The examination of factors impacting spitting or vomiting among children under five years of age during seasonal malaria chemoprevention: A quantitative study in Burkina Faso, Chad, Nigeria and Togo

The examination of factors impacting spitting or vomiting among children under five years of age during seasonal malaria chemoprevention: A quantitative study in Burkina Faso, Chad, Nigeria and Togo | 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 The examination of factors impacting spitting or vomiting among children under five years of age during seasonal malaria chemoprevention: A quantitative study in Burkina Faso, Chad, Nigeria and Togo Chen Gao, Sikai Huang, Taiwo Ibinaiye, Benoît Sawadogo, Adama Traore, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4582131/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Nov, 2024 Read the published version in Tropical Medicine and Health → Version 1 posted 5 You are reading this latest preprint version Abstract Background Since 2012, the World Health Organization has recommended seasonal malaria chemoprevention (SMC) with sulfadoxine-pyrimethamine plus amodiaquine (SPAQ) for children aged 3–⁠59 months in areas with marked seasonality in malaria transmission. Full ingestion of SMC medicines without spitting or vomiting during a complete three-day course is critical to ensure SMC effectiveness and avoid increased antimalarial resistance. Although evidence suggests that spitting or vomiting is not rare, there is limited analytical evidence on potential factors associated with spitting or vomiting. Methods We utilized data from SMC coverage surveys conducted in Burkina Faso, Chad, Togo and Nigeria between 2020 and 2022. Episodes of spitting or vomiting were defined as children spitting out most of the dose or vomiting the entire dose within 30 min after administration on Day 1 by community distributors (CDs) as reported by primary caregivers. We conducted a cross-sectional study through mixed-effects logistic regression specified with socioeconomic variables, and caregiver knowledge of SMC, to identify factors associated with spitting or vomiting. Results The proportion of spitting or vomiting ranged from 1.81% in Nigeria to 4.36% in Chad. The odds of spitting or vomiting were lower if children were administered medicines under directly CD-supervised administration and primary caregivers had a high degree of knowledge of SMC. Spitting or vomiting were negatively associated with caregiver adherence to AQ administration and caregiver reporting of children’s adverse reactions to SMC medicines. Over half of the children did not receive a replacement dose from CDs who spit out or vomited most (or almost all) of the doses. Redosing was positively associated with caregiver educational attainment, caregiver knowledge of SMC, and directly supervised administration. Conclusions The direct CD-supervised administration of SPAQ can facilitate and strengthen community engagement strategies to enhance the appropriate administration and full ingestion of SMC medicines by the SMC delivery protocol. Malaria Cross-sectional survey Child health Chemoprophylaxis Figures Figure 1 Background Malaria remains one of the leading causes of morbidity and mortality in sub-Saharan Africa. Globally, in 2022, there were an estimated 249 million malaria cases in 85 malaria-endemic countries and areas (including the territory of French Guiana), with an estimated 608,000 malaria deaths[ 1 ]. About 95% of estimated deaths were in the World Health Organization (WHO) African Region[ 1 ]. Children aged under five years, representing over 70% of deaths related to malaria, are the most vulnerable group[ 2 ]. Many global efforts, including vector control, preventive chemotherapies, malaria vaccine pipeline, and case management, have been (co-)deployed to protect children from malaria infection[ 2 ]. In 2012, the WHO recommended the introduction of seasonal malaria chemoprevention (SMC) to prevent malaria morbidity and mortality in children aged under 3–59 months in areas of highly seasonal malaria transmission across the Sahel region of Africa[ 3 ]. In 2022, SMC was implemented in 17 sub-Saharan African countries with seasonal malaria transmission, reaching an estimated 49 million eligible children[ 4 , 5 ]. SMC involves intermittent administration of a complete course of sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ) (SPAQ) to prevent malaria cases by maintaining therapeutic drug concentrations in the blood during the high transmission season[ 5 , 6 ]. Before the Corona Virus Infectious Diseases 2019 (COVID-19) pandemic, SMC community distributors (CDs) typically provided a blister pack of SPAQ for a complete three-day course, typically through door-to-door household visits, and directly administered eligible children with SPAQ on Day 1. Subsequently, caregivers of eligible children administered the remaining two daily doses of AQ on both Day 2 and Day 3 without supervision from the CDs. However, during the COVID-19 pandemic, the SMC delivery protocol was adapted to minimize contact with beneficiaries and reduce the risk of COVID-19 transmission between communities and CDs; CDs were requested not to directly administer SMC medicines, but to supervise caregivers when they administer the first dose of SP and AQ to their children on Day 1[ 7 ]. The remaining two doses of AQ were then still administered by caregivers over the following two days. A three-day complete administration of SMC medicines and the following 28-day protective period define a cycle of an annual SMC round which typically involves four to five annual consecutive monthly cycles[ 8 ]. Several randomized trials have suggested that combination therapy preventive strategies using SPAQ outperform other combination therapies (e.g., SP + artesunate, SP + AQ + artesunate) and demonstrate no severe adverse reactions; however, mild to moderate adverse reactions have been linked with AQ administration, with vomiting and headache being the most common[ 9 ]. Due in part to the bitter unpleasant taste of AQ, children often exhibit varying degrees of spitting or vomiting immediately following administration of SMC medicines, ranging from spitting out some of the dose to spitting out or vomiting almost the entire dose[ 10 ]. Failure to fully ingest all doses may undermine the protective effect of SMC against malaria. A monitoring and evaluation study in Burkina Faso reported that 38% of suboptimal administration of SMC medicines was attributable to children’s adverse reactions to SMC medicines, with vomiting accounting for approximately half of these adverse reactions[ 11 ]. A descriptive study in Burkina Faso, Mali and Niger identified vomiting as the second major cause of non-adherence to the second and third doses of AQ administration[ 12 ]. Moreover, another study in Nigeria, Burkina Faso, Chad, and Togo based on data from a routine end-of-round SMC coverage survey found that previous adverse events to SMC medicines by eligible children were associated with reduced caregiver adherence to Day 2 and Day 3 AQ administration[ 13 ]. The WHO recommends administration of a replacement dose after allowing the child to rest for about 10 minutes if a child spits, regurgitates, or vomits within 30 minutes during directly supervised administration of Day 1 SPAQ[ 5 ]; redosing aims to ensure that children receive the accurate dose to decrease the impact of non-adherence on resistance and provide long-lasting protection during the malaria transmission season[ 5 ]. A cross-sectional study conducted by the Malaria Consortium found that some caregivers refused to administer SMC medicines to their children or did not administer them correctly during the COVID-19 pandemic[ 14 , 15 ]. This may exacerbate spitting or vomiting at the time of administration of SMC medicines. Targeted interventions have been developed to promote caregiver compliance with the correct administration amid the pandemic, in addition to message delivery and communication via CDs during household visits and community sensitization activities. In Nigeria, the lead mothers intervention, delivered by female residents of SMC settings aged 18 years and above who visit caregivers in their homes and disseminate messages following door-to-door visits by CDs, has been proven to be effective at promoting caregiver adherence to AQ administration[ 13 ]. In Burkina Faso, Chad, and Togo, the role model approach, a community-driven behavior change strategy has been piloted to explore its potential to address the challenges associated with SPAQ administration including spitting or vomiting[ 16 ]. Several recent studies have highlighted the frequency of vomiting and its impact on non-adherence to AQ administration in various sub-Saharan African countries. However, analysis of spitting or vomiting has largely remained at the summary statistics level, nesting within studies focusing on coverage and cost-effectiveness of SMC rather than specifically analyzing factors that facilitate or prevent spitting or vomiting of SMC medicines. Besides, recent updates to WHO guidance for SMC emphasized monitoring and evaluation and pharmacokinetic considerations at the time of scaling up SMC program or introducing new chemoprevention medicines[ 5 ], highlighting the need to improve understanding of relatively common spitting or vomiting and provide insights into its potential amelioration approach. This study aimed to examine factors influencing spitting or vomiting following receipt of SPAQ on Day 1 during the last cycle of household visits by CDs in four Sahelian countries (Burkina Faso, Chad, Nigeria, and Togo), using data obtained from annual routine end-of-round SMC coverage surveys commissioned by Malaria Consortium. Additionally, this study sought to assess redosing behavior and its associations with factors including characteristics of the selected child, caregiver, head of household, and caregiver awareness and knowledge of SMC. Materials and Methods Study location This study was conducted using data collected in four sub-Saharan African countries including Burkina Faso, Chad, Nigeria, and Togo. Plasmodium falciparum is the dominant species of malaria parasite in these regions, and malaria transmission demonstrated high seasonality[ 5 ]. SMC end-of-round coverage surveys were conducted in these four countries between 2020 and 2022 (except for Burkina Faso in 2021), spanning three annual rounds of SMC under the adapted condition of SMC implementation during the COVID-19 pandemic. Malaria Consortium’s SMC program has been recognized as a major contributor to malaria control and elimination across these four countries[ 17 , 18 ]. In Nigeria, the Malaria Consortium delivered SMC in a total of 9 eligible states in 2022, targeting a population of 10.72 million eligible children. Meanwhile, in Burkina Faso, SMC covered 29 districts across 6 regions, reaching 2.11 million eligible children 18 . In Chad and Togo, 1.2 million from 27 districts and 0.51 million eligible children from 19 districts were reached by the Malaria Consortium’s SMC, respectively 18 . End-of-round surveys conducted by external teams and commissioned by Malaria Consortium were representative of these areas in four countries. Study participants In all four countries, multi-stage random sampling combined with sampling of clusters by probability proportional to population size was used to select settlements at random to achieve a self-weighting sample[ 17 ]. In Nigeria, a modified multi-stage random sampling was conducted to select compounds, settlements, health facility catchment areas, Local Government Areas (LGAs), and states at random with a step-by-step sampling frame for the selection process. Only households with at least one child aged 3–59 months were eligible for inclusion in end-of-round surveys. More detailed information on the end-of-round survey protocol can be found elsewhere[ 13 , 18 , 19 ]. The study sample consisted of 54,100 households surveyed during end-of-round surveys. Households were excluded if: (1) they did not respond to the survey; (2) they arrived in the local community after initiation of the final SMC cycle; (3) the selected child did not receive SMC medicines at the time of door-to-door household visits by CDs in the final cycle; or (4) the selected child was not at home or ineligible for other reasons (e.g., deceased, allergy to SMC medicines, sick) during household visits 5 . After excluding 4,715 households, the final analytical sample comprised 49,385 households (Fig. 1 ). Data source Data were collected during routine SMC end-of-round coverage surveys conducted following the ultimate cycle of SMC treatment between 2020 and 2022 in Burkina Faso, Chad, Nigeria, and Togo. Pairs of data collectors visited each household door-to-door and conducted computer-assisted personal interviews using the application Survey CTO version 2.70 on mobile devices. Survey CTO randomly selected one eligible child from the household from a roster, and all survey questions related to that child, their primary caregiver, their head of household, and the household. A primary caregiver in this survey refers to any individual, aged 15 years or over, with the primary responsibility for the feeding and daily care of at least one child under the age of five and a household head refers to a member of the family who manages the resources and is the final decision maker in the household. Data on a range of variables were available for analysis, including socioeconomic and demographic characteristics of selected household members, key indicators on SMC coverage and adherence, and outcomes of SMC administration. Interviews were conducted in local languages using questionnaires provided by the Malaria Consortium, with data collectors translating on the spot from English or French and assigning responses to predefined answer categories. Informed consent was obtained from all respondents prior to the interview. Variables The outcome, spitting or vomiting, was defined as the eligible child spitting out most (or almost all) of the dose, or vomiting all of the dose, at the time of administration of Day 1 SPAQ during the final cycle of SMC in a given survey year. This was operationalized as a binary variable (yes/no), where ‘no’ indicated that the eligible child ingested all of the doses or spat out some of the doses of SMC medicines. Variables considered as potential predictors of spitting or vomiting included socioeconomic and demographic characteristics of children and their primary caregivers and household, as well as caregiver knowledge and awareness of SMC. Covariates considered for inclusion in the analysis included direct CD-supervised administration (yes/no), child’s sex (female/male), child’s age (years), primary caregiver’s sex (female/male), caregiver’s age (Under 29 years/30–39 years/40–49 years/50 and above), caregiver’s self-reported literacy (yes/no), caregiver’s highest level of education (none or informal/primary/secondary and higher), caregiver’s employment status (yes/no), head of household’s self-reported literacy (yes/no), head of household’s highest level of education (none or informal/primary/secondary and higher), head of household’s employment status (yes/no), and household socioeconomic status. Household socioeconomic status was assessed using the latest country-specific Simple Poverty Scorecards and defined as binary household poverty status (> 70% probability household is below the poverty threshold of 1.90 purchasing power parity [PPP]-adjusted 2011 United States Dollars [USD] per day, 2014/2015 definition)[ 20 – 23 ]. In households where the primary caregiver and head of household were the same, observations for the respective variables were the same. Caregiver awareness and knowledge of SMC was included and operationalized as an ordinal variable (low/medium/high) based on six questions, including caregiver awareness of the purpose of SMC (yes/no), caregiver awareness of criteria for children’s eligibility to SMC (yes/no), caregiver knowledge of the importance of administering SMC medicines only children aged under five years (yes/no), caregiver knowledge of the reason for administration of Day 2 and Day 3 AQ (yes/no), caregiver knowledge of appropriate reporting of adverse reactions following receipt of SMC medicines (yes/no), and caregiver belief in the effectiveness of SMC at providing full protection against malaria (yes/no). Caregivers were considered to have a low level of knowledge and awareness of SMC if they spontaneously responded with the correct answer (or similar response) to at most two questions, medium level if they answered 3–5 questions correctly, and high level if they