Strengthening Service Delivery for Malaria in Pregnancy: An mHealth Pilot Intervention in West Nile, Uganda

“Text messaging, in combination with other capacity building tools and approaches, can be effective in achieving health worker behaviour change in resource-poor settings.”

This research brief describes a pilot intervention in Uganda, developed by Malaria Consortium, which sought to improve health worker knowledge of intermittent preventive treatment for malaria in pregnancy (IPTp) and thereby contribute towards minimising missed opportunities for the provision of IPTp during antenatal care (ANC). The pilot involved the use of text messaging, in combination with other capacity building tools and approaches, and evaluated whether this approach is a feasible and acceptable intervention which has the potential to improve health worker performance.

Pregnant women are more susceptible to malaria than non-pregnant women. They are more likely to get severely ill and die from the disease. Malaria infection during pregnancy is also harmful to the baby. It increases the risk of miscarriage, as well as pre-term delivery and low birth weight. IPTp is a key prevention and control mechanism, which entails administration of a curative dose of an antimalarial drug to all pregnant women, regardless of whether or not the recipient is infected with malaria. It is typically delivered to pregnant women as part of routine ANC visits. The World Health Organization (WHO) currently recommends administration of IPTp at each ANC visit, except during the first trimester and provided that doses are given one month apart. While coverage of ANC is high in most African countries, uptake of IPTp has remained comparatively low.

To explore the reasons why women who attend ANC in Uganda might not receive or take IPTp, Malaria Consortium conducted formative research in two regions of Uganda.  The findings showed that the reasons for the majority of missed opportunities for the provision of IPTp are due to challenges relating to the supply side, i.e. the health service provider. The study found that health workers’ knowledge of the IPTp provision guidelines was inadequate and that health workers frequently failed to encourage women who were initially reluctant to take IPTp.

Based on these findings, Malaria Consortium developed a pilot intervention which involved providing classroom training to health workers on malaria in pregnancy and following up the training with text messages reinforcing the training content, with a focus on IPTp provision according to the WHO recommendation. The pilot study was set up so that one group received malaria in pregnancy training followed by text messages reinforcing the training content, while a control group of health workers only received malaria in pregnancy training. A total of 24 text messages were sent to health workers in the intervention group. Text messaging started in June 2015, with one message sent every weekday over a period of five weeks.  The study used a convergent mixed-methods evaluation design, comparing intervention and control with regard to three evaluation foci: health worker knowledge, IPTp coverage, and feasibility and acceptability.

In brief, the results showed that combining classroom training and text messaging was a feasible approach which was very well accepted by health workers and district officials. There were also strong indications that the approach resulted in better knowledge of IPTp and increased coverage of IPTp. The research brief states that the results of the study support those from two similar studies conducted in two other low income and middle income countries - China and Kenya. It concludes “that text messaging, in combination with other capacity building tools and approaches, can be effective in achieving health worker behaviour change in resource-poor settings. The key strengths of the approach are that text messages do not disrupt service provision and can reach large numbers of health workers. The intervention is well received by health workers and district health staff. It is inexpensive and simple to implement, especially where suitable SMS platforms already exist. If applied to other training areas and at scale, a strategic and coordinated approach will be needed in order to ensure consistent messaging and maintain health workers’ positive attitude towards the messages.”