North Municipality reported receiving IPTp3 [ 17 ]. This qualitative study contributes to the literature by exploring the knowledge, attitudes, uptake and future intentions regarding SP uptake among pregnant women in southern Ghana. Methods Study design The study employed an ethnographic design. In depth interviews (IDIs) were conducted using semi-structured interview guides, to obtain information from pregnant 139 pregnant women, majority of them being ANC registrants. Data were collected from April 2018 to March 2019. The research team comprised of a female medical anthropologist (MA) and nine graduate research assistants (RAs). Of the RAs, three were females and six were males, all of whom spoke the indigenous language of their assigned study areas: the Twi language for RAs who were recruited in the Ashanti Region and the Ewe language for those recruited in the Volta Region. The RAs underwent training on how to carry out community entry and IDIs procedures prior to data collection and during the data collection. Selection of research area The study was conducted in five districts, three in the Ashanti region and two in the Volta region of Ghana. Eight health facilities and eight communities were selected for the study. Ashanti region was chosen to represent the middle belt of the country, while Volta region was selected to represent the southernmost belt. These two regions are linguistically different, Twi is spoken in the Ashanti region and Ewe is spoken in the Volta region. Ashanti Region reported the second highest percentage (98.8%) while the Volta region reported the second lowest percentage (93.9%) of women receiving antenatal care from a skilled provider for the most recent birth in 2014 [ 18 ]. The district hospitals in the five districts automatically qualified to participate in the study. Also, interactions and interviews with pregnant women in some of the study communities revealed preference for specific health facilities for ANC services. Three of such preferred facilities, which are faith-based, were included in the study. Some women preferred the three facilities (2 in the Ashanti region and 1 in the Volta region), because they were closer to their communities than the district hospitals. The women’s assertion regarding proximity to health facilities was further confirmed through a transect walk conducted by the study team to verify the locations of health facilities [ 19 ]. The study team visited the eight health facilities and reviewed ANC and maternity admission records for malaria in pregnancy (MiP) cases. The total number of MiP cases from January 2015 to March 2018 for the different communities that access the services of each facility were tallied. The community with the highest number of MiP cases in each facility was chosen to participate in the study. The average population for each study community was 10,000 inhabitants. The study team conducted community entry activities, including visits to assembly members and chiefs and meetings with a cross-section of opinion leaders to inform them about the study and seek permission to conduct the study in their communities. Selection of study participants Each RA was assigned to a health facility to carry out interactions with healthcare providers and pregnant women attending ANC. Convenience sampling was used to recruit women for interviews [ 20 ]. The RAs recorded the phone numbers of pregnant women who were attending ANC and expressed willingness to participate in the study. These women were later contacted, and arrangement was made to meet each of them in her preferred location for an interview. The snowball method was also used to recruit other pregnant women from the eight study communities [ 21 ]. The first recruited pregnant woman helped the RA in identifying other pregnant women in the community. The study was explained to them and those who were interested were recruited to participate in IDIs after a written consent had been obtained. Data collection techniques and data collection process An RA spent several months in a facility observing ANC procedures, interactions between healthcare providers, and women who were attending ANC. IDIs were conducted in the local language and focused on knowledge, attitudes, and practices related to MiP interventions. Other findings from the study have been reported [ 19 , 22 , 23 ]. The interviews were recorded using digital recorders and they were transcribed verbatim to preserve’ the original messages and experiences of the interviewees. Interviews conducted in Ewe and Twi were transcribed into English to facilitate analysis and comparison (see additional files for IDI guide). Additionally, RAs obtained permission from the women to review their maternal and child health record books to confirm IPTp-SP uptake. Data analysis IDI transcripts were uploaded into qualitative analysis software NVivo Version 11. A code book was developed and a coding list on common themes emerging from the data was generated to guide the coding process. The first author and an expert in qualitative research methods, who was hired to enhance the validity of the process, independently coded the data thematically. The analysis aimed to identify similarities, patterns, differences, and contradictions in the information presented by study participants [ 24 ]. The main themes identified from the analysis formed the basis for interpreting and reporting the study findings. This manuscript is part of the larger study mentioned in the introduction, so aspects of the findings have been previously reported [ 19 ]. Ethical Issues Ethical clearance was obtained from the University of Health and Allied Sciences’ Research Ethics Committee (UHAS-REC A.1 [l] 17–18). Written informed consent was obtained from all interview participants and/or their legal guardian. In this study, women attending ANC were invited to participate in interviews. Those who expressed interest were given time to reflect, and their phone numbers were recorded by the RAs. They were later contacted, and by the RAs and those who remained interested provided written consent before participating. A few individuals declined to be interviewed. One study participant was 16 years old, and permission was obtained from her mother before her inclusion in the study. Permission to conduct the study was also sought from district directors of health, facility managers of the eight study facilities, department managers, chiefs and assembly members in the study communities. To protect the identities of informants, pseudonyms have been used for districts and individuals’ names except for actual country and region names. Health facility pseudonyms beginning with ASF refer to study facilities in the Ashanti Region and ASC refer to study communities in the Ashanti Region. Similarly, the prefix VRF refers to facilities in the Volta region and VRC refers to study communities in the Volta Region. Pseudonyms of respondents are thus predicated by the prefix of the community where the IDI was conducted. Findings The findings explore the perceived benefits and risks in taking SP, the reported number of times that women have taken SP, their knowledge of the recommended SP dosage, pregnant women feel about the SP, and their intentions to take SP in future. The benefits and risks involved in taking sulfadoxine-pyrimethamine during pregnancy Almost half of the respondents consistently emphasized that SP is provided as a preventive measure against malaria for both pregnant women and the unborn children. Other respondents mentioned that it had a positive effect on the unborn child, emphasizing its role in ensuring that the child remains healthy and strong. “That one [SP], they say it is a malaria drug, so when you take it, it helps in protecting you [the pregnant woman] and the baby from malaria.”(ASCommunity01, IDI004) “It helps the unborn child not to get the disease and also makes the child strong.” (VRCommunity02, IDI010) “It protects you and the child from malaria. The mother can pass on the malaria to the baby if she has it. So, if you drink the medicine, it cures the malaria. I have drunk it 2 times and it is left with one to drink. I will finish drinking mine this month.” (ASCommunity04, IDI003) Majority of the study participants had knowledge on the benefits of SP use. Most study participants stated that the primary purpose of administering SP during antenatal clinic visits is to prevent and combat malaria while safeguarding the health of pregnant women. Additionally, participants reported that SP is administered directly at the clinic, as healthcare providers do not allow them to take it home. “… it prevents me from getting malaria. Whenever I go to the laboratory, they do not find malaria parasites in my blood.” ( ASCommunity04, IDI009) “The malaria drug is to prevent malaria. It prevents malaria so that you do not get malaria, because you may have had the mosquito bites already.” (ASCommunity03, IDI001) A few pregnant women had misconceptions regarding the purpose for which they were given SP. Some believed that once they had taken SP, they were completely protected from malaria, making other preventive measures such as avoiding mosquito bites unnecessary. Others mistakenly thought it prevents complications such as rashes on the baby's body and ensures that the newborn's eyes will not remain closed. “Ummm! It helps because I can stay outside very late and I do not also sleep in a net. Without that I would always be going to the hospital for malaria treatment.” (ASCommunity03, IDI001) “The “3–3” [SP] is good. It protects the baby from malaria, sometimes when you deliver the baby, rashes may appear on the body or maybe another child’s eyes too might not open and the likes, so it [SP] prevents them from the afflictions that I mentioned.” (ASCommunity01, IDI005) Knowledge on the number of times that a woman needs to take SP during pregnancy and reported number of times that participants had taken SP The findings reveal variations in the frequency of SP uptake among pregnant women attending ANC, as well as their knowledge on the number of times that they are required to take SP. Some study participants reported receiving the medication two or three times, while others mentioned having taken it up to four times, and others said five times during pregnancy. However, most were unaware of the recommended frequency, with some expecting monthly doses and others anticipating fewer doses. “No, I am done taking it. They said you have to take it for three times from the 4th month to the 7th month. I am in my 8th month now, so I am done.” (VRCommunity02, IDI002) ”I started taking it on my fifth month. I think I have taken it five times [She was eight months pregnant at the time of the interview]. ” (ASCommunity03, IDI008) Most of the study participants mentioned that they were given SP at ANC. With regards to the frequency, some participants indicated that they were given SP every time they visited the ANC, while others indicated that they were given SP every month. “Whenever I go to the hospital, they give me some. I have been given six times (ASCommunity04, IDI009 ) “They said three times, but I have been given four, so I have decided that if they give me some again in any of my next visits, I will ask them.” (ASCommunity03, IDI001) “I take it every month and when you are close to delivery, you report every two weeks. So, I have taken it many times.” (ASCommunity03, IDI007) Some of the participants who had used health facilities in previous pregnancies reported that they were given between three to six doses in their current pregnancy. They indicated that previously they were given three doses but it had been increased over time. “At first we were taking it three times but now any time you go there they will give you some.”