answered all questions correctly. Furthermore, we introduced the secondary outcome, redosing, defined as children receiving a replacement dose of SMC medicines from CDs right after spitting or vomiting at the time of administration of Day 1 SPAQ to examine the patterns of redosing behavior; this was based on caregiver-reporting data operationalized a binary variable (yes/no). Variables of interest included full adherence to both the second and third dose of AQ administration (yes/no), child adverse reactions to SMC to either SPAQ on Day 1 or AQ on Day 2 or Day 3 (yes/no), caregiver reporting of their adverse reactions to CDs or health facility personnel (yes/no), and lead mothers visit during the previous SMC cycle (in Nigeria only, yes/no). Statistical Analysis For the end-of-round data, post-sampling survey weights were generated for country sample size vs. population to account for survey design and adjust for underlying problems of over-presentation or underrepresentation of survey respondents due to differences in the sample size from four countries, the results were designed to be represented across the countries included in the study (Table 1 ). Survey weights were applied throughout this analysis. We used frequency (N) and weighted percentage (% a ) to describe the distribution of respondents’ sociodemographic characteristics by spitting or vomiting. Weighted chi-square tests were performed to assess the association between sociodemographic characteristics and spitting or vomiting. Table 1 Characteristics of the survey household members living in Burkina Faso, Chad, Nigeria and Togo. Characteristics (N = 49,385) Burkina Faso Chad Nigeria Togo Total N (% a ) N (% a ) N (% a ) N (% a ) N (% a ) Survey Year 2020 2139 (43.52) 2285 (29.72) 6361 (27.97) 1861 (32.50) 12646 (29.69) 2021 0 (0.00) 2914 (33.29) 10242 (34.76) 1884 (33.28) 15040 (31.42) 2022 2896 (56.48) 3297 (36.99) 13388 (37.27) 2118 (34.22) 21699 (38.89) Child Directly CD-supervised administration Yes 4473 (88.86) 6805 (79.77) 25649 (84.48) 4938 (84.07) 41865 (84.49) No 562 (11.14) 1691 (20.23) 4342 (15.52) 925 (15.92) 7520 (15.51) Spitting or vomiting Yes 130 (2.59) 360 (4.36) 508 (1.81) 185 (3.19) 1183 (2.13) No 4905 (97.41) 8136 (95.64) 29483 (98.19) 5678 (96.81) 48202 (97.87) Redosing (if child did not ingest all of the SMC medicine dose) Yes 60 (57.19) 150 (40.77) 221 (41.72) 60 (32.11) 491 (42.47) No 46 (42.81) 210 (59.23) 287 (58.28) 125 (67.89) 668 (57.53) Adherence to the second and third dose of AQ Yes 4974 (98.80) 8151 (95.87) 29268 (97.30) 5744 (97.96) 48137 (97.34) No 61 (1.20) 345 (4.13) 723 (2.70) 119 (2.04) 1248 (2.66) Sex Male 2518 (50.02) 4746 (55.84) 15367 (50.96) 3080 (52.52) 25711 (51.32) Female 2517 (49.98) 3750 (44.16) 14624 (49.04) 2783 (47.48) 23674 (48.68) Age 3–11 months 441 (8.79) 695 (8.26) 1924 (5.99) 568 (9.67) 3628 (6.56) 1 year 873 (17.33) 1437 (16.84) 4752 (15.75) 956 (16.27) 8018 (16.00) 2 years 1063 (21.12) 2268 (26.63) 6552 (22.07) 1194 (20.35) 11077 (22.28) 3 years 1061 (21.07) 2033 (23.89) 7010 (23.49) 1312 (22.43) 11416 (23.26) 4 years 1276 (25.32) 1656 (19.51) 7474 (24.96) 1416 (24.14) 11822 (24.53) 5 years 321 (6.37) 407 (4.86) 2279 (7.73) 417 (7.14) 3424 (7.36) Adverse reactions to the SMC medicines b (N = 46,898) Yes 304 (6.24) 1130 (13.99) 2870 (9.91) 543 (9.87) 4847 (9.88) No 4573 (93.76) 6825 (86.01) 27121 (90.09) 4965 (90.13) 42051 (90.12) Primary caregiver Sex Male 539 (10.64) 2238 (26.32) 4723 (16.12) 860 (14.75) 8360 (16.38) Female 4496 (89.36) 6258 (73.68) 25268 (83.88) 5003 (85.25) 41025 (83.62) Age Under 29 years 2356 (46.88) 3800 (44.85) 14134 (47.68) 2649 (45.10) 22939 (47.29) 30–39 years 1993 (39.50) 3032 (35.69) 11045 (35.99) 2351 (40.13) 18421 (36.43) 40–49 years 490 (9.72) 1283 (15.00) 3599 (12.26) 624 (10.67) 5996 (12.19) 50 and more above 196 (3.90) 381 (4.47) 1213 (4.08) 239 (4.10) 2029 (4.09) Self-reported literacy Yes 2057 (40.76) 4467 (52.27) 19652 (64.74) 3089 (52.67) 29265 (61.13) No 2978 (59.24) 4029 (47.73) 10339 (35.26) 2774 (47.33) 20120 (38.87) Level of highest education None or informal 3238 (64.36) 5423 (63.97) 15799 (56.53) 2860 (48.78) 27320 (57.55) Primary 808 (16.02) 1444 (16.80) 4577 (15.44) 1371 (23.41) 8200 (15.89) Secondary or higher 989 (19.62) 1629 (19.23) 9615 (28.03) 1632 (27.81) 13865 (26.56) Employment status Non-employed 1736 (34.40) 4516 (53.54) 10198 (35.08) 1216 (20.85) 17666 (35.97) Employed 3299 (65.60) 3980 (46.46) 19793 (64.92) 4647 (79.15) 31719 (64.03) Awareness and knowledge of SMC Low 397 (7.81) 630 (7.48) 5494 (17.82) 819 (13.90) 7340 (15.94) Medium 1627 (32.33) 2058 (24.53) 8503 (28.78) 2166 (36.98) 14354 (29.07) High 3011 (59.86) 5808 (67.99) 15994 (53.40) 2878 (49.12) 27691 (54.99) Caregivers report adverse reactions to CDs or health facility personnel c (N = 4846) Yes 181 (59.65) 604 (53.04) 1989 (71.10) 276 (51.16) 3050 (67.73) No 123 (40.35) 526 (46.96) 881 (28.90) 266 (48.84) 1796 (32.27) Head of household Self-reported literacy Yes 906 (38.54) 3861 (54.61) 22949 (77.39) 3537 (60.30) 31253 (73.33) No 1444 (61.46) 2166 (45.39) 7041 (23.61) 2325 (39.70) 13976 (26.67) Level of highest education None or informal 1534 (65.29) 4171 (59.47) 12896 (45.92) 1118 (24.57) 19719 (47.14) Primary 386 (16.42) 1148 (16.14) 3426 (10.99) 1338 (29.02) 6298 (12.16) Secondary or higher 430 (18.39) 1708 (24.39) 13668 (43.09) 2139 (46.41) 17945 (40.70) Employment status Not employed 491 (20.75) 3044 (43.40) 4530 (15.28) 546 (9.41) 8611 (17.30) Employed 1859 (79.25) 3983 (56.60) 25325 (84.72) 5316 (90.59) 36483 (82.70) Household Poverty Yes 421 (8.57) 3318 (37.24) 1367 (4.76) 793 (13.82) 5899 (8.01) No 4614 (91.43) 5178 (62.76) 28624 (95.24) 5070 (86.18) 43486 (91.99) Lead mothers visit (in Nigeria, N = 29991) Yes 20780 (69.13) 20780 (69.13) No 9211 (30.87) 9211 (30.87) a Weighted proportion based on corrected χ2 test. b Adverse reactions to the SMC medicines have excluded “vomiting”. c Respondents who answer ‘yes’ to ‘Adverse reactions to the SMC medicines’ are eligible to proceed to this question. SMC, seasonal malaria chemoprevention. AQ, amodiaquine; e; CD, community distributor. We performed random-effects logistic regression models to identify predictors of spitting or vomiting during Day 1 SPAQ administration, with random intercepts for survey year, country, and administrative subdivision (LGAs in Nigeria, districts in other countries) to account for clustering effects on the binary outcome. A forward stepwise regression approach with a significance level of 0.05 based on Collett’s methods was used to select potential predictors for inclusion in the final regression models[ 24 ]. Results were displayed Odds ratio (OR) with 95% Confidence interval (CI). Redosing’s association with caregiver adherence to Day 2 and Day 3 AQ administration and variables related to children’s adverse reactions to SMC medicines (i.e., whether children had any adverse reactions to SMC or whether caregivers reported their adverse reactions to CDs or health facility personnel) was also assessed using summary statistics (N and %) and weighted chi-squared tests. Data were analyzed using Stata 17.0. Results Characteristics of the survey household members in Burkina Faso, Chad, Nigeria and Togo A total of 49,385 children were enrolled across the 2020, 2021 and 2022 SMC end-of-round surveys in the four countries (5035 in Burkina Faso, 8496 in Chad, 29991 in Nigeria, and 5863 in Togo). Table 1 presents the selected child-, caregiver-, head of household-, and household-level characteristics by country. The majority of primary caregivers (84.49%) reported directly supervised administration of Day 1 SPAQ during ultimate-cycle door-to-door household visits by CDs. The overall proportion of caregivers that reported adherence to Day 2 and Day 3 AQ administration to the selected child was 97.34%. The overall weighted proportion of primary caregivers from four countries who reported spitting or vomiting by their child was 2.13%, ranging from 1.81% in Nigeria to 4.36% in Chad. Of caregivers who reported spitting or vomiting, only 42.47% further reported redosing (receiving the replacement dose from CDs), ranging from 32.11% in Togo to 57.19% in Burkina Faso. Regarding primary caregiver characteristics in the four countries, 83.62% surveyed were female, ranging from 73.68% in Chad to 89.36% in Burkina Faso, with ages under 29 (47.29%) and 30–39 (36.43%) accounting for the largest weighted proportions. The proportion of caregivers surveyed reporting being literate varied by country, ranging from 40.76% in Burkina Faso to 64.74% in Nigeria. The overall proportions of caregivers by education attainment were 57.55% with no or no formal education, 15.89% with primary education, and 26.56% with secondary education or higher. Overall, 54.99% of caregivers surveyed had a high level of awareness and knowledge of SMC; this varied by country, ranging from 49.09% in Togo to 67.99% in Chad. Regarding head of household characteristics, the majority of those responding to the survey were in employment (82.70%) and around 10% were considered to be in poverty (> 70% probability of household income below 1.90 PPP-adjusted 2011 USD per day); however, proportions of households in poverty varied by country, ranging from 8.57% in Nigeria to 37.24% in Chad. Characteristics of the survey household members by spitting or vomiting Table 2 presents the results of weighted chi-square tests for associations between child-, caregiver-, head of household-, and household-level characteristics, and spitting or vomiting. Male children were significantly less likely to present spitting or vomiting at the time of Day 1 SPAQ administration (F = 4.50, df = 1, p < 0.042). while those in younger age groups (e.g., 3–11 months) were also less likely to present spitting or vomiting (F = 5.33, df = 5, p = 0.003). Statistically significant associations were found between caregivers’ sex (F = 7.73, df = 1, p = 0.009), caregiver’s literacy (F = 4.27, df = 1, p = 0.047), caregiver’s employment status (F = 3.48, df = 1, p = 0.072), caregiver awareness and knowledge of SMC (F = 32.43, df = 2, p < 0.001), and spitting or vomiting by the selected child. Children who received Day 1 SPAQ administration under the supervision of CDs were significantly less likely to present spitting or vomiting (F = 95.45, df = 1, p < 0.001). In Nigeria, lead mothers visit were negatively associated with spitting or vomiting. Table 2 Characteristics of household members by children spitting or vomiting at Day 1 SPAQ administration. Child Characteristics (N = 49,385) Spitting or vomiting No spitting or vomiting F-statistic P value a N(% b ) N (% b ) Directly CD-supervised administration Yes 778 (64.65) 41087 (84.93) 95.45 0.000*** No 405 (35.35) 7115 (15.07) Sex Male 580 (45.39) 25131 (51.45) 4.50 0.042* Female 603 (54.61) 23071 (48.55) Age 3–11 months 90 (7.38) 3538 (6.54) 5.33 0.003** 1 year 244 (22.41) 7774 (15.86) 2 years 290 (23.56) 10787 (22.26) 3 years 236 (19.23) 11180 (23.35) 4 years 250 (21.47) 11572 (24.60) 5 years 73 (5.95) 3351 (7.39) Sex Male 160 (12.35) 8200 (16.47) 7.73 0.009** Female 1023 (87.65) 40002 (83.53) Primary caregiver Age Under 29 years 580 (48.27) 22359 (47.26) 0.22 0.829 30–39 years 436 (36.67) 17985 (36.43) 40–49 years 125 (11.10) 5871 (12.21) 50 or more above 42 (3.96) 1987 (4.10) Self-reported literacy Yes 655 (55.28) 28610 (61.26) 4.27 0.047* No 528 (44.72) 19592 (38.74) Level of highest education None or informal 636 (56.91) 26684 (57.57) 0.85 0.419 Primary 173 (13.56) 8027 (15.94) Secondary or higher 374 (29.52) 13491 (26.50) Employment status Non-employed 505 (41.84) 17161 (35.84) 3.48 0.072 Employed 678 (58.16) 31041 (64.16) Awareness and knowledge of SMC Low 290 (27.26) 7050 (15.70) 32.43 0.000*** Medium 397 (35.61) 13957 (28.92) High 486 (37.13) 27195 (55.38) Head of household Self-reported literacy Yes 709 (69.87) 30544 (73.40) 3.70 0.064 No 366 (30.13) 13610 (26.60) Level of highest education None or informal 463 (46.34) 19256 (47.16) 0.21 0.787 Primary 137 (11.46) 6161 (12.17) Secondary or higher 441 (42.21) 17504 (40.67) Employment status Non-employed 255 (20.86) 8356 (17.23) 1.23 0.276 Employed 815 (79.14) 35668 (82.77) Household Poverty Yes 172 (9.77) 5727 (7.97) 1.19 0.284 No 1011 (90.23) 42475 (92.03) P < 0.05, **p < 0.01, ***p < 0.001. a P value shows two-sided p value for χ2 test for difference in proportions. b Weighted proportion based on corrected χ2 test. SMC, seasonal malaria chemoprevention; CD, community distributor. Predictors of spitting or vomiting at the time of Day 1 SPAQ administration Table 3 presents the results of logistic regression analysis of spitting or vomiting across the four countries following variable selection by a forward stepwise approach. Variables selected for inclusion in the final model were child’s sex, child’s age, caregiver’s self-reported literacy, caregiver’s level of education, caregiver’s employment status, caregiver awareness and knowledge of SMC, head of household employment status, and directly supervised Day 1 SPAQ administration by CDs. Results of the logistic regression model showed that selected children aged one year had higher odds of spitting or vomiting at the time of Day 1 SPAQ administration, compared with children aged 3–11 months (OR = 1.41, 95% CI 1.08 to 1.83). Such statistically significant association was not found in children aged above two years despite their lower odds of spitting or vomiting, compared with children aged 3–11 months. Male children had lower odds of spitting or vomiting compared with female children (OR = 0.78, 95% CI 0.64 to 0.95). Meanwhile, caregiver’s illiteracy (OR = 0.88, 95% CI 0.86 to 0.90), caregiver’s in-employment status (OR = 0.81, 95% CI 0.73 to 0.91), and a medium or high level of caregiver awareness and knowledge of SMC (OR = 0.80, 95% CI 0.68 to 0.94; OR = 0.62, 95% CI 0.44 to 0.86) were all significantly associated with lower odds of spitting or vomiting. Directly supervised administration of Day 1 SPAQ was significantly associated with lower odds of spitting or vomiting (OR = 0.50, 95% CI 0.34 to 0.73). Table 3 Multilevel logistic regression model of predicting children spitting or vomiting at Day 1 SPAQ administration. Characteristics (N = 45,094) OR 95% CI P value Child Directly CD-supervised administration No 1.00 Yes 0.50 0.34 to 0.73 0.000*** Sex Female 1.00 Male 0.78 0.64 to 0.95 0.012* Age 3–11 months 1.00 1 year 1.41 1.08 to 1.83 0.011* 2 years 1.08 0.94 to 1.23 0.282 3 years 0.88 0.58 to 1.27 0.435 4 years 0.94 0.72 to 1.23 0.634 5 years 0.79 0.45 to 1.29 0.408 Primary caregiver Self-reported literacy No 1.00 Yes 0.88 0.86 to 0.90 0.000*** Level of highest education None or informal 1.00 Primary 0.97 0.63 to 1.50 0.885 Secondary or higher 1.26 0.98 to 1.62 0.067 Employment status Non-employed 1.00 Employed 0.81 0.73 to 0.91 0.000*** Awareness and knowledge of SMC Low 1.00 Medium 0.80 0.68 to 0.94 0.006** High 0.62 0.44 to 0.86 0.005** Head of household Employment status Non-employed 1.00 Employed 0.94 0.73 to 1.20 0.599 *P < 0.05, **p < 0.01, ***p < 0.001. These are selected potential predictors in the final regression models by a forward stepwise regression approach with a significance level of 0.05 based on Collett’s methods. OR calculated using random-effects multilevel logistic regression models for binary outcomes with random intercepts for survey year, country, and subdivision (e.g., LGA s in Nigeria). OR, odds ratio; CI, confidence interval; SMC, seasonal malaria chemoprevention; CD, community distributor. Association between spitting or vomiting at the time of Day 1 SPAQ administration and adherence to AQ administration and caregiver-reported adverse reactions. Table 4 shows the results of chi-square tests of association between spitting or vomiting at the time of Day 1 SPAQ administration, adherence to Day 2 and Day 3 AQ administration, and caregiver reporting behavior following adverse reactions to any doses of medicines by the selected child. Children experiencing spitting or vomiting were less likely to adhere to Day 2 and Day 3 AQ administration by their caregivers (F = 1498.86, df = 1, p < 0.001). Meanwhile, children who experienced spitting or vomiting were more likely to have adverse reactions to SMC medicines other than spitting or vomiting (F = 5.142, df = 1, p = 0.031) and their caregivers were less likely to report their adverse reactions to CDs or health facility personnel (F = 9.089, df = 1, p = 0.005). Table 4 Association between spitting or vomiting and other outcomes related to adverse reaction to SMC medicines. Characteristics Spitting or vomiting No spitting or vomiting F-statistic P value a N ( % b ) N ( % b ) Adherence to the second and third dose of AQ (N = 