The impacts of COVID-19 and its policy response on access and utilization of maternal and child health services in Tanzania: A mixed methods study.

The SARS-Cov-2 virus (COVID-19) has had a global social and economic impact. Despite the growing evidence, its effects on access and delivery of maternal and child health services in low-income countries are still unclear. This cross-sectional case study was conducted in Mjini Magharibi, Chake Chake, and Ilala districts in Tanzania to help fill this gap. The study combined qualitative and quantitative data collection methods, providing an account of the evolution of the pandemic and the associated control measures in Tanzania. We drew from 34 in-depth interviews, 60 semi-structured interviews, and 14 focus group discussions with key informants, patients, and health providers, and complemented the findings with a review of pandemic reports and health facility records. We followed the Standards for Reporting Qualitative Research (SRQR) to provide an account of the findings. Our account of the pandemic shows that there was at times an inconsistent policy response in Tanzania, with diverse control measures adopted at various stages of the epidemic. There was a perception that COVID-19 services were prioritized during the epidemic at the expense of regular ones. There were reports of reorganisation of health facilities, reallocation of staff, rescheduled antenatal and postnatal clinics, and reduced time for health education and child monitoring. Scarcity of essential commodities was reported, such as vaccines, equipment, and medical supplies. Such perceptions were in part supported by the routine utilization evidence in the three districts, showing a lower uptake of antenatal, postnatal, family planning, and immunization services, as well as fewer institutional deliveries. Our findings suggest that, although the policy response in Tanzania was erratic, it was rather fear of the pandemic itself and diversion of resources to control COVID-19, that may have contributed most to lower the utilization of mother and child services. For future emergencies, it will be crucial to ensure the policy response does not weaken the population's demand for services.

Narratives of veterinary drug use in northern Tanzania and consequences for drug stewardship strategies in low-income and middle-income countries.

INTRODUCTION: Awareness-raising campaigns play a central role in efforts to combat drug resistance. These campaigns assume that knowledge deficits drive poor practices that increase resistance. Therefore, increasing awareness will promote prudent practices and reduce resistance. However, most awareness campaigns have been developed and evaluated in high-income and public health settings. Consequently, it is not clear whether these campaigns are effective in low-income and middle-income countries and/or within animal health settings. METHODS: Focus group discussions and in-depth interviews were used to collect narratives of veterinary drug use among Maasai pastoralists (n=70), animal health professionals (n=10) and veterinary drug sellers (n=5). Thematic analysis was used to identify recurring themes across narratives and groups. RESULTS: Narratives of Maasai and animal health professionals indicated that Maasai treated their livestock with limited input from the professional sector and that non-prudent treatment practices were observed (eg, using antimicrobials as 'energizers'). Professionals linked these practices to knowledge and attitudinal deficits among the Maasai, while Maasai narratives highlighted the importance of climatic uncertainties and cultural beliefs surrounding veterinary care. CONCLUSION: Narratives of veterinary drug use from animal health professionals are consistent with the knowledge deficit assumption guiding awareness-raising efforts. In contrast, Maasai narratives highlight how animal health practices are patterned by cultural norms interacting with factors largely outside of Maasai control, including a constrained professional veterinary sector. If these cultural and structural contexts remain unconsidered in awareness-raising strategies, current campaigns are unlikely to motivate practices necessary to limit drug resistance, especially within low-income and middle-income settings.

On the cost-effectiveness of insecticide-treated wall liner and indoor residual spraying as additions to insecticide treated bed nets to prevent malaria: findings from cluster randomized trials in Tanzania.

