title: Facilitators and Barriers to Uptake of an Extended Seasonal Malaria Chemoprevention Programme in Ghana: A Qualitative Study of Caregivers and Community Health Workers.
abstract: BACKGROUND
  Seasonal Malaria Chemoprevention (SMC) is currently recommended for children under five in areas where malaria transmission is highly seasonal. We explored children's caregivers' and community health workers' (CHWs) responses to an extended 5-month SMC programme.
  
  
  METHODS
  Thirteen in-depth interviews and eight focus group discussions explored optimal and suboptimal 'uptake' of SMC to examine facilitators and barriers to caregivers' uptake.
  
  
  RESULTS
  There did not appear to be major differences between caregivers of children with optimal and sub-optimal SMC uptake in terms of their knowledge of malaria, their perceptions of the effect of SMC on a child's health, nor their understanding of chemoprevention. Caregivers experienced difficulty in prioritising SMC for well children, perceiving medication being for treatment rather than prevention. Prior to the study, caregivers had become accustomed to rapid diagnostic testing (RDT) for malaria, and therefore blood testing for malaria during the baseline survey at the start of the SMC programme may have positively influenced uptake. Facilitators of uptake included caregivers' trust in and respect for administrators of SMC (including CHWs), access to medication and supportive (family) networks. Barriers to uptake related to poor communication of timings of community gatherings, travel distances, absence during SMC home deliveries, and limited demand for SMC due to lack of previous experience. Future delivery of SMC by trained CHWs would be acceptable to caregivers.
  
  
  CONCLUSIONS
  A combination of caregivers' physical access to SMC medication, the drug regimen, trust in the medical profession and perceived norms around malaria prevention all likely influenced caregivers' level of uptake. SMC programmes need to consider: 1) developing supportive, accessible and flexible modes of drug administration including home delivery and village community kiosks; 2) improving demand for preventive medication including the harnessing of learnt trust; and 3) developing community-based networks for users to support optimal uptake of SMC.
authors.affiliation: School of Public Health, Kwame Nkrumah University of Science and Technology, KNUST, Kumasi, Ghana.
authors.forename: Gifty D
authors.initials: GD
authors.lastname: Antwi
authors.affiliation: Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.
authors.forename: Laura A
authors.identifier: http://orcid.org/0000-0001-6172-9071
authors.initials: LA
authors.lastname: Bates
authors.affiliation: Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.
authors.forename: Rebecca
authors.initials: R
authors.lastname: King
authors.affiliation: Centre for Global Health Research, KNUST, Kumasi, Ghana.
authors.forename: Princess R
authors.initials: PR
authors.lastname: Mahama
authors.affiliation: School of Public Health, Kwame Nkrumah University of Science and Technology, KNUST, Kumasi, Ghana.
authors.forename: Harry
authors.initials: H
authors.lastname: Tagbor
authors.affiliation: Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Matt
authors.initials: M
authors.lastname: Cairns
authors.affiliation: Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.
authors.forename: James N
authors.initials: JN
authors.lastname: Newell
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D017028:Caregivers; D019090:Case Management; D018890:Chemoprevention / Q000379:methods*; D002675:Child, Preschool; D003150:Community Health Workers; D003955:Diagnostic Tests, Routine / Q000379:methods; D005260:Female; D017144:Focus Groups; D005869:Ghana / Q000453:epidemiology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008288:Malaria / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D008297:Male; D010342:Patient Acceptance of Health Care; D015995:Prevalence; D012621:Seasons
chemical_list: D000962:Antimalarials