49,385) Yes 946 (78.58) 47191 (97.75) 1498.86 0.000*** No 237 (21.42) 1011 (2.25) Lead mothers visit (in Nigeria only, N = 29991) Yes 244 (45.1) 20536 (69.58) 60.794 0.000*** No 264 (54.9) 8947 (30.42) Adverse reactions to the SMC medicines c (N = 46898) Yes 206 (19.31) 4641 (9.72) 5.142 0.031* No 678 (80.69) 41373 (90.28) Caregivers report adverse reactions to CDs or health facility personnel d (N = 4846) Yes 90 (46.18) 2960 (68.47) 9.086 0.005** No 116 (53.82) 1680 (31.53) *P < 0.05, **p < 0.01, ***p < 0.001. a P value shows two-sided p value for χ2 test for difference in proportions. b Weighted proportion based on corrected χ2 test. c Adverse reactions to the SMC medicines have excluded “vomiting”. d Respondents who answer ‘yes’ to ‘Adverse reactions to the SMC medicines’ are eligible to proceed to this question. SMC, seasonal malaria chemoprevention. AQ, amodiaquine, CD, community distributor. Characteristics of the survey household members by redosing Table 5 presents the results of weighted chi-square tests for associations between participants’ child-, caregiver-, head of household-, and household-level characteristics, and redosing of SMC medicines among children who spat or vomited the dose of Day 1 SPAQ. Children of caregivers who reported being literate (F = 18.14, df = 1, p < 0.001), who attained primary, secondary or higher education (F = 5.04, df = 2, p = 0.018), and who had a higher level of awareness and knowledge of SMC were significantly more likely to receive a redosing (F = 18.50, df = 2, p < 0.001). Discussion Latest updates to the WHO guidelines for SMC continue to emphasize the importance of appropriate dosing, and pharmacovigilance of adverse reactions to SMC medicines at the time of scaling up use of SP and AQ and piloting the use of alternative medicines such as dihydroartemisinin piperaquine (DP) which has been identified as an effective, well-tolerated artemisinin-based prevention strategy[ 5 , 25 ]. It is advisable that eligible children with a history of adverse reactions after taking SP or AQ should not receive SMC; nevertheless, vomiting is not a contraindication,[ 2 ] which means vomiting should not be considered as the cause of discontinued administration of SP and AQ. Despite one of the most frequently reported adverse reactions associated with AQ, there has been a lack of investigation of spitting or vomiting and its associated sociodemographic factors under the routine large-scale implementation partly due to its mild safety concerns compared to other adverse reactions.[ 10 , 26 ] Due to seasonal malaria chemoprevention has entered a new phase of exploring scaling-up use and sustainability, the potential impact of spitting or vomiting on both preventing eligible children from fully ingesting SMC medicines, caregivers’ perceptions of SMC, and medicine stock management, warrants further investigation. Our analysis found a small proportion of children spitting or vomiting in the four countries analyzed between 2020 and 2022, ranging from 1.81% in Nigeria to 4.36% in Chad. However, spitting or vomiting should be carefully interpreted as the eligible child spitting out most (almost all) of the dose or vomiting all the dose at the time of administration of Day 1 SPAQ. Spitting or vomiting did not involve mild spitting as anecdotal evidence continues to suggest that mild spitting is very common during medicine administration. The results of the regression models found that the child’s sex, child’s age, caregiver’s literacy, caregiver’s employment status, caregiver awareness and knowledge of SMC, and directly supervised administration of Day 1 SPAQ by CDs were predictors of spitting or vomiting at the time of Day 1 SPAQ. Reports from Burkina Faso, Guinea, Mali, Niger, Nigeria, Senegal, and Togo, suggest that children at a younger age more than two years were likely to vomit; however, the number of reports was similar for females and males[ 5 , 27 ]. We found a strong association between caregiver awareness and knowledge of SMC between spitting or vomiting; the higher the level of knowledge of caregivers about the purpose, importance, and benefits of SMC and adherence to medications to their children in general, the less likely their children experience spitting or vomiting; this finding is consistent with those of both quantitative and qualitative studies which identified the critical role of knowledge of SMC in facilitating caregiver compliance to SMC implementation, such as adherence to the complete course of SMC administration by their child or suspicion elimination regarding safety of free medicines.[ 9 , 13 , 28 ] In addition, spitting or vomiting had a strong negative association with directly supervised administration of Day 1 SPAQ by CDs; this is because CDs are trained to advise caregivers on methods to administer medications and manage adverse reactions, and answer any questions from caregivers. Furthermore, lower odds of adherence to Day 2 and Day 3 AQ administration and reporting of children's adverse reactions to CDs or health facility personnel were found among caregivers whose children experienced spitting or vomiting at the time of Day 1 SPAQ administration. This could be explained by caregivers considering children spitting or vomiting as uncommon adverse reactions and mistrusting the safety offurther doses[ 28 ]. Ibinaiye et al[ 13 ] and Cissé et al[ 9 ] found previous adverse reactions to SMC medicines by eligible children (or perceived risk arising from uptake of SMC) were strongly associated with non-adherence to AQ administration. Caregiver non-reporting of children's adverse reactions may be attributable to inadequate assistance and guidance from CDs. Just under half of caregivers reported that their child did not receive a replacement dose following spitting or vomiting at the time of Day 1 SPAQ administration. Such low coverage of redosing was strongly associated with a low level of caregiver awareness and knowledge of SMC and a lack of directly supervised administration by CDs, consistent with a study by Ogbulafor et al[ 28 ] that underscored the critical role of caregivers and CDs in compliance with SMC implementation protocol. However, it is difficult to determine to what extent each active or passive refusal by caregivers individually contributes to failure to redosing due to the unavailability of data on reasons for not receiving a replacement dose. Moreover, whether or not CDs are strictly implementing SMC in accordance with established procedures or whether or experience difficulties in redosing (e.g., shortage of medicines) is uncertain. Strengths and limitations Strengths of this study include its large, representative sample of households across multiple countries and years, providing high statistical power and wide generalizability of its findings. One limitation of this analysis is the high reliance on retrospective self-reporting by caregivers which can result in potential social desirability bias and recall bias. Another limitation is that it is difficult to generalize the findings of spitting or vomiting at the time of Day 1 SPAQ administration to Day 2 and Day 3 AQ administration due to the unavailability of data. Furthermore, there were no data on the presence of rapid diagnostic test-confirmed malaria cases after the final cycle of SMC administration, and linking health facility data on malaria incidence may have facilitated analysis of causes of spitting or vomiting and failure of redosing. Policy implications Actions taken to put these findings into practice included sharing the key findings from the study with country program management and delivery teams, and then through cascade training to all community drug distributors and others involved in SMC campaigns. Greater emphasis may be placed on sensitization efforts at both distributors and community levels to deliver information, education, and communication to caregivers of children to ensure caregivers of all ages have good awareness of SMC. Particularly, direct messages from CDs may also seek to allay caregivers’ concerns around spitting or vomiting throughout the three-day course of SMC administration by clarifying the importance of full ingestion and adherence to SMC medicines, how to prevent or ameliorate spitting or vomiting, and when to reach out to the nearest point of care to obtain a replacement dose during unsupervised AQ administration on Day 2 and Day 3. It could be assumed that stakeholder support in improving accessibility to health facilities and preventing stockouts of key commodities is critical. Furthermore, lead mothers visits and other country-tailored role model activities (e.g., encouragement tactics or discouragement of forced administration) that have been proven to be effective in Nigeria and other countries to optimize SMC administration may also be effective at preventing spitting or vomiting at the time of SMC administration[ 13 ]. Conclusion This study identified socioeconomic and demographic factors associated with spitting or vomiting and redosing during the last household visit cycle by CDs. Our analysis shows the importance of direct CD-supervised administration of Day 1 SPAQ and caregiver awareness and knowledge of SMC to promote full ingestion of SMC medicines. Continuing community sensitization activities and monitoring and evaluation of adverse reactions to SMC medicines remain essential. Abbreviations AQ Amodiaquine CDs Community distributors CI Confidence interval COVID-19 Corona Virus Infectious Diseases-2019 LGAs Local Government Areas OR Odds ratio PPP purchasing power parity SMC Seasonal Malaria Chemoprevention SP Sulfadoxine-pyrimethamine SPAQ Sulfadoxine-pyrimethamine plus amodiaquine USD United States Dollars WHO World Health Organization Declarations Ethics approval and consent to participate The use and conduct of end-of-round surveys were approved by the relevant ethical review agencies in each country, including the National Health Research Ethics Committee in Nigeria (Approval umber: NHREC/01/01/2007-14/10/2022), the Comité National d'Éthique pour la Recherche en Santé (National Committee for Ethics for Health Research) in Burkina Faso, the Comité National de Bioéthique du Tchad (the National Bioethics Committee of Chad) in Chad, and the Comité Consultatif National de Bioéthique (National Bioethics Committee) in Togo. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available on request from the corresponding author SR. The data are not publicly available due to their containing information that could compromise the privacy of research participants. Competing interests The authors declare that they have no competing interests. Funding This study was carried out as part of evaluation activities for the Malaria Consortium’s SMC program in Burkina Faso, Chad, Nigeria, and Togo. These programs are funded using philanthropic donations received by the Malaria Consortium, primarily as a result of being awarded Top Charity status by GiveWell (https://www.givewell.org/). Author Contributions SR conceived and designed the study. CG and SH conducted data analysis and the interpretation of the results. CG and SH contributed to writing the manuscript. TI, BS, AT, CSC, FA, CN, and KB led the acquisition of data and revised the manuscript. DW and SR provided overall supervision of the research. All authors reviewed the manuscript draft and revised it critically on intellectual content. SR and DW are responsible for the overall content as guarantors. Acknowledgements We thank those involved in the delivery of SMC and their supervisors, and data collectors involved in end-of-round surveys, in the study areas for making both the delivery of SMC and this study possible. References World Health Organization. World Malaria Report 2023. Geneva: World Health Organization. Geneva: World Health Organization. 2023. https://malariaworld.org/blogs/world-malaria-report-2023 . Accessed 14 Mar 2024. World Health Organization. WHO Guidelines for Malaria (16 October 2023). Geneva: World Health Organization. 2023. https://malariaworld.org/blogs/who-guidelines-for-malaria-16-october-2023 . Accessed 14 Mar 2024. WHO Malaria Policy Advisory Committee and Secretariat. Inaugural meeting of the malaria policy advisory committee to the WHO: conclusions and recommendations. Malar J. 2012;11:137. World Health Organization. Seasonal malaria chemoprevention with sulfadoxine–pyrimethamine plus amodiaquine in children: a field guide. Geneva: World Health Organization. 2013. https://iris.who.int/handle/10665/85726 . Accessed 14 Mar 2024. World Health Organization. Seasonal malaria chemoprevention with sulfadoxine–pyrimethamine plus amodiaquine in children: a field guide (Second edition). Geneva: World Health Organization. 2023. https://www.who.int/publications-detail-redirect/9789240073692 . Accessed 14 Mar 2024. Cairns M, Roca-Feltrer A, Garske T, Wilson AL, Diallo D, Milligan PJ, et al. Estimating the potential public health impact of seasonal malaria chemoprevention in African children. Nat Commun. 2012;3:881. RBM Partnership to End Malaria. Adapting seasonal malaria chemoprevention in the context of COVID-19: operational guidance. Geneva: RBM Partnership to End Malaria. 2020. https://www.malariaconsortium.org/media-downloads/1336/Adapting%20seasonal%20malaria%20chemoprevention%20in%20the%20context%20of%20COVID-19:%20operational%20guidance . Accessed 14 Mar 2024. Meremikwu MM, Donegan S, Sinclair D, Esu E, Oringanje C. Intermittent preventive treatment for malaria in children living in areas with seasonal transmission. Cochrane Database Syst Rev. 2012;2012:CD003756. Cissé B, Ba EH, Sokhna C, NDiaye JL, Gomis JF, Dial Y, et al. Effectiveness of Seasonal Malaria Chemoprevention in Children under Ten Years of Age in Senegal: A Stepped-Wedge Cluster-Randomised Trial. PLoS Med. 2016;13:e1002175. Cisse B, Cairns M, Faye E, NDiaye O, Faye B, Cames C, et al. Randomized trial of piperaquine with sulfadoxine-pyrimethamine or dihydroartemisinin for malaria intermittent preventive treatment in children. PLoS ONE. 2009;4:e7164. Ouoba J, Lankoandé-Haro S, Fofana S, Nacoulma AP, Kaboré L, Sombié I, et al. Monitoring of adverse drug reactions during seasonal malaria chemoprevention campaigns in children aged 3–59 months in Burkina Faso. Sante Publique. 2024;35:121–32. Somé AF, Zongo I, Sagara I, Ibrahim A, Ahanhanzo CD, Agbanouvi-Agassi EE, et al. Factors Influencing Second and Third Dose Observance during Seasonal Malaria Chemoprevention (SMC): A Quantitative Study in Burkina Faso, Mali and Niger. Trop Med Infect Dis. 2022;7:214. Ibinaiye T, Oresanya O, Oguoma C, Aidenagbon A, Ogunmola O, Rassi C, et al. Predictors of caregiver adherence to administration of amodiaquine during delivery of seasonal malaria chemoprevention in Nigeria, Burkina Faso, Chad, and Togo. Malar J. 2023;22:148. Ward C, Phillips A, Oresanya O, Olisenekwu G, Arogunade E, Moukénet A, et al. Delivery of seasonal malaria chemoprevention with enhanced infection prevention and control measures during the COVID-19 pandemic in Nigeria, Burkina Faso and Chad: a cross-sectional study. Malar J. 2022;21:103. Richardson S, Ibinaiye T, Nikau J, Oresanya O, Marasciulo M, Roca-Feltrer A, et al. COVID-19 knowledge, beliefs, prevention behaviours and misinformation in the context of an adapted seasonal malaria chemoprevention campaign in six northern Nigerian States. Trop Med Health. 2020;48:101. Malaria Consortium. Malaria Consortium London. Using the role model approach to improve administration of seasonal malaria chemoprevention drugs in Burkina Faso, Chad and Togo. 2022. https://www.malariaconsortium.org/resources/publications/1484/using-the-role-model-approach-to-improve-administration-of-seasonal-malaria-chemoprevention-drugs-in-burkina-faso-chad-and-togo . Accessed 14 Mar 2024. Malaria Consortium. Malaria Consortium London. Coverage and quality of seasonal malaria chemoprevention supported by Malaria Consortium in 2021. 2022. https://www.malariaconsortium.org/resources/publications/1582/coverage-and-quality-of-seasonal-malaria-chemoprevention-supported-by-malaria-consortium-in-2021-results-from-burkina-faso-chad-mozambique-nigeria-togo-and-uganda . Accessed 14 Mar 2024. Malaria Consortium. Malaria Consortium London. Coverage and quality of seasonal malaria chemoprevention supported by Malaria Consortium in 2022. 2023. https://www.malariaconsortium.org/resources/publications/1679/coverage-and-quality-of-seasonal-malaria-chemoprevention-supported-by-malaria-consortium-in-2022 . Accessed 14 Mar 2024. Malaria Consortium. Malaria Consortium London. 2020 Seasonal Malaria Chemoprevention End-of-Round Coverage Survey in Bauchi, Jigawa, Kebbi, Kano, Katsina, Sokoto and Yobe States July 2020. 