Factors Affecting Adherence to National Malaria Treatment Guidelines in the Diagnosis, Treatment and Prevention of Malaria in Pregnancy among Healthcare Workers in Public Health Facilities in Jowhar District, Somalia

Introduction: Early diagnosis and effective treatment remain critical elements of a malaria control strategy in preventing mortality and reducing the incidence of severe malaria illness in Somalia. In Sub-Saharan African countries showed different levels of adherence to their national malaria guidelines for malaria treatment and prevention in pregnancy, while experiences from many countries indicated several challenges and constraints that may make the implementation of the guidelines difficult. Objective: The study aimed to assess factors affecting adherence to revised national malaria treatment guidelines in the diagnosis, treatment and prevention of malaria in pregnancy among health care workers in public health facilities in Jowhar District, Somalia. Methodology: A cross-sectional health facility-based study conducted in Jowhar district. A structured interview questionnaire was used for data collection from (n = 150). Healthcare workers selected from ten health facilities using proportionate stratified sampling technique and an observational checklist was used to assess patient’s medical prescriptions to review their conformity to the guideline and the availability of antimalarial, malaria diagnostic tests (mRDTs and microscopy) and job aids, such as the national malaria treatment guideline, clinical algorithm (flow chart), malaria rapid diagnosis tests mRDTs’ use of wall charts, and drug dose wall charts at the facilities. Data was analyzed through the application of descriptive statistical analysis that includes frequency, and percentages by using Statistical Package for Social Sciences (SPSS) Version 25. Re-sults: Healthcare workers interviewed were 89 (59.3%) aware of the existence


Introduction
Malaria constitutes a major public health problem in Somalia. Almost the whole country is considered endemic [1] [2]. Due to climatic and meteorological factors, malaria transmission varies between different parts of the country, ranging from unstable and epidemic-prone areas in the north and some central regions to moderate-to-high transmission in the southern regions. In areas with stable transmission, particularly along the Juba and Shabelle rivers, children under five years of age, pregnant women, and non-immune migrants carry most of the disease burden. All age groups are affected in unstable transmission settings, including epidemic-prone areas [1] [2] [3]. Two peaks of transmission coincide with the two wet seasons: April to June and October to November [4]. Plasmodium falciparum (pf) is the dominant species throughout Somalia, accounting for more than 90% of infections, while Anopheles arabiensis is the main vector responsible for malaria transmission throughout Somalia [4].
There is limited national data on the true burden of malaria in Somalia. The World Malaria Report 2020 estimated that there were around 759,000 cases and 1942 deaths in Somalia in 2019 [1]. The World Health Organization (WHO) currently recommends a package of interventions for controlling malaria during pregnancy in areas with stable (high) transmission of P. falciparum [1], which includes: the use of insecticide treated nets (ITNs), Intermittent preventive A. M. Mohamoud et al. treatment (IPT) and effective case management of malaria and anaemia [1] [5]. prompt diagnosis and effective treatment are a fundamental pillar of the essential malaria interventions strategy [6]. Therefore, effective implementation of the recommended strategy for malaria in pregnancy requires close collaboration between malaria control and reproductive health programmes at all levels, including policy development, planning, logistics, procurement, training and service delivery. Somalia has endorsed the World Health Organization's (WHO) global strategy for malaria control and has vowed to "Roll back malaria". The objective, as per the national strategic plan 2017-2020, is to diagnose and treat 90% of malaria cases in public and private health facilities and at the community level according to "Guidelines for the Diagnosis and Treatment of Malaria in Somalia, 2016" [7]. Providing timely treatment with effective ACT is the cornerstone of malaria control strategies in malaria-endemic countries, including Somalia. In Somalia, the National Programme for Malaria Control (NPMC) of the Federal Ministry of Health and Human Services updated its national malaria diagnosis and treatment guidelines (NMTG) in 2016, whereby; oral Quinine was recommended as first-line drug for the treatment of uncomplicated Malaria during the first trimester. Artemether-Lumefantrin ALu was recommended as the first-line drug during the second and third trimesters of pregnancy. Oral quinine is recommended as second-line drug for the treatment of uncomplicated malaria during all trimester. Parenteral Artesunate is recommended as the first-line drug for treating severe malaria during all trimester. Quinine Parenteral (if Parenteral Artesunate is unavailable) was recommended as the second-line drug for severe malaria during all trimesters [7]. To prevent malaria in Somalia, all