[This is her second pregnancy] (ASCommunity03, IDI009) On whether the pregnant women had been informed on the number of times that they needed to take in SP, most of them said three times. “They told us we will take it three times.” (ASCommunity04, IDI010) “They told me I will take it four times.” (VRCommunity04, IDI006) Some of the participants indicated that they had no knowledge of the number of times that they were required to take SP, as the nurses had not informed them. However, such participants indicated that they trusted the health providers, so they took in SP whenever they were instructed to do so at the ANC. “I do not know why they let us take it that much but when you are close to delivery, they let you stop taking it.” (ASCommunity03, IDI008) “I do not know, but the nurses know the number of times that I am supposed to take it [SP]. So anytime they give me I take it.” (VRCommunity02, IDI001) “I don’t know that [number of times she is required to take SP], but I was asked to take and I took it.” (VRCommunity04, IDI001) Some women on the other hand lacked proper knowledge on the timing for taking SP, the number of tablets per dose and the number of doses required and thus provided wrong information. “It depends on the gestational age. So, if you [pregnant woman] do not attend ANC for about three months, when you go they will give you [pregnant woman] 3 [SP tablets] for you to take them all. But if you [pregnant woman] attend ANC every month, then you [pregnant woman] would be given only one [SP] tablet.” (ASCommunity01, IDI008) “… we are also given some 3 white tablets to chew in their presence when the pregnancy gets to about six months.” (VRCommunity02, IDI007) Description of how SP is administered to pregnant women at the ANC Majority of the study participants reported that healthcare providers instruct them to bring water, and in the presence of the nurses or midwives, the medication is given to them to swalllow. The method of consumption varies; some study participants mentionedbeing required to chew the medication, while others reported swallowing it whole. There is a strong emphasis on taking the medication under the supervision of healthcare professionals. A few of the study participants highlighted the importance of compliance, noting that they were compelled to take it in front of the nurses may result in not being allowed to take it home. Others also mentioned the bitterness of SP,, underscoring the challenges some women face in adhering to the prescribed regimen. Additionally, there was a recurring theme of women were asked about their eating status before being given the medication, with recommendations to take it with a meal. These findings reported the procedural aspects, challenges, and complexities surrounding the administration of antenatal drugs as narrated by study participants . “They [health providers] ask us to bring water, so when they put it [SP] in your palm then you have to chew it and swallow it in their presence.” (VRCommunity02, IDI, 004) “You drink it there. They don’t allow you to take it [SP] outside.” (ASCommunity03, IDI001) “So they will compel you to take it before leaving; they first ask whether you have eaten. If you have not eaten they will tell you to go and eat and come back to take it [SP.” (VRCommunity03, IDI008) “They [nurses] asked me if I had eaten and I said no, so they [nurses] asked me to go and eat and come after which I was given the SP. I just swallowed it like any other medicine. I took it in front of them [nurses]” (VRCommunity01, IDI07) Information that pregnant women receive from nurses after SP uptake The study sought to find out what information that pregnant women were given by health providers after taking SP. Majority of study participants indicated that nurses did not provide any additional instructions or information beyond the administration of SP. “They don’t tell me anything after drinking the medicine.” (ASCommunity04, IDI002) “They told me to take toffee so that I will not vomit the drug.” (ASCommunity04, IDI 003) “They don’t say anything to us after we have taken the SP.” (VRCommunity01, IDI001) A few of the study participants mentioned receiving various post-consumption advice. These included recommendations to avoid sitting outside for extended periods in the evening, drinking plenty of water, and resting or sleeping, especially when one felt weak. Additionally, few participants reported being advised not to take folic acid immediately after SP intake. Other advice included consuming fruits or toffees to prevent vomiting. “They told me not to sit outside in the evening for too long.” (ASCommunity04, IDI001) “They tell us to take fruits after taking the drug.” (ASCommunity04, IDI006) “They tell us once you have taken the drug, you will sometimes become weak, so when you go home sleep for a while, so that you won’t have any problem.” (ASCommunity04, IDI010) How pregnant women feel about taking in SP Many study participants shared their experiences in taking SP such as not liking the smell, the drug tasting bitter, feeling nausea or weak after intake. Others expressed concerns or discomfort associated with SP intake, such as stomach aches, dizziness, and vomiting after taking SP. Also, it was reported that pregnancy can make it difficult for some to eat which presents a challenge as the health providers demand that pregnant women should eat before taking in SP. “The malaria drug when it comes, it is bitter, extremely bitter. If you are not determined, you will not take it. If you do not take it in the presence of the midwives/nurses, they will not give it [SP] to you to take it home, so they will cease your card and make you buy water to take it.” (ASCommunity01, IDI005) “…there are some medicines we drink at the hospital... they gave me a medicine, which is 3 in number and I chewed it there. I came home after taking the medicine, I felt weak but after some time I regained my strength.” (ASCommunity04, IDI002) “We vomit whenever we take it.” (ASCommunity04, IDI006) “Yes, medicine for malaria and you drink it at the hospital. They will not allow you to bring it home because it is very difficult to drink it. I nearly vomit after drinking it [laughing].” (ASCommunity04, IDI003) “Ehe! The malaria one; Oh! The last time I took it I could not do any work. My whole system felt disturbed; my stomach ached and the child also struggled moving in different directions. I think it was only today, which is three days after before I am feeling fine.” (VRCommunity03, IDI004) “For me when I take the SP, I feel like vomiting and it makes me dizzy and also makes me eat more.” ( VRCommunity04, IDI 008) A few of the study participants indicated that they did not experience any adverse effects whenever they took in SP, although some of them indicated that they were aware that others experienced adverse outcomes. “As for me when I take it, I do not feel anything.” (ASCommunity01, IDI003) “Personally, I do not feel anything.” (ASCommunity01, IDI010) “No, I do not get any problem but some people become weak and vomit. When I take it, I do not experience anything.” (ASCommunity04, IDI007) “Please I do not have any problem with taking drugs whilst pregnant. I don’t vomit or have any problem when I take drugs. I haven’t experienced that in my life.” (ASCommunity04, ID1004) Pregnant women’s intentions of future use of SP Majority of the study participants said that they were willing to take SP in the future. This was commonly linked to the perceived benefits, with a majority of the study participants expressing a willingness to comply with the recommended dosage for the well-being of both themselves and their unborn children. While others acknowledged the challenges in taking it, they still indicated that they had no option but to take it because of the benefits to them and their unborn children. “I do not have any option. I have to drink it [SP] because if you have malaria, you can pass it on to the baby, though it is very difficult to drink it.” (ASCommunity04, 003) “When I become pregnant again, I will like to take it again.” (ASCommunity04, IDI009) “I will like to take it again, because when I take it, it prevents me from those parasites.” (ASCommunity04, IDI006) “Oh why not! For the sake of my ‘health’ I will take it.” (ASCommunity03, IDI008) However, a few of the study participants mentioned uncertainties about future adherence, influenced by factors such as the drug's smell, discomfort, or past adverse reactions. “You know every pregnancy has its own way it makes you feel. If my next pregnancy permits me to take I will take it but for now I have decided not to take it again.” (ASCommunity03, IDI011) “I started taking it the first month I started and I am currently seven months. I take it every time I go there. In fact that drug I won’t take it again .”