2020. Accessed 14 Mar 2024. Schreiner M. Simple Poverty Scorecard® Poverty-Assessment Tool Burkina Faso. 2014. https://www.simplepovertyscorecard.com/BFA_2014_ENG.pdf . Accessed 14 Mar 2024. Schreiner M, Sossou JP. Simple Poverty Scorecard® Poverty-Assessment Tool Chad. https://www.simplepovertyscorecard.com/TCD_2011_ENG.pdf . Accessed 14 Mar 2024. Schreiner M. Simple Poverty Scorecard® Poverty-Assessment Tool Nigeria. 2015. https://www.simplepovertyscorecard.com/NGA_2012_ENG.pdf . Accessed 14 Mar 2024. Schreiner M, Sossou JP. Simple Poverty Scorecard® Poverty-Assessment Tool Togo. https://www.simplepovertyscorecard.com/TGO_2015_ENG.pdf . Accessed 14 Mar 2024. Collett D. Modelling survival data in medical research. London: Chapman and Hall; 1991. Gutman J, Kovacs S, Dorsey G, Stergachis A, Ter Kuile FO. Safety, tolerability, and efficacy of repeated doses of dihydroartemisinin-piperaquine for prevention and treatment of malaria: a systematic review and meta-analysis. Lancet Infect Dis. 2017;17:184–93. Sokhna C, Cissé B, Bâ EH, Milligan P, Hallett R, Sutherland C, et al. A trial of the efficacy, safety and impact on drug resistance of four drug regimens for seasonal intermittent preventive treatment for malaria in Senegalese children. PLoS ONE. 2008;3:e1471. Vigibase [online tool]. Uppsala Safety Monitoring Centre, Sweden. https://whoumc.org/pv-products/vigiflow/ . Accessed 14 Mar 2023. Ogbulafor N, Uhomoibhi P, Shekarau E, Nikau J, Okoronkwo C, Fanou NML, et al. Facilitators and barriers to seasonal malaria chemoprevention (SMC) uptake in Nigeria: a qualitative approach. Malar J. 2023;22:120. 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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-4582131","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":327652983,"identity":"a0977ac3-f60a-467c-972d-d0ae58ab903e","order_by":0,"name":"Chen 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Globally, in 2022, there were an estimated 249\u0026nbsp;million malaria cases in 85 malaria-endemic countries and areas (including the territory of French Guiana), with an estimated 608,000 malaria deaths[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. About 95% of estimated deaths were in the World Health Organization (WHO) African Region[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Children aged under five years, representing over 70% of deaths related to malaria, are the most vulnerable group[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Many global efforts, including vector control, preventive chemotherapies, malaria vaccine pipeline, and case management, have been (co-)deployed to protect children from malaria infection[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In 2012, the WHO recommended the introduction of seasonal malaria chemoprevention (SMC) to prevent malaria morbidity and mortality in children aged under 3\u0026ndash;59 months in areas of highly seasonal malaria transmission across the Sahel region of Africa[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In 2022, SMC was implemented in 17 sub-Saharan African countries with seasonal malaria transmission, reaching an estimated 49\u0026nbsp;million eligible children[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSMC involves intermittent administration of a complete course of sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ) (SPAQ) to prevent malaria cases by maintaining therapeutic drug concentrations in the blood during the high transmission season[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Before the Corona Virus Infectious Diseases 2019 (COVID-19) pandemic, SMC community distributors (CDs) typically provided a blister pack of SPAQ for a complete three-day course, typically through door-to-door household visits, and directly administered eligible children with SPAQ on Day 1. Subsequently, caregivers of eligible children administered the remaining two daily doses of AQ on both Day 2 and Day 3 without supervision from the CDs. However, during the COVID-19 pandemic, the SMC delivery protocol was adapted to minimize contact with beneficiaries and reduce the risk of COVID-19 transmission between communities and CDs; CDs were requested not to directly administer SMC medicines, but to supervise caregivers when they administer the first dose of SP and AQ to their children on Day 1[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The remaining two doses of AQ were then still administered by caregivers over the following two days. A three-day complete administration of SMC medicines and the following 28-day protective period define a cycle of an annual SMC round which typically involves four to five annual consecutive monthly cycles[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral randomized trials have suggested that combination therapy preventive strategies using SPAQ outperform other combination therapies (e.g., SP\u0026thinsp;+\u0026thinsp;artesunate, SP\u0026thinsp;+\u0026thinsp;AQ\u0026thinsp;+\u0026thinsp;artesunate) and demonstrate no severe adverse reactions; however, mild to moderate adverse reactions have been linked with AQ administration, with vomiting and headache being the most common[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Due in part to the bitter unpleasant taste of AQ, children often exhibit varying degrees of spitting or vomiting immediately following administration of SMC medicines, ranging from spitting out some of the dose to spitting out or vomiting almost the entire dose[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Failure to fully ingest all doses may undermine the protective effect of SMC against malaria. A monitoring and evaluation study in Burkina Faso reported that 38% of suboptimal administration of SMC medicines was attributable to children\u0026rsquo;s adverse reactions to SMC medicines, with vomiting accounting for approximately half of these adverse reactions[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A descriptive study in Burkina Faso, Mali and Niger identified vomiting as the second major cause of non-adherence to the second and third doses of AQ administration[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, another study in Nigeria, Burkina Faso, Chad, and Togo based on data from a routine end-of-round SMC coverage survey found that previous adverse events to SMC medicines by eligible children were associated with reduced caregiver adherence to Day 2 and Day 3 AQ administration[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The WHO recommends administration of a replacement dose after allowing the child to rest for about 10 minutes if a child spits, regurgitates, or vomits within 30 minutes during directly supervised administration of Day 1 SPAQ[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]; redosing aims to ensure that children receive the accurate dose to decrease the impact of non-adherence on resistance and provide long-lasting protection during the malaria transmission season[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA cross-sectional study conducted by the Malaria Consortium found that some caregivers refused to administer SMC medicines to their children or did not administer them correctly during the COVID-19 pandemic[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This may exacerbate spitting or vomiting at the time of administration of SMC medicines. Targeted interventions have been developed to promote caregiver compliance with the correct administration amid the pandemic, in addition to message delivery and communication via CDs during household visits and community sensitization activities. In Nigeria, the lead mothers intervention, delivered by female residents of SMC settings aged 18 years and above who visit caregivers in their homes and disseminate messages following door-to-door visits by CDs, has been proven to be effective at promoting caregiver adherence to AQ administration[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In Burkina Faso, Chad, and Togo, the role model approach, a community-driven behavior change strategy has been piloted to explore its potential to address the challenges associated with SPAQ administration including spitting or vomiting[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral recent studies have highlighted the frequency of vomiting and its impact on non-adherence to AQ administration in various sub-Saharan African countries. However, analysis of spitting or vomiting has largely remained at the summary statistics level, nesting within studies focusing on coverage and cost-effectiveness of SMC rather than specifically analyzing factors that facilitate or prevent spitting or vomiting of SMC medicines. Besides, recent updates to WHO guidance for SMC emphasized monitoring and evaluation and pharmacokinetic considerations at the time of scaling up SMC program or introducing new chemoprevention medicines[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], highlighting the need to improve understanding of relatively common spitting or vomiting and provide insights into its potential amelioration approach.\u003c/p\u003e \u003cp\u003eThis study aimed to examine factors influencing spitting or vomiting following receipt of SPAQ on Day 1 during the last cycle of household visits by CDs in four Sahelian countries (Burkina Faso, Chad, Nigeria, and Togo), using data obtained from annual routine end-of-round SMC coverage surveys commissioned by Malaria Consortium. Additionally, this study sought to assess redosing behavior and its associations with factors including characteristics of the selected child, caregiver, head of household, and caregiver awareness and knowledge of SMC.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eStudy location\u003c/p\u003e \u003cp\u003eThis study was conducted using data collected in four sub-Saharan African countries including Burkina Faso, Chad, Nigeria, and Togo. \u003cem\u003ePlasmodium falciparum\u003c/em\u003e is the dominant species of malaria parasite in these regions, and malaria transmission demonstrated high seasonality[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. SMC end-of-round coverage surveys were conducted in these four countries between 2020 and 2022 (except for Burkina Faso in 2021), spanning three annual rounds of SMC under the adapted condition of SMC implementation during the COVID-19 pandemic. Malaria Consortium\u0026rsquo;s SMC program has been recognized as a major contributor to malaria control and elimination across these four countries[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In Nigeria, the Malaria Consortium delivered SMC in a total of 9 eligible states in 2022, targeting a population of 10.72\u0026nbsp;million eligible children. Meanwhile, in Burkina Faso, SMC covered 29 districts across 6 regions, reaching 2.11\u0026nbsp;million eligible children\u003csup\u003e18\u003c/sup\u003e. In Chad and Togo, 1.2\u0026nbsp;million from 27 districts and 0.51\u0026nbsp;million eligible children from 19 districts were reached by the Malaria Consortium\u0026rsquo;s SMC, respectively\u003csup\u003e18\u003c/sup\u003e. End-of-round surveys conducted by external teams and commissioned by Malaria Consortium were representative of these areas in four countries.\u003c/p\u003e \u003cp\u003eStudy participants\u003c/p\u003e \u003cp\u003eIn all four countries, multi-stage random sampling combined with sampling of clusters by probability proportional to population size was used to select settlements at random to achieve a self-weighting sample[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In Nigeria, a modified multi-stage random sampling was conducted to select compounds, settlements, health facility catchment areas, Local Government Areas (LGAs), and states at random with a step-by-step sampling frame for the selection process. Only households with at least one child aged 3\u0026ndash;59 months were eligible for inclusion in end-of-round surveys. More detailed information on the end-of-round survey protocol can be found elsewhere[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study sample consisted of 54,100 households surveyed during end-of-round surveys. Households were excluded if: (1) they did not respond to the survey; (2) they arrived in the local community after initiation of the final SMC cycle; (3) the selected child did not receive SMC medicines at the time of door-to-door household visits by CDs in the final cycle; or (4) the selected child was not at home or ineligible for other reasons (e.g., deceased, allergy to SMC medicines, sick) during household visits\u003csup\u003e5\u003c/sup\u003e. After excluding 4,715 households, the final analytical sample comprised 49,385 households (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eData source\u003c/p\u003e \u003cp\u003eData were collected during routine SMC end-of-round coverage surveys conducted following the ultimate cycle of SMC treatment between 2020 and 2022 in Burkina Faso, Chad, Nigeria, and Togo.\u003c/p\u003e \u003cp\u003ePairs of data collectors visited each household door-to-door and conducted computer-assisted personal interviews using the application Survey CTO version 2.70 on mobile devices. Survey CTO randomly selected one eligible child from the household from a roster, and all survey questions related to that child, their primary caregiver, their head of household, and the household. A primary caregiver in this survey refers to any individual, aged 15 years or over, with the primary responsibility for the feeding and daily care of at least one child under the age of five and a household head refers to a member of the family who manages the resources and is the final decision maker in the household. Data on a range of variables were available for analysis, including socioeconomic and demographic characteristics of selected household members, key indicators on SMC coverage and adherence, and outcomes of SMC administration. Interviews were conducted in local languages using questionnaires provided by the Malaria Consortium, with data collectors translating on the spot from English or French and assigning responses to predefined answer categories. Informed consent was obtained from all respondents prior to the interview.\u003c/p\u003e \u003cp\u003eVariables\u003c/p\u003e \u003cp\u003eThe outcome, spitting or vomiting, was defined as the eligible child spitting out most (or almost all) of the dose, or vomiting all of the dose, at the time of administration of Day 1 SPAQ during the final cycle of SMC in a given survey year. This was operationalized as a binary variable (yes/no), where \u0026lsquo;no\u0026rsquo; indicated that the eligible child ingested all of the doses or spat out some of the doses of SMC medicines.\u003c/p\u003e \u003cp\u003eVariables considered as potential predictors of spitting or vomiting included socioeconomic and demographic characteristics of children and their primary caregivers and household, as well as caregiver knowledge and awareness of SMC. Covariates considered for inclusion in the analysis included direct CD-supervised administration (yes/no), child\u0026rsquo;s sex (female/male), child\u0026rsquo;s age (years), primary caregiver\u0026rsquo;s sex (female/male), caregiver\u0026rsquo;s age (Under 29 years/30\u0026ndash;39 years/40\u0026ndash;49 years/50 and above), caregiver\u0026rsquo;s self-reported literacy (yes/no), caregiver\u0026rsquo;s highest level of education (none or informal/primary/secondary and higher), caregiver\u0026rsquo;s employment status (yes/no), head of household\u0026rsquo;s self-reported literacy (yes/no), head of household\u0026rsquo;s highest level of education (none or informal/primary/secondary and higher), head of household\u0026rsquo;s employment status (yes/no), and household socioeconomic status. Household socioeconomic status was assessed using the latest country-specific Simple Poverty Scorecards and defined as binary household poverty status (\u0026gt;\u0026thinsp;70% probability household is below the poverty threshold of 1.90 purchasing power parity [PPP]-adjusted 2011 United States Dollars [USD] per day, 2014/2015 definition)[\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In households where the primary caregiver and head of household were the same, observations for the respective variables were the same. Caregiver awareness and knowledge of SMC was included and operationalized as an ordinal variable (low/medium/high) based on six questions, including caregiver awareness of the purpose of SMC (yes/no), caregiver awareness of criteria for children\u0026rsquo;s eligibility to SMC (yes/no), caregiver knowledge of the importance of administering SMC medicines only children aged under five years (yes/no), caregiver knowledge of the reason for administration of Day 2 and Day 3 AQ (yes/no), caregiver knowledge of appropriate reporting of adverse reactions following receipt of SMC medicines (yes/no), and caregiver belief in the effectiveness of SMC at providing full protection against malaria (yes/no). Caregivers were considered to have a low level of knowledge and awareness of SMC if they spontaneously responded with the correct answer (or similar response) to at most two questions, medium level if they answered 3\u0026ndash;5 questions correctly, and high level if they answered all questions correctly.