BACKGROUND: Despite widespread use of long-lasting insecticidal nets (LLINs) and other tools, malaria caused 409,000 deaths worldwide in 2019. While indoor residual spraying (IRS) is an effective supplement, IRS is moderately expensive and logistically challenging. In endemic areas, IRS requires yearly application just before the main rainy season and potential interim reapplications. A new technology, insecticide-treated wall liner (ITWL), might overcome these challenges. METHODS: We conducted a 44-cluster two-arm randomized controlled trial in Muheza, Tanzania from 2015 to 2016 to evaluate the cost and efficacy of a non-pyrethroid ITWL to supplement LLINs, analyzing operational changes over three installation phases. The estimated efficacy (with 95% confidence intervals) of IRS as a supplement to LLINs came mainly from a published randomized trial in Muleba, Tanzania. We obtained financial costs of IRS from published reports and conducted a household survey of a similar IRS program near Muleba to determine household costs. The costs of ITWL were amortized over its 4-year expected lifetime and converted to 2019 US dollars using Tanzania's GDP deflator and market exchange rates. RESULTS: Operational improvements from phases 1 to 3 raised ITWL coverage from 35.1 to 67.1% of initially targeted households while reducing economic cost from $34.18 to $30.56 per person covered. However, 90 days after installing ITWL in 5666 households, the randomized trial was terminated prematurely because cone bioassay tests showed that ITWL no longer killed mosquitoes and therefore could not prevent malaria. The ITWL cost $10.11 per person per year compared to $5.69 for IRS. With an efficacy of 57% (3-81%), IRS averted 1162 (61-1651) disability-adjusted life years (DALYs) per 100,000 population yearly. Its incremental cost-effectiveness ratio (ICER) per DALY averted was $490 (45% of Tanzania's per capita gross national income). CONCLUSIONS: These findings provide design specifications for future ITWL development and implementation. It would need to be efficacious and more effective and/or less costly than IRS, so more persons could be protected with a given budget. The durability of a previous ITWL, progress in non-pyrethroid tools, economies of scale and competition (as occurred with LLINs), strengthened community engagement, and more efficient installation and management procedures all offer promise of achieving these goals. Therefore, ITWLs merit ongoing study. FIRST POSTED: 2015 ( NCT02533336 ).

Knowing Is Not Enough: A Mixed-Methods Study of Antimicrobial Resistance Knowledge, Attitudes, and Practises Among Maasai Pastoralists.

Global, national, and local efforts to limit antimicrobial resistance (AMR) often stress the importance of raising awareness among users, sellers, and prescribers of antimicrobial drugs. This emphasis is founded upon two assumptions. First, awareness is limited, particularly concerning the links between antimicrobial use (AMU) and AMR. Second, "filling the awareness gaps" will motivate practises that will limit AMR. The first assumption is supported by knowledge, attitudes, and practises (KAP) surveys but these same studies provide mixed support for the second, with several studies finding that knowledge and attitudes are not correlated with related practises. This disconnect may arise as these surveys typically do not collect data on the cultural or historical contexts that pattern AMU. To explore how these contexts impact KAP related to AMU and AMR, we use a mixed-methods approach to examine veterinary practises among Maasai pastoralists in Tanzania. We combine a quantitative KAP survey (N = 195 households) with extensive qualitative data from focus group discussions (N = 55 participants). Results document limited awareness of AMR but also find that knowledge and attitudes are not correlated with practise. Thematic analysis of qualitative data pointed to three reasons behind this disconnect, including (1) Maasai self-perceptions as veterinary experts, (2) the central role of livestock in Maasai culture, and (3) the use of ethnoveterinary knowledge in animal health treatment. We argue that mixed-method approaches will be critical to developing the targeted awareness campaigns needed to limit the emergence and transmission of AMR.

"We are doctors": Drivers of animal health practices among Maasai pastoralists and implications for antimicrobial use and antimicrobial resistance.

Animal health service providers can play an important role in limiting drug resistance by promoting responsible and prudent use of veterinary drugs. Recognizing this potential, international agencies and governments have called for these providers to receive drug stewardship training, particularly providers in low- and middle-income countries where top-down regulations (e.g., national regulation of veterinary prescriptions) are largely unfeasible. The success of these stewardship trainings to promote responsible and prudent use will depend on many factors, including understanding how livestock-keeping communities currently interact with animal health service providers. Here, we use a mixed methods approach to identify and understand animal health seeking practices among Maasai pastoralists in Tanzania. Combining qualitative interviews (N = 31) and structured surveys (N = 195), we show the majority of Maasai respondents (≈80 %) do not frequently consult animal health service providers with most relying on advice from family and friends. Logistic regression models of health seeking practices find that increasing age, education, observance of treatment failure, and herd disease burdens are associated with greater odds of seeking out health services. Quantitative results were supported by data from focus group discussions and in-depth interviews that showed Maasai view animal health service providers as measures of last resort, whose input is largely sought after self-treatment with veterinary drugs fail. We argue patterns of animal health seeking among the Maasai are partially the consequence of their high confidence in their own abilities in livestock disease and treatment and generally low confidence in the skills of animal health service providers. We link this high sense of self-efficacy to the culturally engrained process by which Maasai develop mastery in animal health and how the roles and norms in Maasai culture surrounding animal health influence Maasai perceptions of animal health professionals. Our results highlight the need for more research to understand Maasai perceptions of animal health service providers as well as the knowledge, attitudes, and practices of these providers. Finally, our study emphasizes that the success of drug stewardship trainings will require efforts to first understand the cultural and historical contexts driving health seeking practices that impact perceptions of animal health service providers and animal health practices more generally.