pregnant women in moderate to high transmission areas should receive three doses of the recommended antimalarial drug sulfadoxine/pyrimethamine SP as an intermittent preventive treatment during pregnancy (IPTp) when scheduled for the ANC visit. The first dose should be administered as early as possible during the second trimester of gestation. Each SP dose should be given with a minimum interval of one month apart and up to delivery. To ensure compliance in the uptake of IPTp-SP doses by pregnant women attending antenatal care (ANC), the guidelines emphasized directly observed treatments (DOTs) by a qualified health worker [7] [8]. Currently, the recommended malaria treatments are summarized in the below box. Regarding Adherence Refers to the extent to which the health worker follows instructions provided by the revised malaria guideline in the diagnosis, treatment and prevention management of malaria in pregnancy. While adherence was categorized as strict, partial; Strict adherence to revised National Malaria Diagnosis and Treatment Guideline (NMTG) meant; diagnosis should be based on parasitological confirmation doing the malaria RDT or a blood smear with all suspected patient. If the result is positive, only recommended anti-malarial drugs are prescribed; if the result is negative no anti-malarial drug is given [7] [9] [10]. Partial adherence was when there was no parasitological confirmation of cases, the patient is treated on the basis of clinical diagnosis meanwhile the choice of antimalarial matched the national guideline for malaria treatment [10]. Non-adherence was when there was no parasitological confirmation of cases, and the choice of antimalarial medicines did not follow the national malaria treatment guidelines [9]. Effective implementation of the recommended strategy for malaria in pregnancy requires close collaboration between malaria control and reproductive health programs at all levels, including policy development, planning, logistics, procurement, training, and service delivery. In many developing countries, including Somalia, inappropriate, ineffective, and inefficient use of drugs commonly occurs at health facilities [11]. Lack of medicines, updated guidelines, laboratory facilities, and inadequate training influence prescribing practices [12]. Early diagnosis and effective treatment remain the key elements of a malaria control strategy in preventing mortality and reducing the incidence of severe illness. In Somalia, the main factors constraining proper diagnosis and treatment can be summarized as follows: Inadequate access to healthcare and low health service utilization, poor quality of diagnosis and treatment, inadequate human resources in the health sector, and inadequate financial resources [13].
Therefore this study is aimed to assess Factors Affecting Adherence to National Malaria Treatment Guidelines in Diagnosis, Treatment and Prevention of Malaria in pregnancy among Healthcare Workers in Public Health Facilities in Jowhar District, Somalia.

Methodology
A cross-sectional health facility-based study was conducted in Jowhar District during the period of the study January to April 2022, using a structured interview questionnaire. A total of (n = 150) health workers including: (physicians, nurses, Auxillary nurses, Midwives, Auxillary Midwives, lab-technicians, lab-technician assistants, pharmacy assistants and community health workers CHWs) who are regular working at selected public health facilities in the district, are involved in the management of malaria in pregnancy, and who were on duty on the date of interview. Health workers were selected by using proportionate stratified sampling technique. These facilities were sampled based on the criteria of being public health facilities and 50 of patient's medical prescription were also reviewed to check that the Antimalarial drug prescribing patterns were adequately labeled with the patient name, drug name, when the drug should be taken and in what quantity in to assess their conformity to the national malaria treatment guidelines in diagnosis, treatment and prevention of malaria in pregnancy. An observational checklist was used to check on the availability of antimalarial drug for treatment and prevention of malaria in pregnancy, malaria diagnostic tests (mRDTs and microscopy) and job aids, such as the national malaria treatment guideline, clinical algorithm (flow chart), malaria rapid diagnosis tests use of wall charts, and drug dose wall charts at the facilities.

Data Analysis
The data was collected, processed, and transferred to computer coding. A descriptive statistics were applied, which includes percentages and frequency distribution tables using the Statistical Package for Social Sciences (SPSS) version 25 computer program. A p-value of ≤0.05 regarded as a statistically significant.

Ethical Consideration
A permission was obtained from health authorities and from all health facilities in-charges, consents were taken verbally from participants. Confidentiality was insured.

Results
According to the data analysis results in Table 1, the majority of participants, 98 (65.3%), were between the ages of 25 and 34. 103 (68%) were women, 126 (84%) of them were married, and 91 (60.7%) of the participants possessed a university degree.