( ASCommunity03, IDI011) Discussion This qualitative study explored pregnant women’s knowledge, attitudes, and practices related to the use of SP in two regions in Ghana. Our findings suggest that most of the study participants understood SP’s role in malaria prevention and expressed high levels of trust in the guidance provided by healthcare providers. Also, their attitude towards SP was positive, with most participants indicating a willingness to take it in future. Nevertheless, some women were unaware of the reasons for SP uptake, its relevance, and the number of times they needed to take it during pregnancy. It was found that most of the study participants had received three or more doses of SP during pregnancy. This is in line with the Ghana National Malaria Elimination Programme recommendations [ 25 , 26 ]. However, a study reported that less than half of postpartum women received up to three doses during pregnancy [ 17 ], while another reported that most pregnant women in the Atwima Kwanwoma District of Ghana, received only two doses of SP during pregnancy [ 27 ]. The reasons for the high uptake of at least three doses of IPTp-SP observed in this study is based on trust in health care providers, as participants indicated that despite the adverse effects of SP they will take it if asked to do so by the health workers, as they trusted that they were doing so in their interest. The role of trust in healthcare has well been noted as crucial to effective health care provision [ 28 , 29 , 30 ]. Majority of the study participants recognized the importance of SP in preventing and combating malaria during pregnancy, demonstrating a good understanding of how IPTp-SP works. Our finding aligns with other studies conducted in Ghana, which reported that most pregnant women had good knowledge of IPTp-SP [ 31 , 32 , 33 , 34 ]. This was evident in the study as most of the pregnant women responded that they trusted the instructions of healthcare providers on the required SP doses given to them, hereby, making no effort to seek knowledge on the required doses to be taken through their ANC sessions. Some of the women reported receiving information on SP intake from healthcare workers at the ANC, while, others reported that they did not. It is therefore not surprising that a good number of the pregnant women were unaware of when they were supposed to start and the number of times that they were required to take in SP during pregnancy. Similarly, previous studies in Ghana found that majority of pregnant women did not know the recommended number of doses of SP [ 31 , 32 , 33 , 34 ]. It is important to note that women in their second or subsequent pregnancies noticed the dosage had increased from three times to four or more in their current pregnancy. However, they did not know why, and most failed to inquire at the ANC. This suggests that healthcare facilities are implementing Ghana’s revised policy, which extends SP administration from three doses to monthly doses from the second trimester until delivery [ 8 ]. Our findings corroborate findings from previous studies on Ghana, which reported that a majority of women receive more than three doses of SP [ 15 , 17 , 32 ]. Similarly, studies in Kenya and Tanzania have reported improved maternal outcomes following increased SP doses, but also noted gaps in patient-provider communication regarding policy changes [ 35 , 36 ]. In contrast, a study in Uganda found that healthcare workers proactively explained the policy change during ANC sessions, significantly improving compliance [ 37 ]. The study participants described common side effects such as nausea, dizziness, and vomiting associated with SP intake. These side effects posed a challenge for study participants, decreasing the interest of some in continuing to take it. This finding aligns with the WHO’s report on common side effects such as nausea, vomiting, dizziness, and general weakness that have been reported following the administration of SP doses, particularly with the first dose of SP [ 3 ]. A scoping review found that first-dose side effects, such as nausea and dizziness, were prevalent across multiple sub-Saharan countries, including Ghana [ 38 ]. However, other studies suggest that side effects are often temporary and decline with subsequent doses [ 39 ]. Moreover, research in Kenya found that prior knowledge about SP, its potential side effects and benefits motivated young mothers to adhere to the treatment [ 40 ]. This indicates that addressing side effects through preemptive communication could mitigate the challenges identified in this study. The finding suggest that a good number of women were not provided information regarding returning for future doses. This communication gap is consistent with findings in Ghana, which found that insufficient guidance from healthcare providers often led to incomplete IPTp-SP regimens [ 33 ]. Similarly, a study conducted in Ghana found that most of the women in their study had no knowledge on the number of times that they were supposed to take SP [ 16 ]. In contrast, pregnant women who received education regarding SP prior to its administration had higher odds of completing the recommended doses. Specifically, those informed about the timing and necessity of follow-up doses demonstrated a greater likelihood of adherence [ 27 , 34 ]. These findings underscore the importance of clear and consistent messaging from ANC providers to enhance adherence to SP guidelines. Majority of the women who participated in the study indicated that they would take SP in future, which was based on knowledge on its benefits, the perception that they had no choice and trust in healthcare providers. Also, all the women indicated that they would be happy to take in SP if they are provided information on its relevance. Similarly, a study in Cameroon noted that women with positive perceptions of their healthcare providers were more likely to comply with IPTp-SP regimens, despite challenges [ 41 ]. This finding aligns with the broader literature which suggest that patient trust in health care providers facilitates adherence and patient satisfaction [ 28 , 29 , 30 , 42 ]. Study limitation This study as in qualitative studies a few participants were purposively sampled to participate in the study and for that matter it cannot be generalized. Nevertheless, our literature suggests that the findings compare with previous studies carried out elsewhere. Conclusion The findings of the study suggest a need for clearer communication and education on SP usage during pregnancy to ensure consistent and accurate understanding among expectant mothers. ANC education on SP should go beyond emphasizing its benefits of SP in malaria prevention to providing a comprehensive understanding of the required doses of SP to be taken during the period of pregnancy. Healthcare providers should ensure that women are educated on SP during waiting times as well as during one-on-one consultations to enable them to become better informed on IPTp-SP. Additionally, it is important that healthcare providers give preemptive education to prepare pregnant women for the possible side effects of SP and the appropriate interventions to be taken in managing these side effects. Declarations Ethics approval and consent to participate Ethical clearance was obtained from the University of Health and Allied Sciences’ Research Ethics Committee [UHAS-REC A.1 [l] 17-18] and the study was conducted according to the principles of the Declaration of Helsinki and good clinical Practice. Written informed consent was obtained from all interview participants and/or their legal guardian. Consent for publication The manuscript does not contain any individual’s data Availability of data and materials Data is available at the University of Health Research repository and can be made available upon reasonable request from the first author Matilda Aberese-Ako (MA) Competing interests All the authors declare no conflict of interest Funding This work was supported through the DELTAS Africa Initiative [MARCAD Grant Number: DEL‑15–010]. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust [WT: 107741/A/15/Z] and the UK government. Authors' contributions The study was conceptualized by MD, PM, GA and HT. MD, KN and WE drafted the manuscript and it was revised by PM, GA and HT. All authors read and approved the final manuscript. Acknowledgments We wish to thank the nine research assistants, ED who supported the coding process, the regional health directorates and regional directors of health, participating districts, facilities, communities and study participants, for the cooperation and support in this study. We also thank the editor and the two reviewers whose inputs have contributed greatly to improve the quality of the manuscript. Authors' information The first author, MA is a senior researcher and the director of the Malaria Research Centre at the Institute of Health Research, University of Health and Allied Sciences References World Health Organization, “World malaria report 2023.” Accessed: Jan. 13, 2025. [Online]. Available: https://iris.who.int/bitstream/handle/10665/374472/9789240086173-eng.pdf?sequence=1 World Health Organization, “World malaria report 2023.” Accessed: Apr. 01, 2025. [Online]. Available: https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2023 World Health Organisation, “WHO policy brief for the implementation of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP).” Accessed: Feb. 03, 2025. [Online]. Available: https://www.who.int/publications/i/item/WHO-HTM-GMP-2014.4 World Health Organisation, “WHO guidelines for malaria.” Accessed: Mar. 29, 2025. [Online]. Available: https://iris.who.int/bitstream/handle/10665/379635/B09146-eng.pdf?sequence=1 Ghana Health Service, “2017 ANNUAL REPORT,” NATIONAL MALARIA CONTROL PROGRAMME, Feb. 2018. Accessed: Mar. 29, 2025. [Online]. Available: https://malariaportal.org/sites/default/files/2023-11/GHN-505_%20NMCP%20Annual%20Report%20_2017.pdf D. K. Dosoo et al. , “Epidemiology of malaria among pregnant women during their first antenatal clinic visit in the middle belt of Ghana: a cross sectional study,” Malar. J. , vol. 19, no. 1, p. 381, Dec. 2020, doi: 10.1186/s12936-020-03457-5. J. Osarfo, G. D. Ampofo, and H. Tagbor, “Trends of malaria infection in pregnancy in Ghana over the past two decades: a review,” Malar. J. , vol. 21, no. 1, p. 3, Jan. 2022, doi: 10.1186/s12936-021-04031-3. United States Agency for International Development, & Centre for Disease Control and Prevention, “The President’s Malaria Initiative Eleventh Annual Report to Congress.” Accessed: Jan. 13, 2025. [Online]. 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J. , vol. 21, no. 1, Dec. 2022, doi: 10.1186/s12936-022-04205-7. D. Klu and L. Owusu, “Factors affecting the uptake of optimal doses of intermittent preventive treatment of malaria in pregnancy using sulfadoxine pyrimethamine in Ghana: new evidence from the 2019 malaria indicator survey,” J. Public Health , vol. 33, no. 2, pp. 269–279, Feb. 2025, doi: 10.1007/s10389-023-02024-x. V. N. Orish et al. , “Assessing nursing mothers’ knowledge, perceptions and uptake of Sulphadoxine Pyrimethamine (IPTp-SP) during pregnancy in the Ho Teaching Hospital of the Volta Region of Ghana,” PLOS Glob. Public Health , vol. 3, no. 2, p. e0000904, Feb. 2023, doi: 10.1371/journal.pgph.0000904. D. Ansong, D. M. Otoo, and V. Mensah, “Knowledge, uptake and therapeutic effectiveness of sulfadoxine-pyrimethamine (IPTp-SP) among pregnant women attending the antenatal clinic at ayeduase Health Centre in Oforikrom Municipality in the Ashanti-region, Ghana,” BMC Pregnancy Childbirth , vol. 25, no. 1, p. 265, Mar. 2025, doi: 10.1186/s12884-024-07089-4. L. Asem, A.