Towards a bottom-up understanding of antimicrobial use and resistance on the farm: A knowledge, attitudes, and practices survey across livestock systems in five African countries.

The nutritional and economic potentials of livestock systems are compromised by the emergence and spread of antimicrobial resistance. A major driver of resistance is the misuse and abuse of antimicrobial drugs. The likelihood of misuse may be elevated in low- and middle-income countries where limited professional veterinary services and inadequately controlled access to drugs are assumed to promote non-prudent practices (e.g., self-administration of drugs). The extent of these practices, as well as the knowledge and attitudes motivating them, are largely unknown within most agricultural communities in low- and middle-income countries. The main objective of this study was to document dimensions of knowledge, attitudes and practices related to antimicrobial use and antimicrobial resistance in livestock systems and identify the livelihood factors associated with these dimensions. A mixed-methods ethnographic approach was used to survey households keeping layers in Ghana (N = 110) and Kenya (N = 76), pastoralists keeping cattle, sheep, and goats in Tanzania (N = 195), and broiler farmers in Zambia (N = 198), and Zimbabwe (N = 298). Across countries, we find that it is individuals who live or work at the farm who draw upon their knowledge and experiences to make decisions regarding antimicrobial use and related practices. Input from animal health professionals is rare and antimicrobials are sourced at local, privately owned agrovet drug shops. We also find that knowledge, attitudes, and particularly practices significantly varied across countries, with poultry farmers holding more knowledge, desirable attitudes, and prudent practices compared to pastoralist households. Multivariate models showed that variation in knowledge, attitudes and practices is related to several factors, including gender, disease dynamics on the farm, and source of animal health information. Study results emphasize that interventions to limit antimicrobial resistance should be founded upon a bottom-up understanding of antimicrobial use at the farm-level given limited input from animal health professionals and under-resourced regulatory capacities within most low- and middle-income countries. Establishing this bottom-up understanding across cultures and production systems will inform the development and implementation of the behavioral change interventions to combat antimicrobial resistance globally.

Multiple-level stakeholder engagement in malaria clinical trials: addressing the challenges of conducting clinical research in resource-limited settings.

BACKGROUND: Multinational clinical trials are logistically complex and require close coordination between various stakeholders. They must comply with global clinical standards and are accountable to multiple regulatory and ethical bodies. In resource-limited settings, it is challenging to understand how to apply global clinical standards to international, national, and local factors in clinical trials, making multiple-level stakeholder engagement an important element in the successful conduct of these clinical trials. MAIN BODY: During the planning and implementation of a large multinational clinical trial for intermittent preventive treatment of malaria in pregnancy in resource-limited areas of sub-Saharan Africa, we encountered numerous challenges, which required implementation of a range of engagement measures to ensure compliance with global clinical and regulatory standards. These challenges included coordination with ongoing global malaria efforts, heterogeneity in national regulatory structures, sub-optimal healthcare infrastructure, local practices and beliefs, and perspectives that view healthcare providers with undue trust or suspicion. In addition to engagement with international bodies, such as the World Health Organization, the Malaria in Pregnancy Consortium, the Steve Biko Centre for Bioethics, and the London School of Hygiene and Tropical Medicine, in order to address the challenges just described, Pfizer Inc. and Medicines for Malaria Venture (the "Sponsoring Entities" for these studies) and investigators liaised with national- and district-level stakeholders such as health ministers and regional/local community health workers. Community engagement measures undertaken by investigators included local meetings with community leaders to explain the research aims and answer questions and concerns voiced by the community. The investigators also engaged with family members of prospective trial participants in order to be sensitive to local practices and beliefs. CONCLUSION: Engagement with key stakeholders at international and national levels enabled the Sponsoring Entities to address challenges by aligning the study design with the requirements of health and regulatory agencies and to understand and address healthcare infrastructure needs prior to trial initiation. Local stakeholder engagement, including community members, study participants, and family enabled the investigators to address challenges by ensuring that study design and conduct were adapted to local considerations and ensuring accurate information about the study aims was shared with the public. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT01103063 . Registered on 7 April 2010.

Contributing to the debate on categorising shared sanitation facilities as 'unimproved': An account based on field researchers' observations and householders' opinions in three regions, Tanzania.