As shown in Table 2, according to the distribution of the data by job category, 61 (40.7%) qualified nurses were the majority, followed by 33 (22%) qualified midwives and 21 (14%) Auxillary nurses. 77 (51.3%) of the healthcare workers have experience ranging from 1 to 5 years. OPD, according to departments, had the highest number at 54 (36%).
As shown in Table 3, when asked whether the respondent was aware of NMG, the data indicates that all 8 (100%) physicians were aware. Apart from the physicians, 37 (60.7%) qualified nurses, 22 (66.7%) qualified midwives, 8 (38.1%) Auxillary nurses, 7 (53.8%) Auxillary midwives, 4 (57.1%) lab technicians, 1 (50%) lab technician assistants, and 2 (66.7%) pharmacy assistants were also aware of NMG. None of the HCWs reported knowing about it. There was no statistically significant difference in awareness or knowledge of NMG and type  of job category or Cadre of Health workers with (p = 0.098). A total of 46 (30.7%) received training, while 104 (69.3%) did not. In the analysis of data on special training in MIP, 6 (75.0%) physicians attended the special training, followed by 14 (41.4%) qualified midwives, 3 (41.9%) lab-technicians and 18 (29.5%) qualified nurses. There was a statistically significant difference in MIP training attendance, with a p-value of 0.022.
In response to whether healthcare workers adhering to national malaria guideline, 5 (62.5%) physicians were the most likely job category or Cadre of Health workers showed adherence to the protocol. 4 (33%) of the qualified midwives and 4 (23%) of the qualified nurses showed adherence to the protocol. There was a statistically significant difference (p-value = 0.017) between type of job category or Cadre of Health workers and adherence of the national malaria guideline. As shown in Table 4 depicts the reasons given by healthcare workers for not adhering to the current national malaria guidelines 2016 for malaria in pregnancy treatment and prevention. 3 (37.5%) of the physicians had a negative attitude toward malaria guidelines and 2 (25%) indicated inadequate awareness of malaria guidelines.
As shown in Table 4, most of the qualified nurses, 29 (47.5%), indicated inadequate awareness of malaria guidelines as the reason for non-adherence to the guideline. Other reasons were negative attitude toward malaria guidelines, inadequate supply of anti-malaria and diagnostic tests, and lack of regular supervision and monitoring.
Like nurses, most of the midwives, 16 (48.5%), did not adhere to the guidelines because of inadequate awareness of malaria guidelines. 6 (18.2%) of the midwifery nurses said the adherence to the guideline was hindered by a lack of revised copies of national guidelines at the facility. 5 (15.2%) pointed out that non-adherence to the guideline is a negative attitude toward malaria guidelines. Other reasons include inadequate supply of anti-malaria and diagnostic tests and diagnostic tests and a lack of regular supervision and monitoring.
Among Auxillary nurses, 18 (85.7%) believed inadequate awareness of malaria guidelines was a reason for non adherence to the guideline. Other reasons mentioned were 1 (4.8%) lack of in-service training, 1 (4.8%) revised copies of national malaria guideline available at the facility, 1 (4.8%) lack of regular supervision and monitoring, and 1 (4.8%) inadequate awareness of malaria guidelines.  11 (84.6%) of the Auxillary midwives indicated that inadequate awareness of malaria guidelines was the reason for non-adherence to the guideline. 1 (7.7%) indicated patient satisfaction with antimalarial drug compliance, and 1 (7.7%) indicated lack of national malaria guideline availability at facility. Furthermore, lab technician assistants 2 (100%), pharmacy assistants 3 (100%), and CHWs 2 (100%) unanimously indicated that inadequate awareness of malaria guidelines was a hindrance to non-adherence to the protocol.
Generally, 89 (59.3%) of the respondents' job categories indicated that the implementation was hindered by inadequate awareness of malaria guidelines. About 20 (13.3%) indicated a negative attitude toward malaria guidelines, while 11 (7.3%) pointed out revised copies of the national malaria guideline' availability at the facility. However, there was no statistically significant difference (p-value = 0.274) among the job categories regarding the reason for the non-adherence to the guideline. Table 5 shows the findings of an analysis of ten health facilities for the availability A. M. Mohamoud et al.  The study reveals a significant shortage of appropriate job aids, including the availability of national malaria treatment guideline at health facilities were 0 (0%). In addition, the results showed that 4 (40%) of the availability of Malaria educational, teaching aides or materials e.g. information and education & communication IEC materials for malaria prevention in pregnancy displayed as wall charts at health facilities. About 4 (40%) had Clinical algorithm (flow chart), and drug dose wall charts at all facilities, and 0 (0%) of RDT used wall charts at the health facilities.