-G. Abdulia, P. O. Assuming, and G. Abeka-Nkrumah, “Knowledge, and attitude of service user of intermittent preventive treatment of malaria in pregnancy using sulfadoxine pyrimethamine in the Volta Region of Ghana,” PLOS ONE , vol. 19, no. 9, p. e0309340, Sep. 2024, doi: 10.1371/journal.pone.0309340. A. K. Yeboah et al. , “Factors and barriers to sulfadoxine-pyrimethamine uptake for intermittent preventive treatment during pregnancy in Ghana,” Acad. Med. , vol. 1, no. 4, Nov. 2024, doi: 10.20935/AcadMed7414. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International, “Ghana Demographic and Health Survey 2014,” Oct. 2015. Accessed: Mar. 29, 2025. [Online]. Available: https://dhsprogram.com/pubs/pdf/fr307/fr307.pdf#page=1.00&gsr=0 M. Aberese-Ako, P. Magnussen, M. Gyapong, G. D. Ampofo, and H. Tagbor, “Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions,” Malar. J. , vol. 19, no. 1, p. 347, Dec. 2020, doi: 10.1186/s12936-020-03422-2. S. W. VanderStoep and D. J. Deirdre, “Research Methods in Everyday Life: Blending Qualitative and Quantitative Approaches | Request PDF,” ResearchGate. Accessed: Jan. 13, 2025. [Online]. Available: https://www.researchgate.net/publication/254607059_Research_Methods_in_Everyday_Life_Blending_Qualitative_and_Quantitative_Approaches A. Rubin and Babbie, “(PDF) Research Methods for Social Work,” ResearchGate. Accessed: Jan. 13, 2025. [Online]. Available: https://www.researchgate.net/publication/237131811_Research_Methods_for_Social_Work M. Aberese-Ako, P. Magnussen, G. D. Ampofo, M. Gyapong, E. Ansah, and H. Tagbor, “An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context,” PLOS ONE , vol. 16, no. 10, p. e0257666, Oct. 2021, doi: 10.1371/journal.pone.0257666. M. Aberese-Ako, P. Magnussen, G. D. Ampofo, and H. Tagbor, “Health system, socio-cultural, economic, environmental and individual factors influencing bed net use in the prevention of malaria in pregnancy in two Ghanaian regions,” Malar. J. , vol. 18, no. 1, p. 363, Dec. 2019, doi: 10.1186/s12936-019-2994-5. C. V. Som, “Exploring the human resource implications of clinical governance,” Health Policy , vol. 80, no. 2, pp. 281–296, Feb. 2007, doi: 10.1016/j.healthpol.2006.03.010. Y. N. Agyeman, B. Bassoumah, and J. Owusu-Marfo, “Predictors of optimal uptake of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine and outcome of pregnancy in selected health facilities: a cross-sectional study in Northern Ghana,” Malar. J. , vol. 22, no. 1, p. 80, Mar. 2023, doi: 10.1186/s12936-023-04501-w. A. Mama et al. , “Intermittent preventive treatment in pregnancy with sulfadoxine–pyrimethamine and parasite resistance: cross-sectional surveys from antenatal care visit and delivery in rural Ghana,” Malar. J. , vol. 21, no. 1, p. 107, Dec. 2022, doi: 10.1186/s12936-022-04124-7. E. Kumah et al. , “Intermittent Preventive Treatment of Malaria in Pregnancy with Sulphadoxine-Pyrimethamine and its Associated Factors in the Atwima Kwanwoma District, Ghana,” Ann. Glob. Health , vol. 88, no. 1, p. 27, Apr. 2022, doi: 10.5334/aogh.3560. J. Birkhäuer et al. , “Trust in the health care professional and health outcome: A meta-analysis,” PLOS ONE , vol. 12, no. 2, p. e0170988, Feb. 2017, doi: 10.1371/journal.pone.0170988. L. Gilson, “Trust and the development of health care as a social institution,” Soc. Sci. Med. , vol. 56, no. 7, pp. 1453–1468, Apr. 2003, doi: 10.1016/S0277-9536(02)00142-9. L. Gilson, “Trust in health care: theoretical perspectives and research needs,” J. Health Organ. Manag. , vol. 20, no. 5, pp. 359–375, Sep. 2006, doi: 10.1108/14777260610701768. V. N. Orish et al. , “Assessing nursing mothers’ knowledge, perceptions and uptake of Sulphadoxine Pyrimethamine (IPTp-SP) during pregnancy in the Ho Teaching Hospital of the Volta Region of Ghana,” PLOS Glob. Public Health , vol. 3, no. 2, p. e0000904, Feb. 2023, doi: 10.1371/journal.pgph.0000904. G. D. Ampofo, A. K. Ahiakpa, and J. Osarfo, “Interventions for malaria prevention in pregnancy; factors influencing uptake and their effect on pregnancy outcomes among post-natal women in a tertiary facility in the Volta Region of Ghana,” SAGE Open Med. , vol. 11, p. 20503121231199653, Jan. 2023, doi: 10.1177/20503121231199653. F. Dun-Dery et al. , “Uptake challenges of intermittent preventive malaria therapy among pregnant women and their health care providers in the Upper West Region of Ghana: A mixed-methods study,” Parasite Epidemiol. Control , vol. 15, p. e00222, Aug. 2021, doi: 10.1016/j.parepi.2021.e00222. H. Ibrahim, E. T. Maya, K. Issah, P. A. Apanga, E. G. Bachan, and C. L. Noora, “Factors influencing uptake of intermittent preventive treatment of malaria in pregnancy using sulphadoxine pyrimethamine in Sunyani Municipality, Ghana,” Pan Afr. Med. J. , vol. 28, 2017, doi: 10.11604/pamj.2017.28.122.12611. W. P. Mikomangwa et al. , “Effect of sulfadoxine-pyrimethamine doses for prevention of malaria during pregnancy in hypoendemic area in Tanzania,” Malar. J. , vol. 19, no. 1, p. 160, Dec. 2020, doi: 10.1186/s12936-020-03234-4. S. W. Nganga et al. , “Patient and provider perspectives on how trust influences maternal vaccine acceptance among pregnant women in Kenya,” BMC Health Serv. Res. , vol. 19, no. 1, p. 747, Dec. 2019, doi: 10.1186/s12913-019-4537-8. E. Ssegujja, I. Ddumba, and M. Andipartin, “Prioritization of interventions in pursuit of maternal health policy objectives to mitigate stillbirth risks. An exploratory qualitative study at subnational level in Uganda,” BMC Health Serv. Res. , vol. 21, no. 1, p. 53, Jan. 2021, doi: 10.1186/s12913-020-06046-z. G. O. Berchie et al. , “Uptake and Effectiveness of Intermittent Preventive Treatment with Sulfadoxine-Pyrimethamine during Pregnancy in Africa: A Scoping Review,” Dis. Basel Switz. , vol. 12, no. 9, p. 203, Sep. 2024, doi: 10.3390/diseases12090203. E. Lufele et al. , “Acceptability of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine plus dihydroartemisinin-piperaquine in Papua New Guinea: a qualitative study,” Malar. J. , vol. 24, no. 1, p. 13, Jan. 2025, doi: 10.1186/s12936-024-05233-1. D. J. Matanda, T. Zulu, G. Odwe, O. Okoth, and Z. Nakuya, “Experiences of young mothers with the uptake of Sulfadoxine-Pyrimethamine for intermittent preventive treatment of malaria in pregnancy: a cross-sectional study in the Lake endemic region, Kenya,” Front. Glob. Womens Health , vol. 5, p. 1294893, Mar. 2024, doi: 10.3389/fgwh.2024.1294893. D. K. Guimsop, A. F. K. Talla, H. Kodji, and J. Ateudjieu, “Factors associated with the uptake of intermittent preventive treatment for malaria during pregnancy in Cameroon: An analysis of data from the 2018 Cameroon Demographic and Health Survey,” PLOS Glob. Public Health , vol. 4, no. 3, p. e0001245, 2024, doi: 10.1371/journal.pgph.0001245. J. Goudge and L. Gilson, “How can trust be investigated? Drawing lessons from past experience,” Soc. Sci. Med. , vol. 61, no. 7, pp. 1439–1451, Oct. 2005, doi: 10.1016/j.socscimed.2004.11.071. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6482390","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":459780666,"identity":"c9a8b5ac-d809-43b9-8872-332f262ae7fb","order_by":0,"name":"Matilda Aberese-Ako","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYFACHhiDjYHhA8MBMFMCiBOI0sI4g2QtzDzEaNFtP3vwcUVFnRwD+7HEx7Ztd+TlG5gP3uZhqM3DpcXsTF6y4Zkzh40ZeNIOG+e2PTPccIAt2ZqH4XgxTi0HcswkG9sOJO4/kN4mndt2mHEDA4+ZNA/DscQGXFrOvzH/2fivrr6B/3mbtGXbYfv5Dfzf8Gu5kWPG2NjAnMAgkXZMmrHtcGLDAR42oJYaPFreJUs2HDts2CDxLNmw59zh5A2H2Ywt5xgcwOOw3IMfG2rq5Bn40wwf/Cg7bDu/vfnhjTcVdTi1YAHMIMLgMPEaYKCOdC2jYBSMglEwXAEAeVxbnftKObkAAAAASUVORK5CYII=","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":true,"prefix":"","firstName":"Matilda","middleName":"","lastName":"Aberese-Ako","suffix":""},{"id":459780667,"identity":"8f15fc58-dc6a-4a6a-80ed-793d64e85ec1","order_by":1,"name":"Wisdom Eberlin","email":"","orcid":"","institution":"Evangelical Presbyterian Headquarters","correspondingAuthor":false,"prefix":"","firstName":"Wisdom","middleName":"","lastName":"Eberlin","suffix":""},{"id":459780668,"identity":"5b9e09a3-997a-4e8d-895c-fb2909736014","order_by":2,"name":"Pascal Magnussen","email":"","orcid":"","institution":"University of Copenhagen","correspondingAuthor":false,"prefix":"","firstName":"Pascal","middleName":"","lastName":"Magnussen","suffix":""},{"id":459780669,"identity":"e8bdccb4-2457-4609-92d3-f510b5eebe47","order_by":3,"name":"Kingsford Norshie","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Kingsford","middleName":"","lastName":"Norshie","suffix":""},{"id":459780670,"identity":"94d22cdc-5a55-40c8-9c2c-f61a9f72b482","order_by":4,"name":"Desmond Klu","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Desmond","middleName":"","lastName":"Klu","suffix":""},{"id":459780671,"identity":"759c52f8-f430-405d-b648-5db9a4f4fe48","order_by":5,"name":"Mustapha Immurana","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mustapha","middleName":"","lastName":"Immurana","suffix":""},{"id":459780672,"identity":"60de9f5f-891e-46a7-a418-77c36d59144f","order_by":6,"name":"Gifty D. Ampofo","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Gifty","middleName":"D.","lastName":"Ampofo","suffix":""},{"id":459780673,"identity":"167c60de-1157-43e5-9cbb-88de871f1a21","order_by":7,"name":"Harry Tagbor","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Harry","middleName":"","lastName":"Tagbor","suffix":""}],"badges":[],"createdAt":"2025-04-19 04:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6482390/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6482390/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91617020,"identity":"6fe689a3-edcd-4123-a753-b2471818cfd1","added_by":"auto","created_at":"2025-09-18 10:47:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":606170,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6482390/v1/f7c9e51b-306a-4f81-a1a5-67afff2de986.