\u003c/p\u003e \u003cp\u003eFurthermore, we introduced the secondary outcome, redosing, defined as children receiving a replacement dose of SMC medicines from CDs right after spitting or vomiting at the time of administration of Day 1 SPAQ to examine the patterns of redosing behavior; this was based on caregiver-reporting data operationalized a binary variable (yes/no). Variables of interest included full adherence to both the second and third dose of AQ administration (yes/no), child adverse reactions to SMC to either SPAQ on Day 1 or AQ on Day 2 or Day 3 (yes/no), caregiver reporting of their adverse reactions to CDs or health facility personnel (yes/no), and lead mothers visit during the previous SMC cycle (in Nigeria only, yes/no).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eFor the end-of-round data, post-sampling survey weights were generated for country sample size vs. population to account for survey design and adjust for underlying problems of over-presentation or underrepresentation of survey respondents due to differences in the sample size from four countries, the results were designed to be represented across the countries included in the study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Survey weights were applied throughout this analysis. We used frequency (N) and weighted percentage (%\u003csup\u003ea\u003c/sup\u003e) to describe the distribution of respondents\u0026rsquo; sociodemographic characteristics by spitting or vomiting. Weighted chi-square tests were performed to assess the association between sociodemographic characteristics and spitting or vomiting.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the survey household members living in Burkina Faso, Chad, Nigeria and Togo.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics (N\u0026thinsp;=\u0026thinsp;49,385)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBurkina Faso\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChad\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTogo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%\u003csup\u003ea\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%\u003csup\u003ea\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN (%\u003csup\u003ea\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN (%\u003csup\u003ea\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN (%\u003csup\u003ea\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvey Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2139\u003c/p\u003e \u003cp\u003e(43.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2285\u003c/p\u003e \u003cp\u003e(29.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6361\u003c/p\u003e \u003cp\u003e(27.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1861\u003c/p\u003e \u003cp\u003e(32.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12646\u003c/p\u003e \u003cp\u003e(29.69)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2914\u003c/p\u003e \u003cp\u003e(33.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10242\u003c/p\u003e \u003cp\u003e(34.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1884\u003c/p\u003e \u003cp\u003e(33.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15040\u003c/p\u003e \u003cp\u003e(31.42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2896\u003c/p\u003e \u003cp\u003e(56.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3297\u003c/p\u003e \u003cp\u003e(36.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13388\u003c/p\u003e \u003cp\u003e(37.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2118\u003c/p\u003e \u003cp\u003e(34.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21699\u003c/p\u003e \u003cp\u003e(38.89)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDirectly CD-supervised administration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4473\u003c/p\u003e \u003cp\u003e(88.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6805\u003c/p\u003e \u003cp\u003e(79.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25649\u003c/p\u003e \u003cp\u003e(84.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4938\u003c/p\u003e \u003cp\u003e(84.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41865\u003c/p\u003e \u003cp\u003e(84.49)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e562\u003c/p\u003e \u003cp\u003e(11.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1691\u003c/p\u003e \u003cp\u003e(20.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4342\u003c/p\u003e \u003cp\u003e(15.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e925\u003c/p\u003e \u003cp\u003e(15.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7520\u003c/p\u003e \u003cp\u003e(15.51)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpitting or vomiting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003cp\u003e(2.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e360\u003c/p\u003e \u003cp\u003e(4.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e508\u003c/p\u003e \u003cp\u003e(1.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e185\u003c/p\u003e \u003cp\u003e(3.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1183\u003c/p\u003e \u003cp\u003e(2.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4905\u003c/p\u003e \u003cp\u003e(97.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8136\u003c/p\u003e \u003cp\u003e(95.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29483\u003c/p\u003e \u003cp\u003e(98.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5678\u003c/p\u003e \u003cp\u003e(96.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48202\u003c/p\u003e \u003cp\u003e(97.87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRedosing (if child did not ingest all of the SMC medicine dose)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003cp\u003e(57.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003cp\u003e(40.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e221\u003c/p\u003e \u003cp\u003e(41.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60\u003c/p\u003e \u003cp\u003e(32.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e491\u003c/p\u003e \u003cp\u003e(42.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003cp\u003e(42.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e210\u003c/p\u003e \u003cp\u003e(59.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e287\u003c/p\u003e \u003cp\u003e(58.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e125\u003c/p\u003e \u003cp\u003e(67.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e668\u003c/p\u003e \u003cp\u003e(57.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdherence to the second and third dose of AQ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4974\u003c/p\u003e \u003cp\u003e(98.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8151\u003c/p\u003e \u003cp\u003e(95.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29268\u003c/p\u003e \u003cp\u003e(97.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5744\u003c/p\u003e \u003cp\u003e(97.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48137\u003c/p\u003e \u003cp\u003e(97.34)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003cp\u003e(1.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e345\u003c/p\u003e \u003cp\u003e(4.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e723\u003c/p\u003e \u003cp\u003e(2.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e119\u003c/p\u003e \u003cp\u003e(2.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1248\u003c/p\u003e \u003cp\u003e(2.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2518\u003c/p\u003e \u003cp\u003e(50.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4746\u003c/p\u003e \u003cp\u003e(55.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15367\u003c/p\u003e \u003cp\u003e(50.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3080\u003c/p\u003e \u003cp\u003e(52.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25711\u003c/p\u003e \u003cp\u003e(51.32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2517\u003c/p\u003e \u003cp\u003e(49.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3750\u003c/p\u003e \u003cp\u003e(44.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14624\u003c/p\u003e \u003cp\u003e(49.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2783\u003c/p\u003e \u003cp\u003e(47.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23674\u003c/p\u003e \u003cp\u003e(48.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;11 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e441\u003c/p\u003e \u003cp\u003e(8.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e695\u003c/p\u003e \u003cp\u003e(8.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1924\u003c/p\u003e \u003cp\u003e(5.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e568\u003c/p\u003e \u003cp\u003e(9.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3628\u003c/p\u003e \u003cp\u003e(6.56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e873\u003c/p\u003e \u003cp\u003e(17.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1437\u003c/p\u003e \u003cp\u003e(16.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4752\u003c/p\u003e \u003cp\u003e(15.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e956\u003c/p\u003e \u003cp\u003e(16.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8018\u003c/p\u003e \u003cp\u003e(16.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1063\u003c/p\u003e \u003cp\u003e(21.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2268\u003c/p\u003e \u003cp\u003e(26.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6552\u003c/p\u003e \u003cp\u003e(22.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1194\u003c/p\u003e \u003cp\u003e(20.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11077\u003c/p\u003e \u003cp\u003e(22.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1061\u003c/p\u003e \u003cp\u003e(21.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2033\u003c/p\u003e \u003cp\u003e(23.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7010\u003c/p\u003e \u003cp\u003e(23.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003cp\u003e(22.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11416\u003c/p\u003e \u003cp\u003e(23.26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1276\u003c/p\u003e \u003cp\u003e(25.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1656\u003c/p\u003e \u003cp\u003e(19.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7474\u003c/p\u003e \u003cp\u003e(24.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1416\u003c/p\u003e \u003cp\u003e(24.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11822\u003c/p\u003e \u003cp\u003e(24.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e321\u003c/p\u003e \u003cp\u003e(6.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e407\u003c/p\u003e \u003cp\u003e(4.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2279\u003c/p\u003e \u003cp\u003e(7.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e417\u003c/p\u003e \u003cp\u003e(7.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3424\u003c/p\u003e \u003cp\u003e(7.36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdverse reactions to the SMC medicines\u003c/b\u003e \u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e \u003cb\u003e(N\u0026thinsp;=\u0026thinsp;46,898)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e304\u003c/p\u003e \u003cp\u003e(6.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1130\u003c/p\u003e \u003cp\u003e(13.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2870\u003c/p\u003e \u003cp\u003e(9.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e543\u003c/p\u003e \u003cp\u003e(9.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4847\u003c/p\u003e \u003cp\u003e(9.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4573\u003c/p\u003e \u003cp\u003e(93.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6825\u003c/p\u003e \u003cp\u003e(86.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27121\u003c/p\u003e \u003cp\u003e(90.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4965\u003c/p\u003e \u003cp\u003e(90.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42051\u003c/p\u003e \u003cp\u003e(90.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrimary caregiver\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e539\u003c/p\u003e \u003cp\u003e(10.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2238\u003c/p\u003e \u003cp\u003e(26.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4723\u003c/p\u003e \u003cp\u003e(16.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e860\u003c/p\u003e \u003cp\u003e(14.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8360\u003c/p\u003e \u003cp\u003e(16.38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4496\u003c/p\u003e \u003cp\u003e(89.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6258\u003c/p\u003e \u003cp\u003e(73.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25268\u003c/p\u003e \u003cp\u003e(83.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5003\u003c/p\u003e \u003cp\u003e(85.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41025\u003c/p\u003e \u003cp\u003e(83.62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 29 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2356\u003c/p\u003e \u003cp\u003e(46.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3800\u003c/p\u003e \u003cp\u003e(44.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14134\u003c/p\u003e \u003cp\u003e(47.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2649\u003c/p\u003e \u003cp\u003e(45.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22939\u003c/p\u003e \u003cp\u003e(47.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1993\u003c/p\u003e \u003cp\u003e(39.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3032\u003c/p\u003e \u003cp\u003e(35.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11045\u003c/p\u003e \u003cp\u003e(35.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2351\u003c/p\u003e \u003cp\u003e(40.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18421\u003c/p\u003e \u003cp\u003e(36.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e490\u003c/p\u003e \u003cp\u003e(9.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1283\u003c/p\u003e \u003cp\u003e(15.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3599\u003c/p\u003e \u003cp\u003e(12.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e624\u003c/p\u003e \u003cp\u003e(10.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5996\u003c/p\u003e \u003cp\u003e(12.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50 and more above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e196\u003c/p\u003e \u003cp\u003e(3.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e381\u003c/p\u003e \u003cp\u003e(4.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1213\u003c/p\u003e \u003cp\u003e(4.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e239\u003c/p\u003e \u003cp\u003e(4.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2029\u003c/p\u003e \u003cp\u003e(4.09)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-reported literacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2057\u003c/p\u003e \u003cp\u003e(40.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4467\u003c/p\u003e \u003cp\u003e(52.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19652\u003c/p\u003e \u003cp\u003e(64.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3089\u003c/p\u003e \u003cp\u003e(52.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29265\u003c/p\u003e \u003cp\u003e(61.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2978\u003c/p\u003e \u003cp\u003e(59.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4029\u003c/p\u003e \u003cp\u003e(47.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10339\u003c/p\u003e \u003cp\u003e(35.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2774\u003c/p\u003e \u003cp\u003e(47.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20120\u003c/p\u003e \u003cp\u003e(38.87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of highest education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone or informal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3238\u003c/p\u003e \u003cp\u003e(64.