LLINs/ITNs were not distributed or dispensed at ANC in these facilities during the day of visits. While 3 (30%) were only have referral system for pre-referral treatmentfor severe malaria before transfer to the inpatient ward. while all health facilities had in place malaria cases recording and reporting system.
As shown in Table 6 is based on 50 of patient's medical prescription to review medical prescriptions their conformity to the guideline antimalarial drug prescriptions were adequately labeled if they included the patient's name, the drug name, when the drug should be taken, and the dosage. The results indicated that only 17(34%) of the antimalarial prescriptions were appropriately labeled, while 33 (66%) were not. This increased to 24 (48.0%) at the posttest. The results indicated that only 17 (34%) of the antimalarial prescriptions were appropriately labeled, while 33 (66%) were not. 31 (62%) artemether plus lumefantrine ALU (Coartem) was the most prescribed antimalarial drug as a first-line treatment for uncomplicated malaria, followed by 9 (18.0%) Oral quinine. About 7 (14%) artemether injectable were prescribed for first-line treatment for uncomplicated malaria in some health facilities, which is contrary to national malaria guidelines. In addition, only 1 (2%) Parenteral quinine was prescribed as an antimalarial drug for the first-line treatment for severe malaria and 2 (4%) Parenteral artesunate was prescribed for severe malaria.
The pattern of antimalarial drug prescriptions reveals that 10 (20%) patients were prescribed antimalarial drugs in injectable form. In 9 (18%), antibiotics were combined with antimalarial drug, while in 31 (62%), iron and folic acid tablets were combined with antimalarial drug.

Discussion
Early diagnosis and effective treatment remain the critical elements of a malaria control strategy in preventing mortality and reducing the incidence of severe illness. In Somalia, low access to healthcare and low health service utilization, poor diagnosis and treatment quality, inadequacy of health human resources in the health sector, and inadequacy of financial resources are the main constraints to proper diagnosis, treatment and prevention of malaria. This study highlights factors affecting adherence to current national malaria treatment guidelines in diagnosis, treatment and prevention of malaria in pregnancy among health care workers in public health facilities in Jowhar District, Somalia. The study participants were 150 health workers, comprising of physicians, nurses, Auxillary nurses, midwives, Auxillary midwives, lab-technicians, lab-technician assistants, pharmacy assistants, and CHWs who regularly work in selected ten public health facilities. The demographic characteristics of the participants indicate that 98 (65.3%) were between the ages of 25 and 34. 103 (68.7%) of the participants were women. 126 (84%) of the participants were married. At the university level, 91 (60.7%) participants possessed a university degree. The data distribution by job category was such that qualified nurses made up 61 (40.7%), qualified midwives were 33 (22%), and Auxillary nurses were 21 (14%). 77 (51.3%) of the healthcare workers have experience ranging from 1 to 5 years. OPD, according to departments, was the highest at 54 (36.0%).
A lack of national malaria guidelines, especially malaria in pregnancy A. M. Mohamoud et al. awareness, is revealed in the study as one of the significant factors, specifically among qualified nurses, of whom more than two-thirds did not know. The study results have shown a huge gap in awareness among Auxillary nurses, Auxillary midwives, lab-technicians, lab-technician Assistants and pharmacy assistants. A significant proportion of the healthcare workers indicated a lack of special training. The study reveals that implementation varies significantly (p-value = 0.017) as per the job category. Physicians 5 (62.5%) were the most likely of all Cadre of Health workers showed adherence to the guideline, with 11 (33.3%) qualified midwives and 14 (23%) qualified nurses showed adherence to the protocol respectively.
This study shows that implementation among 3 (37.5%) physicians was hampered by a negative attitude toward malaria guidelines and 2 (25%) because of inadequate awareness of malaria guidelines. 29 (47.5%) of the qualified nurses indicated that inadequate awareness of malaria guidelines was the reason for non-implementation. Other reasons were a negative attitude toward malaria guidelines, inadequate supply of anti-malaria and diagnostic tests and diagnostic tests, and a lack of regular supervision and monitoring.