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Knowledge, attitudes, practices, and future intentions to use intermittent preventive treatment with sulfadoxine-pyrimethamine among pregnant women in southern Ghana","fulltext":[{"header":"Background","content":"\u003cp\u003eMalaria in pregnancy is a significant public health concern. The WHO African Region accounted for 233\u0026nbsp;million cases (94%) of global cases of malaria in 2022 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Additionally, the prevalence of exposure to malaria during pregnancy in 2022 was highest in west Africa, where about 6.4\u0026nbsp;million (39.3%) of an estimated 16.2\u0026nbsp;million pregnant women had malaria infections [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The World Health Organization (WHO) recommends several malaria prevention strategies for pregnant women in areas with moderate to high malaria transmission in Africa [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These include the use of long-lasting insecticidal nets (LLINs), case management of malaria in pregnancy through prompt diagnosis and treatment as well as intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) under directly observed therapy (DOT), as part of ANC in areas with moderate to high malaria transmission in Africa [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Intermittent preventive treatment of malaria in pregnancy involves administering a full therapeutic course of sulfadoxine-pyrimethamine (SP) to pregnant women at each routine ANC visit, starting in the second trimester, with doses given at least one month apart [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2017, 34% of outpatient department (OPD) cases were suspected to be malaria-related, with malaria accounting for about 19% of total hospital admission and 2% of total deaths [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In that same year, 399,736 suspected cases of malaria in pregnancy were recorded at OPDs, of which 133,687 (33.4%) were confirmed [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In Ghana, Malaria infection during pregnancy significantly contributes to both maternal and fetal health complications, including illness and death [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although Ghana has made progress in reducing malaria infections, a significant number of cases still occur among pregnant women each year [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo improve malaria prevention, Ghana revised its IPTp policy from the recommended three dose regime to a minimum of three doses and a maximum of seven, offering SP every month from the second trimester till delivery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Ghana has incorporated the IPTp intervention into the free maternal health delivery through ANC services [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, in 2023 an estimated 78% and 60% of pregnant women received at least two and three doses of SP/Fansidar respectively for malaria prevention [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These figures fall short of the National Malaria Elimination Programme\u0026rsquo;s target of 85% set in 2011 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite various malaria prevention efforts, key questions remain unanswered, such as why the targets are not being met, how women perceive SP, their experiences in taking SP and their future intentions regarding uptake. Earlier studies attempted to address such questions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A study conducted in the Volta Region of Ghana, found that while majority of nursing mothers had heard of IPTp-SP, only half of them had knowledge of IPTp-SP, and most had a poor perception of the intervention [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The study also found that women with higher IPTp-SP uptake were those with tertiary education. Other studies on pregnant women in southern Ghana found that majority or all had heard of IPTp-SP, recognized its benefits during pregnancy and identified healthcare providers as their main source of information [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, a study conducted in Ghana reported low levels of knowledge about IPTp-SP and above average attitude towards it among postpartum women in the Volta Region [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, another study conducted in Ghana found that less than half of postpartum women in the Asunafo North Municipality reported receiving IPTp3 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This qualitative study contributes to the literature by exploring the knowledge, attitudes, uptake and future intentions regarding SP uptake among pregnant women in southern Ghana.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe study employed an ethnographic design. In depth interviews (IDIs) were conducted using semi-structured interview guides, to obtain information from pregnant 139 pregnant women, majority of them being ANC registrants.\u003c/p\u003e \u003cp\u003eData were collected from April 2018 to March 2019. The research team comprised of a female medical anthropologist (MA) and nine graduate research assistants (RAs). Of the RAs, three were females and six were males, all of whom spoke the indigenous language of their assigned study areas: the Twi language for RAs who were recruited in the Ashanti Region and the Ewe language for those recruited in the Volta Region. The RAs underwent training on how to carry out community entry and IDIs procedures prior to data collection and during the data collection.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSelection of research area\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in five districts, three in the Ashanti region and two in the Volta region of Ghana. Eight health facilities and eight communities were selected for the study. Ashanti region was chosen to represent the middle belt of the country, while Volta region was selected to represent the southernmost belt. These two regions are linguistically different, Twi is spoken in the Ashanti region and Ewe is spoken in the Volta region. Ashanti Region reported the second highest percentage (98.8%) while the Volta region reported the second lowest percentage (93.9%) of women receiving antenatal care from a skilled provider for the most recent birth in 2014 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The district hospitals in the five districts automatically qualified to participate in the study. Also, interactions and interviews with pregnant women in some of the study communities revealed preference for specific health facilities for ANC services. Three of such preferred facilities, which are faith-based, were included in the study. Some women preferred the three facilities (2 in the Ashanti region and 1 in the Volta region), because they were closer to their communities than the district hospitals. The women’s assertion regarding proximity to health facilities was further confirmed through a transect walk conducted by the study team to verify the locations of health facilities [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The study team visited the eight health facilities and reviewed ANC and maternity admission records for malaria in pregnancy (MiP) cases. The total number of MiP cases from January 2015 to March 2018 for the different communities that access the services of each facility were tallied. The community with the highest number of MiP cases in each facility was chosen to participate in the study. The average population for each study community was 10,000 inhabitants.\u003c/p\u003e \u003cp\u003eThe study team conducted community entry activities, including visits to assembly members and chiefs and meetings with a cross-section of opinion leaders to inform them about the study and seek permission to conduct the study in their communities.\u003c/p\u003e\n\u003ch3\u003eSelection of study participants\u003c/h3\u003e\n\u003cp\u003eEach RA was assigned to a health facility to carry out interactions with healthcare providers and pregnant women attending ANC. Convenience sampling was used to recruit women for interviews [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The RAs recorded the phone numbers of pregnant women who were attending ANC and expressed willingness to participate in the study. These women were later contacted, and arrangement was made to meet each of them in her preferred location for an interview. The snowball method was also used to recruit other pregnant women from the eight study communities [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The first recruited pregnant woman helped the RA in identifying other pregnant women in the community. The study was explained to them and those who were interested were recruited to participate in IDIs after a written consent had been obtained.\u003c/p\u003e\n\u003ch3\u003eData collection techniques and data collection process\u003c/h3\u003e\n\u003cp\u003eAn RA spent several months in a facility observing ANC procedures, interactions between healthcare providers, and women who were attending ANC. IDIs were conducted in the local language and focused on knowledge, attitudes, and practices related to MiP interventions. Other findings from the study have been reported [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe interviews were recorded using digital recorders and they were transcribed verbatim to preserve’ the original messages and experiences of the interviewees. Interviews conducted in Ewe and Twi were transcribed into English to facilitate analysis and comparison (see additional files for IDI guide). Additionally, RAs obtained permission from the women to review their maternal and child health record books to confirm IPTp-SP uptake.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eIDI transcripts were uploaded into qualitative analysis software NVivo Version 11. A code book was developed and a coding list on common themes emerging from the data was generated to guide the coding process. The first author and an expert in qualitative research methods, who was hired to enhance the validity of the process, independently coded the data thematically. The analysis aimed to identify similarities, patterns, differences, and contradictions in the information presented by study participants [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The main themes identified from the analysis formed the basis for interpreting and reporting the study findings. This manuscript is part of the larger study mentioned in the introduction, so aspects of the findings have been previously reported [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical Issues\u003c/h2\u003e \u003cp\u003e Ethical clearance was obtained from the University of Health and Allied Sciences’ Research Ethics Committee (UHAS-REC A.1 [l] 17–18). Written informed consent was obtained from all interview participants and/or their legal guardian.\u003c/p\u003e \u003cp\u003eIn this study, women attending ANC were invited to participate in interviews. Those who expressed interest were given time to reflect, and their phone numbers were recorded by the RAs. They were later contacted, and by the RAs and those who remained interested provided written consent before participating. A few individuals declined to be interviewed. One study participant was 16 years old, and permission was obtained from her mother before her inclusion in the study.