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5423\u003c/p\u003e \u003cp\u003e(63.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15799\u003c/p\u003e \u003cp\u003e(56.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2860\u003c/p\u003e \u003cp\u003e(48.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27320\u003c/p\u003e \u003cp\u003e(57.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e808\u003c/p\u003e \u003cp\u003e(16.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1444\u003c/p\u003e \u003cp\u003e(16.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4577\u003c/p\u003e \u003cp\u003e(15.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1371\u003c/p\u003e \u003cp\u003e(23.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8200\u003c/p\u003e \u003cp\u003e(15.89)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e989\u003c/p\u003e \u003cp\u003e(19.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1629\u003c/p\u003e \u003cp\u003e(19.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9615\u003c/p\u003e \u003cp\u003e(28.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1632\u003c/p\u003e \u003cp\u003e(27.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13865\u003c/p\u003e \u003cp\u003e(26.56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1736\u003c/p\u003e \u003cp\u003e(34.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4516\u003c/p\u003e \u003cp\u003e(53.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10198\u003c/p\u003e \u003cp\u003e(35.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1216\u003c/p\u003e \u003cp\u003e(20.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17666\u003c/p\u003e \u003cp\u003e(35.97)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3299\u003c/p\u003e \u003cp\u003e(65.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3980\u003c/p\u003e \u003cp\u003e(46.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19793\u003c/p\u003e \u003cp\u003e(64.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4647\u003c/p\u003e \u003cp\u003e(79.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31719\u003c/p\u003e \u003cp\u003e(64.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAwareness and knowledge of SMC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e397\u003c/p\u003e \u003cp\u003e(7.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e630\u003c/p\u003e \u003cp\u003e(7.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5494\u003c/p\u003e \u003cp\u003e(17.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e819\u003c/p\u003e \u003cp\u003e(13.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7340\u003c/p\u003e \u003cp\u003e(15.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1627\u003c/p\u003e \u003cp\u003e(32.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2058\u003c/p\u003e \u003cp\u003e(24.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8503\u003c/p\u003e \u003cp\u003e(28.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2166\u003c/p\u003e \u003cp\u003e(36.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14354\u003c/p\u003e \u003cp\u003e(29.07)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3011\u003c/p\u003e \u003cp\u003e(59.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5808\u003c/p\u003e \u003cp\u003e(67.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15994\u003c/p\u003e \u003cp\u003e(53.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2878\u003c/p\u003e \u003cp\u003e(49.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27691\u003c/p\u003e \u003cp\u003e(54.99)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaregivers report adverse reactions to CDs or health facility personnel\u003c/b\u003e \u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e \u003cb\u003e(N\u0026thinsp;=\u0026thinsp;4846)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e181\u003c/p\u003e \u003cp\u003e(59.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e604\u003c/p\u003e \u003cp\u003e(53.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1989\u003c/p\u003e \u003cp\u003e(71.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e276\u003c/p\u003e \u003cp\u003e(51.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3050\u003c/p\u003e \u003cp\u003e(67.73)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123\u003c/p\u003e \u003cp\u003e(40.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e526\u003c/p\u003e \u003cp\u003e(46.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e881\u003c/p\u003e \u003cp\u003e(28.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e266\u003c/p\u003e \u003cp\u003e(48.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1796\u003c/p\u003e \u003cp\u003e(32.27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHead of household\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-reported literacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e906\u003c/p\u003e \u003cp\u003e(38.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3861\u003c/p\u003e \u003cp\u003e(54.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22949\u003c/p\u003e \u003cp\u003e(77.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3537\u003c/p\u003e \u003cp\u003e(60.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31253\u003c/p\u003e \u003cp\u003e(73.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1444\u003c/p\u003e \u003cp\u003e(61.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2166\u003c/p\u003e \u003cp\u003e(45.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7041\u003c/p\u003e \u003cp\u003e(23.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2325\u003c/p\u003e \u003cp\u003e(39.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13976\u003c/p\u003e \u003cp\u003e(26.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of highest education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone or informal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1534\u003c/p\u003e \u003cp\u003e(65.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4171\u003c/p\u003e \u003cp\u003e(59.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12896\u003c/p\u003e \u003cp\u003e(45.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1118\u003c/p\u003e \u003cp\u003e(24.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19719\u003c/p\u003e \u003cp\u003e(47.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e386\u003c/p\u003e \u003cp\u003e(16.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1148\u003c/p\u003e \u003cp\u003e(16.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3426\u003c/p\u003e \u003cp\u003e(10.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1338\u003c/p\u003e \u003cp\u003e(29.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6298\u003c/p\u003e \u003cp\u003e(12.16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e430\u003c/p\u003e \u003cp\u003e(18.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1708\u003c/p\u003e \u003cp\u003e(24.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13668\u003c/p\u003e \u003cp\u003e(43.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2139\u003c/p\u003e \u003cp\u003e(46.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17945\u003c/p\u003e \u003cp\u003e(40.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e491\u003c/p\u003e \u003cp\u003e(20.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3044\u003c/p\u003e \u003cp\u003e(43.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4530\u003c/p\u003e \u003cp\u003e(15.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e546\u003c/p\u003e \u003cp\u003e(9.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8611\u003c/p\u003e \u003cp\u003e(17.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1859\u003c/p\u003e \u003cp\u003e(79.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3983\u003c/p\u003e \u003cp\u003e(56.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25325\u003c/p\u003e \u003cp\u003e(84.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5316\u003c/p\u003e \u003cp\u003e(90.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36483\u003c/p\u003e \u003cp\u003e(82.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePoverty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e421\u003c/p\u003e \u003cp\u003e(8.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3318\u003c/p\u003e \u003cp\u003e(37.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1367\u003c/p\u003e \u003cp\u003e(4.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e793\u003c/p\u003e \u003cp\u003e(13.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5899\u003c/p\u003e \u003cp\u003e(8.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4614\u003c/p\u003e \u003cp\u003e(91.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5178\u003c/p\u003e \u003cp\u003e(62.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28624\u003c/p\u003e \u003cp\u003e(95.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5070\u003c/p\u003e \u003cp\u003e(86.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43486\u003c/p\u003e \u003cp\u003e(91.99)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLead mothers visit (in Nigeria, N\u0026thinsp;=\u0026thinsp;29991)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20780\u003c/p\u003e \u003cp\u003e(69.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20780\u003c/p\u003e \u003cp\u003e(69.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9211\u003c/p\u003e \u003cp\u003e(30.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9211\u003c/p\u003e \u003cp\u003e(30.87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Weighted proportion based on corrected χ2 test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e Adverse reactions to the SMC medicines have excluded \u0026ldquo;vomiting\u0026rdquo;.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ec\u003c/sup\u003e Respondents who answer \u0026lsquo;yes\u0026rsquo; to \u0026lsquo;Adverse reactions to the SMC medicines\u0026rsquo; are eligible to proceed to this question.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSMC, seasonal malaria chemoprevention. AQ, amodiaquine; e; CD, community distributor.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe performed random-effects logistic regression models to identify predictors of spitting or vomiting during Day 1 SPAQ administration, with random intercepts for survey year, country, and administrative subdivision (LGAs in Nigeria, districts in other countries) to account for clustering effects on the binary outcome. A forward stepwise regression approach with a significance level of 0.05 based on Collett\u0026rsquo;s methods was used to select potential predictors for inclusion in the final regression models[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Results were displayed Odds ratio (OR) with 95% Confidence interval (CI).\u003c/p\u003e \u003cp\u003eRedosing\u0026rsquo;s association with caregiver adherence to Day 2 and Day 3 AQ administration and variables related to children\u0026rsquo;s adverse reactions to SMC medicines (i.e., whether children had any adverse reactions to SMC or whether caregivers reported their adverse reactions to CDs or health facility personnel) was also assessed using summary statistics (N and %) and weighted chi-squared tests. Data were analyzed using Stata 17.0.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eCharacteristics of the survey household members in Burkina Faso, Chad, Nigeria and Togo\u003c/p\u003e\n\u003cp\u003eA total of 49,385 children were enrolled across the 2020, 2021 and 2022 SMC end-of-round surveys in the four countries (5035 in Burkina Faso, 8496 in Chad, 29991 in Nigeria, and 5863 in Togo). Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the selected child-, caregiver-, head of household-, and household-level characteristics by country. The majority of primary caregivers (84.49%) reported directly supervised administration of Day 1 SPAQ during ultimate-cycle door-to-door household visits by CDs. The overall proportion of caregivers that reported adherence to Day 2 and Day 3 AQ administration to the selected child was 97.34%. The overall weighted proportion of primary caregivers from four countries who reported spitting or vomiting by their child was 2.13%, ranging from 1.81% in Nigeria to 4.36% in Chad. Of caregivers who reported spitting or vomiting, only 42.47% further reported redosing (receiving the replacement dose from CDs), ranging from 32.11% in Togo to 57.19% in Burkina Faso.\u003c/p\u003e\n\u003cp\u003eRegarding primary caregiver characteristics in the four countries, 83.62% surveyed were female, ranging from 73.68% in Chad to 89.36% in Burkina Faso, with ages under 29 (47.29%) and 30\u0026ndash;39 (36.43%) accounting for the largest weighted proportions. The proportion of caregivers surveyed reporting being literate varied by country, ranging from 40.76% in Burkina Faso to 64.74% in Nigeria. The overall proportions of caregivers by education attainment were 57.55% with no or no formal education, 15.89% with primary education, and 26.56% with secondary education or higher. Overall, 54.99% of caregivers surveyed had a high level of awareness and knowledge of SMC; this varied by country, ranging from 49.09% in Togo to 67.99% in Chad. Regarding head of household characteristics, the majority of those responding to the survey were in employment (82.70%) and around 10% were considered to be in poverty (\u0026gt;\u0026thinsp;70% probability of household income below 1.90 PPP-adjusted 2011 USD per day); however, proportions of households in poverty varied by country, ranging from 8.57% in Nigeria to 37.24% in Chad.\u003c/p\u003e\n\u003cp\u003eCharacteristics of the survey household members by spitting or vomiting\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the results of weighted chi-square tests for associations between child-, caregiver-, head of household-, and household-level characteristics, and spitting or vomiting. Male children were significantly less likely to present spitting or vomiting at the time of Day 1 SPAQ administration (F\u0026thinsp;=\u0026thinsp;4.50, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.042). while those in younger age groups (e.g., 3\u0026ndash;11 months) were also less likely to present spitting or vomiting (F\u0026thinsp;=\u0026thinsp;5.33, df\u0026thinsp;=\u0026thinsp;5, p\u0026thinsp;=\u0026thinsp;0.003). Statistically significant associations were found between caregivers\u0026rsquo; sex (F\u0026thinsp;=\u0026thinsp;7.73, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;0.009), caregiver\u0026rsquo;s literacy (F\u0026thinsp;=\u0026thinsp;4.27, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;0.047), caregiver\u0026rsquo;s employment status (F\u0026thinsp;=\u0026thinsp;3.48, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;0.072), caregiver awareness and knowledge of SMC (F\u0026thinsp;=\u0026thinsp;32.43, df\u0026thinsp;=\u0026thinsp;2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and spitting or vomiting by the selected child. Children who received Day 1 SPAQ administration under the supervision of CDs were significantly less likely to present spitting or vomiting (F\u0026thinsp;=\u0026thinsp;95.45, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In Nigeria, lead mothers visit were negatively associated with spitting or vomiting.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of household members by children spitting or vomiting at Day 1 SPAQ administration.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eChild\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCharacteristics (N\u0026thinsp;=\u0026thinsp;49,385)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSpitting or vomiting\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo spitting or vomiting\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF-statistic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN(%\u003csup\u003eb\u003c/sup\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (%\u003csup\u003eb\u003c/sup\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDirectly CD-supervised administration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e778 (64.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41087 (84.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e405 (35.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7115 (15.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e580 (45.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25131 (51.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.042*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e603 (54.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23071 (48.