BACKGROUND: Health risks associated with poor sanitation behaviours continue to be reported mostly from low-income countries (LICs). Reports show that various factors limit many people from accessing and using improved latrines, forcing some to opt for sharing latrines with neighbours, others practicing open defecation. Meanwhile, debate prevails on whether shared latrines should be categorised as unimproved according to WHO/UNICEF-JMP criteria. We contribute to this debate based on results from a study undertaken in three regions, Tanzania. MATERIALS AND METHODS: Data were collected through observations in 1,751 households with latrines, coupled with collection of opinions from heads of such households regarding the latrine-sharing practices. Bivariate and multivariate logistic regression analyses were performed to assess associations between the outcome and possible predictor variables. RESULTS: Of all 1,751 latrines, 14.6% were shared. Among the shared latrines, 74.2% were found being generally clean as compared to 69.2% of the non-shared ones. Comparing the shared and non-shared latrines, the non-shared latrines were significantly less likely to be found with floors built with permanent materials (OR = 0.73, 95% CI: 0.55, 0.98); washable floors (OR = 0.69; 95% CI: 0.51, 0.93); and lockable doors (OR = 0.73; 95% CI: 0.56, 0.95). Shared latrines were less likely to have floors with faecal matter, functional handwashing facilities (HWFs), HWFs with running water, and roofs; albeit the differences in all these scenarios were not statistically significant. Respondents expressed desire for improved latrines, but also did not find it wrong to share latrines if cleanliness was maintained. CONCLUSION: Having an 'improved' latrine remains important as JMP recommends, but based on our study findings, we argue that possessing a non-shared latrine neither guarantees safety to its users nor its categorisation as 'improved'. Instead, the state of the latrine, the construction technology used and the behaviours of the users may be more important.

Using local language syndromic terminology in participatory epidemiology: Lessons for One Health practitioners among the Maasai of Ngorongoro, Tanzania.

Pastoralists and agro-pastoralists often occupy remote and hostile environments, which lack infrastructure and capacity in human and veterinary healthcare and disease surveillance systems. Participatory epidemiology (PE) and Participatory Disease Surveillance (PDS) are particularly useful in situations of resource scarcity, where conventional diagnostics and surveillance data of disease prevalence may be intermittent or limited. Livestock keepers, when participating in PE studies about health issues, commonly use their local language terms, which are often syndromic and descriptive in nature. Practitioners of PE recommend confirmation of their findings with triangulation including biomedical diagnostic techniques. However, the latter is not practiced in all studies, usually due to time, financial or logistical constraints. A cross sectional study was undertaken with the Maasai of Ngorongoro District, Tanzania. It aimed to identify the terms used to describe the infectious diseases of livestock and humans with the greatest perceived impact on livelihoods. Furthermore, it aimed to characterise the usefulness and limitations of relying on local terminology when conducting PE studies in which diagnoses were not confirmed. Semi-structured interviews were held with 23 small groups, totalling 117 community members within five villages across the district. In addition, informal discussions and field observations were conducted with village elders, district veterinary and medical officers, meat inspectors and livestock field officers. For human conditions including zoonoses, several biomedical terms are now part of the common language. Conversely, livestock conditions are described using local Maasai terms, usually associated with the signs observed by the livestock keeper. Several of these descriptive, syndromic terms are used inconsistently and showed temporal and spatial variations. This study highlights the complexity and ambiguity which may exist in local terminology when used in PE studies. It emphases the need for further analysis of such findings, including laboratory diagnosis where possible to improve specificity before incorporating them into PDS or disease control interventions.

Exploring local knowledge and perceptions on zoonoses among pastoralists in northern and eastern Tanzania.

BACKGROUND: Zoonoses account for the most commonly reported emerging and re-emerging infectious diseases in Sub-Saharan Africa. However, there is limited knowledge on how pastoral communities perceive zoonoses in relation to their livelihoods, culture and their wider ecology. This study was carried out to explore local knowledge and perceptions on zoonoses among pastoralists in Tanzania. METHODOLOGY AND PRINCIPAL FINDINGS: This study involved pastoralists in Ngorongoro district in northern Tanzania and Kibaha and Bagamoyo districts in eastern Tanzania. Qualitative methods of focus group discussions, participatory epidemiology and interviews were used. A total of 223 people were involved in the study. Among the pastoralists, there was no specific term in their local language that describes zoonosis. Pastoralists from northern Tanzania possessed a higher understanding on the existence of a number of zoonoses than their eastern districts' counterparts. Understanding of zoonoses could be categorized into two broad groups: a local syndromic framework, whereby specific symptoms of a particular illness in humans concurred with symptoms in animals, and the biomedical framework, where a case definition is supported by diagnostic tests. Some pastoralists understand the possibility of some infections that could cross over to humans from animals but harm from these are generally tolerated and are not considered as threats. A number of social and cultural practices aimed at maintaining specific cultural functions including social cohesion and rites of passage involve animal products, which present zoonotic risk. CONCLUSIONS: These findings show how zoonoses are locally understood, and how epidemiology and biomedicine are shaping pastoralists perceptions to zoonoses. Evidence is needed to understand better the true burden and impact of zoonoses in these communities. More studies are needed that seek to clarify the common understanding of zoonoses that could be used to guide effective and locally relevant interventions. Such studies should consider in their approaches the pastoralists' wider social, cultural and economic set up.