\u003c/p\u003e \u003cp\u003ePermission to conduct the study was also sought from district directors of health, facility managers of the eight study facilities, department managers, chiefs and assembly members in the study communities. To protect the identities of informants, pseudonyms have been used for districts and individuals’ names except for actual country and region names. Health facility pseudonyms beginning with ASF refer to study facilities in the Ashanti Region and ASC refer to study communities in the Ashanti Region. Similarly, the prefix VRF refers to facilities in the Volta region and VRC refers to study communities in the Volta Region. Pseudonyms of respondents are thus predicated by the prefix of the community where the IDI was conducted.\u003c/p\u003e "},{"header":"Findings","content":"\u003cp\u003eThe findings explore the perceived benefits and risks in taking SP, the reported number of times that women have taken SP, their knowledge of the recommended SP dosage, pregnant women feel about the SP, and their intentions to take SP in future.\u003c/p\u003e\u003cp\u003eThe benefits and risks involved in taking sulfadoxine-pyrimethamine during pregnancy\u003c/p\u003e\u003cp\u003eAlmost half of the respondents consistently emphasized that SP is provided as a preventive measure against malaria for both pregnant women and the unborn children. Other respondents mentioned that it had a positive effect on the unborn child, emphasizing its role in ensuring that the child remains healthy and strong.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“That one [SP], they say it is a malaria drug, so when you take it, it helps in protecting you [the pregnant woman] and the baby from malaria.”(ASCommunity01, IDI004)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e“It helps the unborn child not to get the disease and also makes the child strong.”\u003c/em\u003e (VRCommunity02, IDI010)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“It protects you and the child from malaria. The mother can pass on the malaria to the baby if she has it. So, if you drink the medicine, it cures the malaria. I have drunk it 2 times and it is left with one to drink. I will finish drinking mine this month.”\u003c/em\u003e (ASCommunity04, IDI003)\u003c/p\u003e\u003cp\u003eMajority of the study participants had knowledge on the benefits of SP use. Most study participants stated that the primary purpose of administering SP during antenatal clinic visits is to prevent and combat malaria while safeguarding the health of pregnant women. Additionally, participants reported that SP is administered directly at the clinic, as healthcare providers do not allow them to take it home.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“… it prevents me from getting malaria. Whenever I go to the laboratory, they do not find malaria parasites in my blood.” (\u003c/em\u003eASCommunity04, IDI009)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“The malaria drug is to prevent malaria. It prevents malaria so that you do not get malaria, because you may have had the mosquito bites already.”\u003c/em\u003e (ASCommunity03, IDI001)\u003c/p\u003e\u003cp\u003eA few pregnant women had misconceptions regarding the purpose for which they were given SP. Some believed that once they had taken SP, they were completely protected from malaria, making other preventive measures such as avoiding mosquito bites unnecessary. Others mistakenly thought it prevents complications such as rashes on the baby's body and ensures that the newborn's eyes will not remain closed.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“Ummm! It helps because I can stay outside very late and I do not also sleep in a net. Without that I would always be going to the hospital for malaria treatment.”\u003c/em\u003e (ASCommunity03, IDI001)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“The “3–3” [SP] is good. It protects the baby from malaria, sometimes when you deliver the baby, rashes may appear on the body or maybe another child’s eyes too might not open and the likes, so it [SP] prevents them from the afflictions that I mentioned.”\u003c/em\u003e (ASCommunity01, IDI005)\u003c/p\u003e\u003cp\u003eKnowledge on the number of times that a woman needs to take SP during pregnancy and reported number of times that participants had taken SP\u003c/p\u003e\u003cp\u003eThe findings reveal variations in the frequency of SP uptake among pregnant women attending ANC, as well as their knowledge on the number of times that they are required to take SP.\u003c/p\u003e\u003cp\u003eSome study participants reported receiving the medication two or three times, while others mentioned having taken it up to four times, and others said five times during pregnancy. However, most were unaware of the recommended frequency, with some expecting monthly doses and others anticipating fewer doses.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“No, I am done taking it. They said you have to take it for three times from the 4th month to the 7th month. I am in my 8th month now, so I am done.”\u003c/em\u003e (VRCommunity02, IDI002)\u003c/p\u003e\u003cp\u003e \u003cem\u003e”I started taking it on my fifth month. I think I have taken it five times\u003c/em\u003e [She was eight months pregnant at the time of the interview].\u003cem\u003e”\u003c/em\u003e (ASCommunity03, IDI008)\u003c/p\u003e\u003cp\u003eMost of the study participants mentioned that they were given SP at ANC. With regards to the frequency, some participants indicated that they were given SP every time they visited the ANC, while others indicated that they were given SP every month.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“Whenever I go to the hospital, they give me some. I have been given six times\u003c/em\u003e (ASCommunity04, IDI009\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e“They said three times, but I have been given four, so I have decided that if they give me some again in any of my next visits, I will ask them.”\u003c/em\u003e (ASCommunity03, IDI001)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I take it every month and when you are close to delivery, you report every two weeks. So, I have taken it many times.”\u003c/em\u003e (ASCommunity03, IDI007)\u003c/p\u003e\u003cp\u003eSome of the participants who had used health facilities in previous pregnancies reported that they were given between three to six doses in their current pregnancy. They indicated that previously they were given three doses but it had been increased over time.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“At first we were taking it three times but now any time you go there they will give you some.”[This is her second pregnancy]\u003c/em\u003e (ASCommunity03, IDI009)\u003c/p\u003e\u003cp\u003eOn whether the pregnant women had been informed on the number of times that they needed to take in SP, most of them said three times.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“They told us we will take it three times.”\u003c/em\u003e (ASCommunity04, IDI010)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“They told me I will take it four times.”\u003c/em\u003e (VRCommunity04, IDI006)\u003c/p\u003e\u003cp\u003eSome of the participants indicated that they had no knowledge of the number of times that they were required to take SP, as the nurses had not informed them. However, such participants indicated that they trusted the health providers, so they took in SP whenever they were instructed to do so at the ANC.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I do not know why they let us take it that much but when you are close to delivery, they let you stop taking it.”\u003c/em\u003e (ASCommunity03, IDI008)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I do not know, but the nurses know the number of times that I am supposed to take it [SP]. So anytime they give me I take it.”\u003c/em\u003e (VRCommunity02, IDI001)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I don’t know that\u003c/em\u003e [number of times she is required to take SP], \u003cem\u003ebut I was asked to take and I took it.”\u003c/em\u003e (VRCommunity04, IDI001)\u003c/p\u003e\u003cp\u003eSome women on the other hand lacked proper knowledge on the timing for taking SP, the number of tablets per dose and the number of doses required and thus provided wrong information.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“It depends on the gestational age. So, if you\u003c/em\u003e [pregnant woman] \u003cem\u003edo not attend ANC for about three months, when you go they will give you [pregnant woman] 3 [SP tablets] for you to take them all. But if you\u003c/em\u003e [pregnant woman] \u003cem\u003eattend ANC every month, then you [pregnant woman] would be given only one [SP] tablet.”\u003c/em\u003e (ASCommunity01, IDI008)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“… we are also given some 3 white tablets to chew in their presence when the pregnancy gets to about six months.”\u003c/em\u003e (VRCommunity02, IDI007)\u003c/p\u003e\u003cp\u003eDescription of how SP is administered to pregnant women at the ANC\u003c/p\u003e\u003cp\u003eMajority of the study participants reported that healthcare providers instruct them to bring water, and in the presence of the nurses or midwives, the medication is given to them to swalllow. The method of consumption varies; some study participants mentionedbeing required to chew the medication, while others reported swallowing it whole. There is a strong emphasis on taking the medication under the supervision of healthcare professionals. A few of the study participants highlighted the importance of compliance, noting that they were compelled to take it in front of the nurses may result in not being allowed to take it home. Others also mentioned the bitterness of SP,, underscoring the challenges some women face in adhering to the prescribed regimen. Additionally, there was a recurring theme of women were asked about their eating status before being given the medication, with recommendations to take it with a meal. These findings reported the procedural aspects, challenges, and complexities surrounding the administration of antenatal drugs as narrated by study participants .\u003c/p\u003e\u003cp\u003e\u003cem\u003e“They\u003c/em\u003e [health providers] \u003cem\u003eask us to bring water, so when they put it [SP] in your palm then you have to chew it and swallow it in their presence.”