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u0026ndash;11 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (7.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3538 (6.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e244 (22.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7774 (15.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e290 (23.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10787 (22.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e236 (19.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11180 (23.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e250 (21.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11572 (24.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73 (5.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3351 (7.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e160 (12.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8200 (16.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.009**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1023 (87.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40002 (83.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary caregiver\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnder 29 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e580 (48.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22359 (47.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.829\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;39 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e436 (36.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17985 (36.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u0026ndash;49 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125 (11.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5871 (12.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 or more above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42 (3.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1987 (4.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-reported literacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e655 (55.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28610 (61.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.047*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e528 (44.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19592 (38.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of highest education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone or informal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e636 (56.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26684 (57.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.419\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e173 (13.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8027 (15.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e374 (29.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13491 (26.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e505 (41.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17161 (35.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e678 (58.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31041 (64.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness and knowledge of SMC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e290 (27.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7050 (15.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e397 (35.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13957 (28.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e486 (37.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27195 (55.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eHead of household\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-reported literacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e709 (69.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30544 (73.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e366 (30.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13610 (26.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of highest education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone or informal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e463 (46.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19256 (47.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.787\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e137 (11.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6161 (12.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e441 (42.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17504 (40.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e255 (20.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8356 (17.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.276\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e815 (79.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35668 (82.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePoverty\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e172 (9.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5727 (7.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1011 (90.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42475 (92.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e P value shows two-sided p value for \u0026chi;2 test for difference in proportions.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003eb\u003c/sup\u003e Weighted proportion based on corrected \u0026chi;2 test.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eSMC, seasonal malaria chemoprevention; CD, community distributor.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ePredictors of spitting or vomiting at the time of Day 1 SPAQ administration\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e presents the results of logistic regression analysis of spitting or vomiting across the four countries following variable selection by a forward stepwise approach. Variables selected for inclusion in the final model were child\u0026rsquo;s sex, child\u0026rsquo;s age, caregiver\u0026rsquo;s self-reported literacy, caregiver\u0026rsquo;s level of education, caregiver\u0026rsquo;s employment status, caregiver awareness and knowledge of SMC, head of household employment status, and directly supervised Day 1 SPAQ administration by CDs. Results of the logistic regression model showed that selected children aged one year had higher odds of spitting or vomiting at the time of Day 1 SPAQ administration, compared with children aged 3\u0026ndash;11 months (OR\u0026thinsp;=\u0026thinsp;1.41, 95% CI 1.08 to 1.83). Such statistically significant association was not found in children aged above two years despite their lower odds of spitting or vomiting, compared with children aged 3\u0026ndash;11 months. Male children had lower odds of spitting or vomiting compared with female children (OR\u0026thinsp;=\u0026thinsp;0.78, 95% CI 0.64 to 0.95). Meanwhile, caregiver\u0026rsquo;s illiteracy (OR\u0026thinsp;=\u0026thinsp;0.88, 95% CI 0.86 to 0.90), caregiver\u0026rsquo;s in-employment status (OR\u0026thinsp;=\u0026thinsp;0.81, 95% CI 0.73 to 0.91), and a medium or high level of caregiver awareness and knowledge of SMC (OR\u0026thinsp;=\u0026thinsp;0.80, 95% CI 0.68 to 0.94; OR\u0026thinsp;=\u0026thinsp;0.62, 95% CI 0.44 to 0.86) were all significantly associated with lower odds of spitting or vomiting. Directly supervised administration of Day 1 SPAQ was significantly associated with lower odds of spitting or vomiting (OR\u0026thinsp;=\u0026thinsp;0.50, 95% CI 0.34 to 0.73).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMultilevel logistic regression model of predicting children spitting or vomiting at Day 1 SPAQ administration.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics (N\u0026thinsp;=\u0026thinsp;45,094)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eChild\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDirectly CD-supervised administration\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34 to 0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64 to 0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.012*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u0026ndash;11 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.08 to 1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.011*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 to 1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.282\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58 to 1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.435\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72 to 1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.634\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.45 to 1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.408\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary caregiver\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-reported literacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86 to 0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of highest education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone or informal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63 to 1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.885\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.98 to 1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73 to 0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness and knowledge of SMC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.68 to 0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.44 to 0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.005**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eHead of household\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73 to 1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.599\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eThese are selected potential predictors in the final regression models by a forward stepwise regression approach with a significance level of 0.05 based on Collett\u0026rsquo;s methods.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eOR calculated using random-effects multilevel logistic regression models for binary outcomes with random intercepts for survey year, country, and subdivision (e.g., LGA s in Nigeria).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eOR, odds ratio; CI, confidence interval; SMC, seasonal malaria chemoprevention; CD, community distributor.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAssociation between spitting or vomiting at the time of Day 1 SPAQ administration and adherence to AQ administration and caregiver-reported adverse reactions.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows the results of chi-square tests of association between spitting or vomiting at the time of Day 1 SPAQ administration, adherence to Day 2 and Day 3 AQ administration, and caregiver reporting behavior following adverse reactions to any doses of medicines by the selected child. Children experiencing spitting or vomiting were less likely to adhere to Day 2 and Day 3 AQ administration by their caregivers (F\u0026thinsp;=\u0026thinsp;1498.86, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Meanwhile, children who experienced spitting or vomiting were more likely to have adverse reactions to SMC medicines other than spitting or vomiting (F\u0026thinsp;=\u0026thinsp;5.142, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;0.031) and their caregivers were less likely to report their adverse reactions to CDs or health facility personnel (F\u0026thinsp;=\u0026thinsp;9.089, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation between spitting or vomiting and other outcomes related to adverse reaction to SMC medicines.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSpitting or vomiting\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo spitting or vomiting\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF-statistic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (\u003cstrong\u003e%\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/sup\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (\u003cstrong\u003e%\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/sup\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdherence to the second and third dose of AQ (N\u0026thinsp;=\u0026thinsp;49,385)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e946 (78.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47191 (97.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1498.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e237 (21.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1011 (2.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLead mothers visit (in Nigeria only, N\u0026thinsp;=\u0026thinsp;29991)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e244 (45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20536 (69.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60.794\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e264 (54.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8947 (30.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdverse reactions to the SMC medicines\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003ec\u003c/strong\u003e\u003c/sup\u003e \u003cstrong\u003e(N\u0026thinsp;=\u0026thinsp;46898)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e206 (19.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4641 (9.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.031*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e678 (80.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41373 (90.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregivers report adverse reactions to CDs or health facility personnel\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003ed\u003c/strong\u003e\u003c/sup\u003e \u003cstrong\u003e(N\u0026thinsp;=\u0026thinsp;4846)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e90 (46.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2960 (68.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e116 (53.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1680 (31.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e P value shows two-sided p value for \u0026chi;2 test for difference in proportions.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Weighted proportion based on corrected \u0026chi;2 test.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u003c/sup\u003e Adverse reactions to the SMC medicines have excluded \u0026ldquo;vomiting\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ed\u003c/sup\u003e Respondents who answer \u0026lsquo;yes\u0026rsquo; to \u0026lsquo;Adverse reactions to the SMC medicines\u0026rsquo; are eligible to proceed to this question.\u003c/p\u003e\n\u003cp\u003eSMC, seasonal malaria chemoprevention. AQ, amodiaquine, CD, community distributor.\u003c/p\u003e\n\u003cp\u003eCharacteristics of the survey household members by redosing\u003c/p\u003e\n\u003cp\u003eTable 5 presents the results of weighted chi-square tests for associations between participants\u0026rsquo; child-, caregiver-, head of household-, and household-level characteristics, and redosing of SMC medicines among children who spat or vomited the dose of Day 1 SPAQ. Children of caregivers who reported being literate (F\u0026thinsp;=\u0026thinsp;18.14, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), who attained primary, secondary or higher education (F\u0026thinsp;=\u0026thinsp;5.04, df\u0026thinsp;=\u0026thinsp;2, p\u0026thinsp;=\u0026thinsp;0.018), and who had a higher level of awareness and knowledge of SMC were significantly more likely to receive a redosing (F\u0026thinsp;=\u0026thinsp;18.50, df\u0026thinsp;=\u0026thinsp;2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLatest updates to the WHO guidelines for SMC continue to emphasize the importance of appropriate dosing, and pharmacovigilance of adverse reactions to SMC medicines at the time of scaling up use of SP and AQ and piloting the use of alternative medicines such as dihydroartemisinin piperaquine (DP) which has been identified as an effective, well-tolerated artemisinin-based prevention strategy[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It is advisable that eligible children with a history of adverse reactions after taking SP or AQ should not receive SMC; nevertheless, vomiting is not a contraindication,[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] which means vomiting should not be considered as the cause of discontinued administration of SP and AQ. Despite one of the most frequently reported adverse reactions associated with AQ, there has been a lack of investigation of spitting or vomiting and its associated sociodemographic factors under the routine large-scale implementation partly due to its mild safety concerns compared to other adverse reactions.