Inadequate awareness of national malaria guidelines by 16 (48.5%) of midwives hindered its adherence. Furthermore, the data shows that midwifery nurses said the implementation was hindered by a lack of revised copies of national guidelines at the facility. Other reasons indicated include the negative attitude toward malaria guidelines, inadequate supply of anti-malaria and diagnostic tests and diagnostic tests, and lack of regular supervision and monitoring.
Additionally, inadequate awareness of malaria guidelines among auxiliary nurses 18 (85.7%) was a reason for no implementation. 11 (84.6%) assistant midwives indicated that inadequate awareness of malaria guidelines was the reason for non-implementation. They also indicated patient satisfaction with antimalarial drug compliance and revised copies of national malaria guideline availability at the facility. Furthermore, lab-technician assistants 2 (100%), pharmacy assistants 3 (100%), and CHWs 2 (100%) unanimously indicated that inadequate awareness of national malaria guideline was a hindrance to implementation.
About 89 (59.3%) of Cadre of Health workers indicated that the implementation was hindered by inadequate awareness of malaria guidelines, 20 (13.3%) as a result of a negative attitude toward malaria guidelines, and 11 (7.3%) were revised copies of national guidelines available at the facility. However, there was no statistically significant difference (p-value = 0.274) among the Cadre of Health workers regarding the reason for the non-adherence to the protocol.
The study reveals a significant shortage of appropriate job aids, including the national malaria guideline, clinical algorithms, and malaria educational materials for conducting IEC sessions displayed on wall charts, drug dose wall charts at all facilities, and mRDTs use of wall charts. Furthermore, the study reveals a A. M. Mohamoud et al. lack of distribution of LLINs/ITNs to pregnant women at ANC for malaria prevention. A few of the HFs provide referral system for pre-referral treatment for severe malaria before transferring patients to the inpatient ward. The data shows a shortage of quinine drugs, crucial for first-trimester pregnant women in health facilities while all health facilities had in place malaria cases recording and reporting system. Oral quinine were available in 4 (40%) HFs and parenteral quinine were available in 2 (20%) HFs. There was a scarcity of malaria chemoprevention in pregnancy, given that the sulfadoxine/pyrimethamine (SP) fansidar table was available in only 4 (40%) of the HFs. There is limited access and utilization of parasitological diagnostics (mRDTs and microscopy) at the facility as the study revealed that only 2 (20%) of the HFs had microscopy and 9 (90%) had mRDT.
The study reveals inappropriate prescription practices and inadequate compliance with national malaria guidelines. The results indicated that only 17 (34%) of the antimalarial prescriptions were appropriately labeled. 31 (62%) of public health facilities prescribed the nationally recommended first-line therapy for uncomplicated malaria in pregnant women in the second and third trimesters of artemether plus lumefantrine ALU (Coartem) that complies with the national first-line treatment guidelines.
The use of artemether injectable further evinces inappropriate practices for first-line treatment for uncomplicated malaria for some health workers at health facilities, contrary to national malaria guidelines. In addition, while only 1 (2%) Parenteral quinine was prescribed as an antimalarial drug for the first-line treatment for severe malaria, 2 (4%) Parenteral artesunate was prescribed for severe malaria. The pattern of antimalarial drug prescriptions reveals that 10 (20%) patients were prescribed antimalarial drugs in injectable form. In 9 (18.0%), antibiotics were combined with antimalarials, while in 31 (62%), iron and folic acid tablets were combined with antimalarials.

Conclusion
In conclusion, the study showed that adherence to the national malaria guidelines for Malaria diagnosis, treatment and prevention in pregnancy among health care workers are associated with inadequate awareness of the revised malaria guidelines, inadequate supply of diagnostic tests (mRDTs and microscopy) and lack of access to revised national guidelines for malaria diagnosis and treatment 2016, a lack of regular supervision and monitoring and lack of in-service training respectively. Therefore, effective implementation of the recommended strategy for malaria in pregnancy requires close collaboration between national malaria control programme and reproductive health programmes at all levels, including policy development, planning, logistics, procurement, training and service delivery. The national malaria control program should intensify efforts to strengthen the readiness of the public health facilities in the district to provide malaria in pregnancy case diagnosis, treatment, and prevention and improve the availability of drugs and diagnostic kits. The national malaria control programme should also provide appropriate job aids and training for health workers, and constant supervision should be done to ensure that the national malaria guidelines for malaria diagnosis, treatment, and prevention in pregnancy among healthcare workers continue to be effectively implemented in at all levels of health care service delivery points across the country.