\u003c/em\u003e (VRCommunity02, IDI, 004)\u003c/p\u003e\u003cp\u003e\u003cem\u003e“You drink it there. They don’t allow you to take it [SP] outside.”\u003c/em\u003e (ASCommunity03, IDI001)\u003c/p\u003e\u003cp\u003e\u003cem\u003e“So they will compel you to take it before leaving; they first ask whether you have eaten. If you have not eaten they will tell you to go and eat and come back to take it [SP.”\u003c/em\u003e (VRCommunity03, IDI008)\u003c/p\u003e\u003cp\u003e\u003cem\u003e“They [nurses] asked me if I had eaten and I said no, so they [nurses] asked me to go and eat and come after which I was given the SP. I just swallowed it like any other medicine. I took it in front of them [nurses]”\u003c/em\u003e (VRCommunity01, IDI07)\u003c/p\u003e\u003cp\u003eInformation that pregnant women receive from nurses after SP uptake\u003c/p\u003e\u003cp\u003eThe study sought to find out what information that pregnant women were given by health providers after taking SP. Majority of study participants indicated that nurses did not provide any additional instructions or information beyond the administration of SP.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“They don’t tell me anything after drinking the medicine.”\u003c/em\u003e (ASCommunity04, IDI002)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“They told me to take toffee so that I will not vomit the drug.”\u003c/em\u003e (ASCommunity04, IDI 003)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“They don’t say anything to us after we have taken the SP.”\u003c/em\u003e (VRCommunity01, IDI001)\u003c/p\u003e\u003cp\u003eA few of the study participants mentioned receiving various post-consumption advice. These included recommendations to avoid sitting outside for extended periods in the evening, drinking plenty of water, and resting or sleeping, especially when one felt weak. Additionally, few participants reported being advised not to take folic acid immediately after SP intake. Other advice included consuming fruits or toffees to prevent vomiting.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“They told me not to sit outside in the evening for too long.”\u003c/em\u003e (ASCommunity04, IDI001)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“They tell us to take fruits after taking the drug.”\u003c/em\u003e (ASCommunity04, IDI006)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“They tell us once you have taken the drug, you will sometimes become weak, so when you go home sleep for a while, so that you won’t have any problem.”\u003c/em\u003e (ASCommunity04, IDI010)\u003c/p\u003e\u003cp\u003eHow pregnant women feel about taking in SP\u003c/p\u003e\u003cp\u003e Many study participants shared their experiences in taking SP such as not liking the smell, the drug tasting bitter, feeling nausea or weak after intake. Others expressed concerns or discomfort associated with SP intake, such as stomach aches, dizziness, and vomiting after taking SP. Also, it was reported that pregnancy can make it difficult for some to eat which presents a challenge as the health providers demand that pregnant women should eat before taking in SP.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“The malaria drug when it comes, it is bitter, extremely bitter. If you are not determined, you will not take it. If you do not take it in the presence of the midwives/nurses, they will not give it [SP] to you to take it home, so they will cease your card and make you buy water to take it.”\u003c/em\u003e(ASCommunity01, IDI005)\u003c/p\u003e\u003cp\u003e\u003cem\u003e“…there are some medicines we drink at the hospital... they gave me a medicine, which is 3 in number and I chewed it there. I came home after taking the medicine, I felt weak but after some time I regained my strength.”\u003c/em\u003e (ASCommunity04, IDI002)\u003c/p\u003e\u003cp\u003e\u003cem\u003e“We vomit whenever we take it.”\u003c/em\u003e (ASCommunity04, IDI006)\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Yes, medicine for malaria and you drink it at the hospital. They will not allow you to bring it home because it is very difficult to drink it. I nearly vomit after drinking it [laughing].”\u003c/em\u003e (ASCommunity04, IDI003)\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Ehe! The malaria one; Oh! The last time I took it I could not do any work. My whole system felt disturbed; my stomach ached and the child also struggled moving in different directions. I think it was only today, which is three days after before I am feeling fine.”\u003c/em\u003e (VRCommunity03, IDI004)\u003c/p\u003e\u003cp\u003e\u003cem\u003e“For me when I take the SP, I feel like vomiting and it makes me dizzy and also makes me eat more.”\u003c/em\u003e( VRCommunity04, IDI 008)\u003c/p\u003e\u003cp\u003eA few of the study participants indicated that they did not experience any adverse effects whenever they took in SP, although some of them indicated that they were aware that others experienced adverse outcomes.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“As for me when I take it, I do not feel anything.”\u003c/em\u003e (ASCommunity01, IDI003)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“Personally, I do not feel anything.”\u003c/em\u003e (ASCommunity01, IDI010)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“No, I do not get any problem but some people become weak and vomit. When I take it, I do not experience anything.”\u003c/em\u003e (ASCommunity04, IDI007)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“Please I do not have any problem with taking drugs whilst pregnant. I don’t vomit or have any problem when I take drugs. I haven’t experienced that in my life.”\u003c/em\u003e (ASCommunity04, ID1004)\u003c/p\u003e\u003cp\u003ePregnant women’s intentions of future use of SP\u003c/p\u003e\u003cp\u003eMajority of the study participants said that they were willing to take SP in the future. This was commonly linked to the perceived benefits, with a majority of the study participants expressing a willingness to comply with the recommended dosage for the well-being of both themselves and their unborn children. While others acknowledged the challenges in taking it, they still indicated that they had no option but to take it because of the benefits to them and their unborn children.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I do not have any option. I have to drink it [SP] because if you have malaria, you can pass it on to the baby, though it is very difficult to drink it.”\u003c/em\u003e (ASCommunity04, 003)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“When I become pregnant again, I will like to take it again.”\u003c/em\u003e (ASCommunity04, IDI009)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I will like to take it again, because when I take it, it prevents me from those parasites.”\u003c/em\u003e (ASCommunity04, IDI006)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“Oh why not! For the sake of my ‘health’ I will take it.”\u003c/em\u003e(ASCommunity03, IDI008)\u003c/p\u003e\u003cp\u003eHowever, a few of the study participants mentioned uncertainties about future adherence, influenced by factors such as the drug's smell, discomfort, or past adverse reactions.\u003c/p\u003e\u003cp\u003e \u003cem\u003e“You know every pregnancy has its own way it makes you feel. If my next pregnancy permits me to take I will take it but for now I have decided not to take it again.”\u003c/em\u003e (ASCommunity03, IDI011)\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I started taking it the first month I started and I am currently seven months. I take it every time I go there. In fact that drug I won’t take it again\u003c/em\u003e.”( ASCommunity03, IDI011)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study explored pregnant women\u0026rsquo;s knowledge, attitudes, and practices related to the use of SP in two regions in Ghana. Our findings suggest that most of the study participants understood SP\u0026rsquo;s role in malaria prevention and expressed high levels of trust in the guidance provided by healthcare providers. Also, their attitude towards SP was positive, with most participants indicating a willingness to take it in future. Nevertheless, some women were unaware of the reasons for SP uptake, its relevance, and the number of times they needed to take it during pregnancy.\u003c/p\u003e \u003cp\u003eIt was found that most of the study participants had received three or more doses of SP during pregnancy. This is in line with the Ghana National Malaria Elimination Programme recommendations [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, a study reported that less than half of postpartum women received up to three doses during pregnancy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], while another reported that most pregnant women in the Atwima Kwanwoma District of Ghana, received only two doses of SP during pregnancy [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The reasons for the high uptake of at least three doses of IPTp-SP observed in this study is based on trust in health care providers, as participants indicated that despite the adverse effects of SP they will take it if asked to do so by the health workers, as they trusted that they were doing so in their interest. The role of trust in healthcare has well been noted as crucial to effective health care provision [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMajority of the study participants recognized the importance of SP in preventing and combating malaria during pregnancy, demonstrating a good understanding of how IPTp-SP works. Our finding aligns with other studies conducted in Ghana, which reported that most pregnant women had good knowledge of IPTp-SP [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This was evident in the study as most of the pregnant women responded that they trusted the instructions of healthcare providers on the required SP doses given to them, hereby, making no effort to seek knowledge on the required doses to be taken through their ANC sessions.