“If they take it without knowing, they will default…”: perceptions of targeted information transfer to promote adherence to intermittent preventive treatment with dihydroartemisinin-piperaquine for the prevention of malaria in pregnancy in western Kenya
Authors: Hoyt Jenna , Barsosio Hellen C. , Odero Isdorah A. , Omondi Benson , Achieng Florence , Kariuki Simon , Hill Jenny , Webster Jayne 
Published: November 2024

Abstract
Background
Increasing resistance to sulfadoxine-pyrimethamine (SP) threatens the effectiveness of intermittent preventive treatment (IPTp) to prevent malaria in pregnancy. Dihydroartemisinin-piperaquine (DP) is the most promising candidate to emerge from clinical trials, but requires a multi-day regimen. Despite being a single-dose regimen, coverage of IPTp-SP remains low, fuelling concerns about adherence to multi-day drug options. An implementation feasibility trial in routine antenatal care settings in western Kenya demonstrated that adherence to the multi-day DP regimen was improved when IPTp-DP was delivered with a targeted information transfer intervention that comprised healthcare provider training and communication tools to support delivery and uptake. This study explored healthcare provider and pregnant women perspectives to understand (1) how the targeted information transfer improved adherence to IPTp-DP and (2) if improved adherence to IPTp-DP influenced provider perceptions towards implementation feasibility of multi-day drug regimens for IPTp.

Methods
In-depth interviews were conducted with 64 healthcare providers and 64 pregnant women, selected using a convenience sampling approach from across the three trial arms: IPTp-DP+ (with intervention), IPTp-DP, and current standard of care IPTp-SP. Transcripts from healthcare providers and pregnant women were coded in Nvivo-12 using separate a priori frameworks that included components of the consolidated framework for implementation research. Thematic analysis was used to understand how the targeted information transfer affected adherence to IPTp-DP and how concerns about adherence might influence provider perceptions towards multi-day drug regimens for IPTp.

Results
Adherence to IPTp-DP doses taken at home was compromised when women experienced unpleasant side effects. Pregnant women valued being given information about IPTp-DP, including potential side effects and how to manage them. Among providers in the IPTp-DP + arm, confidence in advising women on how to manage side effects increased, and they believed this guidance improved adherence. When concerns about adherence were reduced, providers in the IPTp-DP + arm were positive about implementation feasibility, whereas providers in the IPTp-SP arm remained focused on the dosing complexities and were less convinced of the feasibility of implementing IPTp-DP.

Conclusions
Healthcare provider confidence in advising women on how to minimize side effects was boosted through targeted information transfer, which was perceived to improve adherence to IPTp-DP. Policy makers are encouraged to consider supportive interventions that enhance provider confidence around adherence should they shift to multi-day drug regimens for IPTp.