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Due to seasonal malaria chemoprevention has entered a new phase of exploring scaling-up use and sustainability, the potential impact of spitting or vomiting on both preventing eligible children from fully ingesting SMC medicines, caregivers\u0026rsquo; perceptions of SMC, and medicine stock management, warrants further investigation.\u003c/p\u003e \u003cp\u003eOur analysis found a small proportion of children spitting or vomiting in the four countries analyzed between 2020 and 2022, ranging from 1.81% in Nigeria to 4.36% in Chad. However, spitting or vomiting should be carefully interpreted as the eligible child spitting out most (almost all) of the dose or vomiting all the dose at the time of administration of Day 1 SPAQ. Spitting or vomiting did not involve mild spitting as anecdotal evidence continues to suggest that mild spitting is very common during medicine administration.\u003c/p\u003e \u003cp\u003eThe results of the regression models found that the child\u0026rsquo;s sex, child\u0026rsquo;s age, caregiver\u0026rsquo;s literacy, caregiver\u0026rsquo;s employment status, caregiver awareness and knowledge of SMC, and directly supervised administration of Day 1 SPAQ by CDs were predictors of spitting or vomiting at the time of Day 1 SPAQ. Reports from Burkina Faso, Guinea, Mali, Niger, Nigeria, Senegal, and Togo, suggest that children at a younger age more than two years were likely to vomit; however, the number of reports was similar for females and males[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. We found a strong association between caregiver awareness and knowledge of SMC between spitting or vomiting; the higher the level of knowledge of caregivers about the purpose, importance, and benefits of SMC and adherence to medications to their children in general, the less likely their children experience spitting or vomiting; this finding is consistent with those of both quantitative and qualitative studies which identified the critical role of knowledge of SMC in facilitating caregiver compliance to SMC implementation, such as adherence to the complete course of SMC administration by their child or suspicion elimination regarding safety of free medicines.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] In addition, spitting or vomiting had a strong negative association with directly supervised administration of Day 1 SPAQ by CDs; this is because CDs are trained to advise caregivers on methods to administer medications and manage adverse reactions, and answer any questions from caregivers.\u003c/p\u003e \u003cp\u003eFurthermore, lower odds of adherence to Day 2 and Day 3 AQ administration and reporting of children's adverse reactions to CDs or health facility personnel were found among caregivers whose children experienced spitting or vomiting at the time of Day 1 SPAQ administration. This could be explained by caregivers considering children spitting or vomiting as uncommon adverse reactions and mistrusting the safety offurther doses[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Ibinaiye et al[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and Ciss\u0026eacute; et al[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] found previous adverse reactions to SMC medicines by eligible children (or perceived risk arising from uptake of SMC) were strongly associated with non-adherence to AQ administration. Caregiver non-reporting of children's adverse reactions may be attributable to inadequate assistance and guidance from CDs.\u003c/p\u003e \u003cp\u003e Just under half of caregivers reported that their child did not receive a replacement dose following spitting or vomiting at the time of Day 1 SPAQ administration. Such low coverage of redosing was strongly associated with a low level of caregiver awareness and knowledge of SMC and a lack of directly supervised administration by CDs, consistent with a study by Ogbulafor et al[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] that underscored the critical role of caregivers and CDs in compliance with SMC implementation protocol. However, it is difficult to determine to what extent each active or passive refusal by caregivers individually contributes to failure to redosing due to the unavailability of data on reasons for not receiving a replacement dose. Moreover, whether or not CDs are strictly implementing SMC in accordance with established procedures or whether or experience difficulties in redosing (e.g., shortage of medicines) is uncertain.\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eStrengths of this study include its large, representative sample of households across multiple countries and years, providing high statistical power and wide generalizability of its findings. One limitation of this analysis is the high reliance on retrospective self-reporting by caregivers which can result in potential social desirability bias and recall bias. Another limitation is that it is difficult to generalize the findings of spitting or vomiting at the time of Day 1 SPAQ administration to Day 2 and Day 3 AQ administration due to the unavailability of data.\u003c/p\u003e \u003cp\u003eFurthermore, there were no data on the presence of rapid diagnostic test-confirmed malaria cases after the final cycle of SMC administration, and linking health facility data on malaria incidence may have facilitated analysis of causes of spitting or vomiting and failure of redosing.\u003c/p\u003e \u003cp\u003ePolicy implications\u003c/p\u003e \u003cp\u003eActions taken to put these findings into practice included sharing the key findings from the study with country program management and delivery teams, and then through cascade training to all community drug distributors and others involved in SMC campaigns. Greater emphasis may be placed on sensitization efforts at both distributors and community levels to deliver information, education, and communication to caregivers of children to ensure caregivers of all ages have good awareness of SMC. Particularly, direct messages from CDs may also seek to allay caregivers\u0026rsquo; concerns around spitting or vomiting throughout the three-day course of SMC administration by clarifying the importance of full ingestion and adherence to SMC medicines, how to prevent or ameliorate spitting or vomiting, and when to reach out to the nearest point of care to obtain a replacement dose during unsupervised AQ administration on Day 2 and Day 3. It could be assumed that stakeholder support in improving accessibility to health facilities and preventing stockouts of key commodities is critical. Furthermore, lead mothers visits and other country-tailored role model activities (e.g., encouragement tactics or discouragement of forced administration) that have been proven to be effective in Nigeria and other countries to optimize SMC administration may also be effective at preventing spitting or vomiting at the time of SMC administration[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identified socioeconomic and demographic factors associated with spitting or vomiting and redosing during the last household visit cycle by CDs. Our analysis shows the importance of direct CD-supervised administration of Day 1 SPAQ and caregiver awareness and knowledge of SMC to promote full ingestion of SMC medicines. Continuing community sensitization activities and monitoring and evaluation of adverse reactions to SMC medicines remain essential.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmodiaquine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity distributors\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOVID-19\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCorona Virus Infectious Diseases-2019\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLGAs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLocal Government Areas\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epurchasing power parity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSeasonal Malaria Chemoprevention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSulfadoxine-pyrimethamine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPAQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSulfadoxine-pyrimethamine plus amodiaquine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States Dollars\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe use and conduct of end-of-round surveys were approved by the relevant ethical review agencies in each country, including the National Health Research Ethics Committee in Nigeria (Approval umber: NHREC/01/01/2007-14/10/2022), the Comit\u0026eacute; National d\u0026apos;\u0026Eacute;thique pour la Recherche en Sant\u0026eacute; (National Committee for Ethics for Health Research) in Burkina Faso, the Comit\u0026eacute; National de Bio\u0026eacute;thique du Tchad (the National Bioethics Committee of Chad) in Chad, and the Comit\u0026eacute; Consultatif National de Bio\u0026eacute;thique (National Bioethics Committee) in Togo.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author SR. The data are not publicly available due to their containing information that could compromise the privacy of research participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was carried out as part of evaluation activities for the Malaria Consortium\u0026rsquo;s SMC program in Burkina Faso, Chad, Nigeria, and Togo. These programs are funded using philanthropic donations received by the Malaria Consortium, primarily as a result of being awarded Top Charity status by GiveWell (https://www.givewell.org/).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSR conceived and designed the study. CG and SH conducted data analysis and the interpretation of the results. CG and SH contributed to writing the manuscript. TI, BS, AT, CSC, FA, CN, and KB led the acquisition of data and revised the manuscript. DW and SR provided overall supervision of the research. All authors reviewed the manuscript draft and revised it critically on intellectual content. SR and DW are responsible for the overall content as guarantors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank those involved in the delivery of SMC and their supervisors, and data collectors involved in end-of-round surveys, in the study areas for making both the delivery of SMC and this study possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. World Malaria Report 2023. Geneva: World Health Organization. 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London: Chapman and Hall; 1991.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGutman J, Kovacs S, Dorsey G, Stergachis A, Ter Kuile FO. Safety, tolerability, and efficacy of repeated doses of dihydroartemisinin-piperaquine for prevention and treatment of malaria: a systematic review and meta-analysis. Lancet Infect Dis. 2017;17:184\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSokhna C, Ciss\u0026eacute; B, B\u0026acirc; EH, Milligan P, Hallett R, Sutherland C, et al. A trial of the efficacy, safety and impact on drug resistance of four drug regimens for seasonal intermittent preventive treatment for malaria in Senegalese children. PLoS ONE. 2008;3:e1471.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVigibase [online tool]. Uppsala Safety Monitoring Centre, Sweden. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://whoumc.org/pv-products/vigiflow/\u003c/span\u003e\u003cspan address=\"https://whoumc.org/pv-products/vigiflow/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 14 Mar 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgbulafor N, Uhomoibhi P, Shekarau E, Nikau J, Okoronkwo C, Fanou NML, et al. Facilitators and barriers to seasonal malaria chemoprevention (SMC) uptake in Nigeria: a qualitative approach. Malar J. 2023;22:120.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"tropical-medicine-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tmah","sideBox":"Learn more about [Tropical Medicine and Health](https://tropmedhealth.biomedcentral.com/)","snPcode":"41182","submissionUrl":"https://submission.springernature.com/new-submission/41182/3","title":"Tropical Medicine and Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Malaria, Cross-sectional survey, Child health, Chemoprophylaxis","lastPublishedDoi":"10.21203/rs.3.rs-4582131/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4582131/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSince 2012, the World Health Organization has recommended seasonal malaria chemoprevention (SMC) with sulfadoxine-pyrimethamine plus amodiaquine (SPAQ) for children aged 3\u0026ndash;⁠59 months in areas with marked seasonality in malaria transmission. Full ingestion of SMC medicines without spitting or vomiting during a complete three-day course is critical to ensure SMC effectiveness and avoid increased antimalarial resistance. Although evidence suggests that spitting or vomiting is not rare, there is limited analytical evidence on potential factors associated with spitting or vomiting.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe utilized data from SMC coverage surveys conducted in Burkina Faso, Chad, Togo and Nigeria between 2020 and 2022. Episodes of spitting or vomiting were defined as children spitting out most of the dose or vomiting the entire dose within 30 min after administration on Day 1 by community distributors (CDs) as reported by primary caregivers. We conducted a cross-sectional study through mixed-effects logistic regression specified with socioeconomic variables, and caregiver knowledge of SMC, to identify factors associated with spitting or vomiting.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe proportion of spitting or vomiting ranged from 1.81% in Nigeria to 4.36% in Chad. The odds of spitting or vomiting were lower if children were administered medicines under directly CD-supervised administration and primary caregivers had a high degree of knowledge of SMC. Spitting or vomiting were negatively associated with caregiver adherence to AQ administration and caregiver reporting of children\u0026rsquo;s adverse reactions to SMC medicines. Over half of the children did not receive a replacement dose from CDs who spit out or vomited most (or almost all) of the doses. Redosing was positively associated with caregiver educational attainment, caregiver knowledge of SMC, and directly supervised administration.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe direct CD-supervised administration of SPAQ can facilitate and strengthen community engagement strategies to enhance the appropriate administration and full ingestion of SMC medicines by the SMC delivery protocol.\u003c/p\u003e","manuscriptTitle":"The examination of factors impacting spitting or vomiting among children under five years of age during seasonal malaria chemoprevention: A quantitative study in Burkina Faso, Chad, Nigeria and Togo","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-16 16:08:17","doi":"10.21203/rs.3.rs-4582131/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2024-08-22T05:10:58+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-07-28T22:51:17+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-16T09:50:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-17T01:33:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Tropical Medicine and Health","date":"2024-06-14T08:40:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"tropical-medicine-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tmah","sideBox":"Learn more about [Tropical Medicine and Health](https://tropmedhealth.biomedcentral.com/)","snPcode":"41182","submissionUrl":"https://submission.springernature.com/new-submission/41182/3","title":"Tropical Medicine and Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dd832438-db48-4111-b955-407fd9285794","owner":[],"postedDate":"August 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T19:22:12+00:00","versionOfRecord":{"articleIdentity":"rs-4582131","link":"https://doi.org/10.1186/s41182-024-00642-z","journal":{"identity":"tropical-medicine-and-health","isVorOnly":false,"title":"Tropical Medicine and Health"},"publishedOn":"2024-11-12 15:57:29","publishedOnDateReadable":"November 12th, 2024"},"versionCreatedAt":"2024-08-16 16:08:17","video":"","vorDoi":"10.1186/s41182-024-00642-z","vorDoiUrl":"https://doi.org/10.1186/s41182-024-00642-z","workflowStages":[]},"version":"v1","identity":"rs-4582131","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4582131","identity":"rs-4582131","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}