\u003c/p\u003e \u003cp\u003eSome of the women reported receiving information on SP intake from healthcare workers at the ANC, while, others reported that they did not. It is therefore not surprising that a good number of the pregnant women were unaware of when they were supposed to start and the number of times that they were required to take in SP during pregnancy. Similarly, previous studies in Ghana found that majority of pregnant women did not know the recommended number of doses of SP [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is important to note that women in their second or subsequent pregnancies noticed the dosage had increased from three times to four or more in their current pregnancy. However, they did not know why, and most failed to inquire at the ANC. This suggests that healthcare facilities are implementing Ghana\u0026rsquo;s revised policy, which extends SP administration from three doses to monthly doses from the second trimester until delivery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our findings corroborate findings from previous studies on Ghana, which reported that a majority of women receive more than three doses of SP [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Similarly, studies in Kenya and Tanzania have reported improved maternal outcomes following increased SP doses, but also noted gaps in patient-provider communication regarding policy changes [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In contrast, a study in Uganda found that healthcare workers proactively explained the policy change during ANC sessions, significantly improving compliance [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study participants described common side effects such as nausea, dizziness, and vomiting associated with SP intake. These side effects posed a challenge for study participants, decreasing the interest of some in continuing to take it. This finding aligns with the WHO\u0026rsquo;s report on common side effects such as nausea, vomiting, dizziness, and general weakness that have been reported following the administration of SP doses, particularly with the first dose of SP [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A scoping review found that first-dose side effects, such as nausea and dizziness, were prevalent across multiple sub-Saharan countries, including Ghana [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, other studies suggest that side effects are often temporary and decline with subsequent doses [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Moreover, research in Kenya found that prior knowledge about SP, its potential side effects and benefits motivated young mothers to adhere to the treatment [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This indicates that addressing side effects through preemptive communication could mitigate the challenges identified in this study.\u003c/p\u003e \u003cp\u003eThe finding suggest that a good number of women were not provided information regarding returning for future doses. This communication gap is consistent with findings in Ghana, which found that insufficient guidance from healthcare providers often led to incomplete IPTp-SP regimens [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Similarly, a study conducted in Ghana found that most of the women in their study had no knowledge on the number of times that they were supposed to take SP [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In contrast, pregnant women who received education regarding SP prior to its administration had higher odds of completing the recommended doses. Specifically, those informed about the timing and necessity of follow-up doses demonstrated a greater likelihood of adherence [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. These findings underscore the importance of clear and consistent messaging from ANC providers to enhance adherence to SP guidelines.\u003c/p\u003e \u003cp\u003eMajority of the women who participated in the study indicated that they would take SP in future, which was based on knowledge on its benefits, the perception that they had no choice and trust in healthcare providers. Also, all the women indicated that they would be happy to take in SP if they are provided information on its relevance. Similarly, a study in Cameroon noted that women with positive perceptions of their healthcare providers were more likely to comply with IPTp-SP regimens, despite challenges [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. This finding aligns with the broader literature which suggest that patient trust in health care providers facilitates adherence and patient satisfaction [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudy limitation\u003c/p\u003e \u003cp\u003eThis study as in qualitative studies a few participants were purposively sampled to participate in the study and for that matter it cannot be generalized. Nevertheless, our literature suggests that the findings compare with previous studies carried out elsewhere.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of the study suggest a need for clearer communication and education on SP usage during pregnancy to ensure consistent and accurate understanding among expectant mothers. ANC education on SP should go beyond emphasizing its benefits of SP in malaria prevention to providing a comprehensive understanding of the required doses of SP to be taken during the period of pregnancy.\u003c/p\u003e \u003cp\u003eHealthcare providers should ensure that women are educated on SP during waiting times as well as during one-on-one consultations to enable them to become better informed on IPTp-SP.\u003c/p\u003e \u003cp\u003eAdditionally, it is important that healthcare providers give preemptive education to prepare pregnant women for the possible side effects of SP and the appropriate interventions to be taken in managing these side effects.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the University of Health and Allied Sciences\u0026rsquo; Research Ethics Committee [UHAS-REC A.1 [l] 17-18] and the study was conducted according to the principles of the Declaration of Helsinki and good clinical Practice. Written informed consent was obtained from all interview participants and/or their legal guardian. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe manuscript does not contain any individual\u0026rsquo;s data\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available at the University of Health Research repository and can be made available upon reasonable request from the first author Matilda Aberese-Ako (MA)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors declare no conflict of interest\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported through the DELTAS Africa Initiative [MARCAD Grant Number: DEL‑15\u0026ndash;010]. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)\u0026rsquo;s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa\u0026rsquo;s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust [WT: 107741/A/15/Z] and the UK government.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conceptualized by MD, PM, GA and HT. MD, KN and WE drafted the manuscript and it was revised by PM, GA and HT. All authors read and approved the\u003c/p\u003e\n\u003cp\u003efinal manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to thank the nine research assistants, ED who supported the coding process, the\u003cbr\u003e\u0026nbsp;regional health directorates and regional directors of health, participating districts, facilities, communities and study participants, for the cooperation and support in this study. We also thank the editor and the two reviewers whose inputs have contributed greatly to improve the quality of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first author, MA is a senior researcher and the director of the Malaria Research Centre at the Institute of Health Research, University of Health and Allied Sciences\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization, \u0026ldquo;World malaria report 2023.\u0026rdquo; Accessed: Jan. 13, 2025. [Online]. Available: https://iris.who.int/bitstream/handle/10665/374472/9789240086173-eng.pdf?sequence=1\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, \u0026ldquo;World malaria report 2023.\u0026rdquo; Accessed: Apr. 01, 2025. [Online]. 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Med.\u003c/em\u003e, vol. 61, no. 7, pp. 1439\u0026ndash;1451, Oct. 2005, doi: 10.1016/j.socscimed.2004.11.071.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"IPTp-SP, pregnant women, Ghana, healthcare providers, qualitative study, knowledge, attitudes, practices","lastPublishedDoi":"10.21203/rs.3.rs-6482390/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6482390/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eMalaria in pregnancy is a significant public health concern in sub-Saharan Africa, affecting an estimated 32 million pregnant women annually. One of WHO’s recommendations for malaria prevention is the use of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). However, reports indicate that less than 100% of women in Ghana access IPTp service. This study explored knowledge, attitudes, uptake and future intentions to take IPTp-SP among pregnant women in southern Ghana.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e An ethnographic study design was used. In-depth interviews were carried out among 70 pregnant women in Ghana. The interviews were recorded digitally, transcribed, and uploaded into NVivo Version 11 for coding and thematic analysis. All ethical procedures were followed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Majority of the study participants received three or more doses of SP, suggesting that healthcare facilities were implementing the revised national guidelines. Most particpants were aware of the benefits of SP in malaria prevention and expressed trust in the guidance provided by healthcare providers. Participants lacked knowledge on the exact timing and number of SP doses required during pregnancy and they expressed their desire to receive information from healthcare providers. Despite some women experiencing side effects such as nausea and dizziness in taking SP, most of them continued to adhere to the prescribed SP regimen and indicated their intention to continue taking it due to its benefits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Strengthening communication between healthcare providers and pregnant women regarding dosing schedules, potential side effects, and follow-up doses could improve adherence and optimize the effectiveness of malaria prevention strategies.\u003c/p\u003e","manuscriptTitle":"Knowledge, attitudes, practices, and future intentions to use intermittent preventive treatment with sulfadoxine-pyrimethamine among pregnant women in southern Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-22 08:42:32","doi":"10.21203/rs.3.rs-6482390/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d41a5d91-3d05-4b1c-9b49-ba5669957316","owner":[],"postedDate":"May 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-23T21:53:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-22 08:42:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6482390","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6482390","identity":"rs-6482390","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}