The effectiveness of non-pyrethroid insecticide-treated durable wall lining to control malaria in rural Tanzania: study protocol for a two-armed cluster randomized trial.

BACKGROUND: Despite considerable reductions in malaria achieved by scaling-up long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), maintaining sustained community protection remains operationally challenging. Increasing insecticide resistance also threatens to jeopardize the future of both strategies. Non-pyrethroid insecticide-treated wall lining (ITWL) may represent an alternate or complementary control method and a potential tool to manage insecticide resistance. To date no study has demonstrated whether ITWL can reduce malaria transmission nor provide additional protection beyond the current best practice of universal coverage (UC) of LLINs and prompt case management. METHODS/DESIGN: A two-arm cluster randomized controlled trial will be conducted in rural Tanzania to assess whether non-pyrethroid ITWL and UC of LLINs provide added protection against malaria infection in children, compared to UC of LLINs alone. Stratified randomization based on malaria prevalence will be used to select 22 village clusters per arm. All 44 clusters will receive LLINs and half will also have ITWL installed on interior house walls. Study children, aged 6 months to 11 years old, will be enrolled from each cluster and followed monthly to estimate cumulative incidence of malaria parasitaemia (primary endpoint), time to first malaria episode and prevalence of anaemia before and after intervention. Entomological inoculation rate will be estimated using indoor CDC light traps and outdoor tent traps followed by detection of Anopheles gambiae species, sporozoite infection, insecticide resistance and blood meal source. ITWL bioefficacy and durability will be monitored using WHO cone bioassays and household surveys, respectively. Social and cultural factors influencing community and household ITWL acceptability will be explored through focus-group discussions and in-depth interviews. Cost-effectiveness, compared between study arms, will be estimated per malaria case averted. DISCUSSION: This protocol describes the large-scale evaluation of a novel vector control product, designed to overcome some of the known limitations of existing methods. If ITWL is proven to be effective and durable under field conditions, it may warrant consideration for programmatic implementation, particularly in areas with long transmission seasons and where pyrethroid-resistant vectors predominate. Trial findings will provide crucial information for policy makers in Tanzania and other malaria-endemic countries to guide resource allocations for future control efforts. TRIAL REGISTRATION: NCT02533336 registered on 13 July 2014.

"Every drug goes to treat its own disease " - a qualitative study of perceptions and experiences of taking anti-retrovirals concomitantly with anti-malarials among those affected by HIV and malaria in Tanzania.

BACKGROUND: Little is known about how people living with human immunodeficiency virus (HIV) experience malaria and the concomitant use of anti-malarial treatments with anti-retrovirals (ARVs). An understanding of how patients make sense of these experiences is important to consider in planning and supporting the clinical management and treatment for co-infected individuals. METHODS: A qualitative study was conducted in Tanzania alongside a clinical trial of concomitant treatment for HIV and malaria co-infection. Focus group discussions were held with people receiving treatment for HIV and/or malaria, and in-depth interviews with health workers responsible for HIV care and members of the clinical trial team. Data were analysed inductively to identify themes and develop theoretical narratives. RESULTS: Results suggest that people living with HIV perceived malaria to be more harmful to them due to their compromised immune status but saw the disease as unavoidable. For those enrolled in the clinical controlled study, taking anti-malarials together with ARVs was largely seen as unproblematic, with health workers' advice and endorsement of concomitant drug taking influential in reported adherence. However, perceptions of drug strength appeared to compel some people not enrolled in the clinical study to take the drugs at separate times to avoid anticipated harm to the body. CONCLUSIONS: Management of HIV and malaria concurrently often requires individuals to cross the domains of different disease programmes. In the context of a trial concerned with both diseases, patients experienced the support of clinicians in guiding and reassuring them about when and how to take drugs concomitantly. This points towards the need to continue to strive for integrated care for patients with HIV.

' in the project they really care for us': meaning and experiences of participating in a clinical study of first-line treatment for malaria and HIV in Tanzanian adults.

Critiques of biomedical research in low-resource settings typically centre on clinical trials and the 'dissymmetries of power' between the researched and those benefiting from the products of research. It is important to extend this critical lens to other forms of global health research. We conducted a qualitative study in Tanzania to explore meaning and experiences of participating in a clinical observational study evaluating the safety and efficacy of current practice for treating HIV and malaria co-infection. Focus group discussions and in-depth interviews were undertaken with 124 study participants, study staff and health workers. Participants' understanding of the study's research aims was limited, but the practice of participation - engaging with research staff and materials - appeared to facilitate interpretations of the study's value, conceptualised as a 'service'. For those peripheral to the study, however, interpretations of it reflected existing suspicions of experimental research. Our findings indicate the importance of considering the expectations, roles and responsibilities constructed through the practice of participation in different types of research, and how they relate to legacies of research. Understanding how networks of research practice intersect local social and historical contexts can extend discussions of collaboration and engagement with research in low-resource settings.

Quality assurance of qualitative research: a review of the discourse.

BACKGROUND: Increasing demand for qualitative research within global health has emerged alongside increasing demand for demonstration of quality of research, in line with the evidence-based model of medicine. In quantitative health sciences research, in particular clinical trials, there exist clear and widely-recognised guidelines for conducting quality assurance of research. However, no comparable guidelines exist for qualitative research and although there are long-standing debates on what constitutes 'quality' in qualitative research, the concept of 'quality assurance' has not been explored widely. In acknowledgement of this gap, we sought to review discourses around quality assurance of qualitative research, as a first step towards developing guidance. METHODS: A range of databases, journals and grey literature sources were searched, and papers were included if they explicitly addressed quality assurance within a qualitative paradigm. A meta-narrative approach was used to review and synthesise the literature. RESULTS: Among the 37 papers included in the review, two dominant narratives were interpreted from the literature, reflecting contrasting approaches to quality assurance. The first focuses on demonstrating quality within research outputs; the second focuses on principles for quality practice throughout the research process. The second narrative appears to offer an approach to quality assurance that befits the values of qualitative research, emphasising the need to consider quality throughout the research process. CONCLUSIONS: The paper identifies the strengths of the approaches represented in each narrative and recommend these are brought together in the development of a flexible framework to help qualitative researchers to define, apply and demonstrate principles of quality in their research.

Community response to intermittent preventive treatment of malaria in infants (IPTi) delivered through the expanded programme of immunization in five African settings.

BACKGROUND: IPTi delivered through EPI has been shown to reduce the incidence of clinical malaria by 20-59%. However, new health interventions can only be effective if they are also socially and culturally acceptable. It is also crucial to ensure that attitudes to IPTi do not negatively influence attitudes to and uptake of immunization, or that people do not misunderstand IPTi as immunization against malaria and neglect other preventive measures or delay treatment seeking. METHODS: These issues were studied in five African countries in the context of clinical trials and implementation studies of IPTi. Mixed methods were used, including structured questionnaires (1,296), semi-structured interviews (168), in-depth interviews (748) and focus group discussions (95) with mothers, fathers, health workers, community members, opinion leaders, and traditional healers. Participant observation was also carried out in the clinics. RESULTS: IPTi was widely acceptable because it resonated with existing traditional preventive practices and a general concern about infant health and good motherhood. It also fit neatly within already widely accepted routine vaccination. Acceptance and adherence were further facilitated by the hierarchical relationship between health staff and mothers and by the fact that clinic attendance had a social function for women beyond acquiring health care. Type of drug and regimen were important, with newer drugs being seen as more effective, but potentially also more dangerous. Single dose infant formulations delivered in the clinic seem to be the most likely to be both acceptable and adhered to. There was little evidence that IPTi per se had a negative impact on attitudes to EPI or that it had any affect on EPI adherence. There was also little evidence of IPTi having a negative impact on health seeking for infants with febrile illness or existing preventive practices. CONCLUSION: IPTi is generally acceptable across a wide range of settings in Africa and involving different drugs and regimens, though there is a strong preference for a single dose infant formulation. IPTi does not appear to have any negative effect on attitudes to EPI, and it is not interpreted as immunization against malaria.