Recent data confirm persistently low IPTp uptake in Southeast Nigeria. In Ebonyi State, only 24.0% of pregnant women received the recommended three or more doses of IPTp-SP [6] . In a rural Abia State study, 80.8% of women were aware of IPTp, but just 26.3% completed the full regimen [7] . Furthermore, a study found that increased IPTp uptake significantly improves birth outcomes, such as higher birth weights and reduced neonatal mortality [8] .

Analysis of the 2018 Nigeria DHS reveals notable inequalities: while wealthier women are more likely to receive three or more IPTp doses, rural areas exhibit a pro-poor pattern, indicating complexity beyond simple wealth gradients [9] . This means that malaria prevention is not determined by income alone. Other factors such as education, distance to health facilities, women’s decision-making power, and cultural beliefs also influence whether a woman receives preventive treatment during pregnancy [6] [10] [11] . For example, a woman who lives far from a clinic or depends on her husband to approve medical visits may miss IPTp doses even if the drugs are free [4] . Poor road networks, limited transport, and low awareness about malaria prevention make the problem worse, especially in isolated rural communities [12] . Recognizing this complexity, the proposed framework emphasizes community and faith-based engagement to ensure preventive interventions reach women across all social and economic groups [13] .

Although the Widal test is still widely used in Nigeria’s rural settings, it has notoriously poor diagnostic accuracy. For instance, a study from a tertiary hospital found the test’s sensitivity to be only 35% and specificity at 51%, with a low positive predictive value (17%), meaning it frequently produces false positives and falsely classifies non-typhoid cases as typhoid, especially in malaria-prevalent contexts [14] . This inaccuracy contributes to misdiagnoses, unnecessary antibiotic use, and ongoing confusion over malaria–typhoid co-infection. Blood culture remains the reference standard for confirming typhoid fever, as it directly detects Salmonella Typhi [15] . Nevertheless, newer rapid diagnostic assays, such as Typhidot and TUBEX-TF, have demonstrated greater accuracy and reliability than the traditional Widal test in several studies [5] [14] .

Recent literature emphasizes the importance of community engagement, improved diagnostics, and targeted behavioral interventions to counteract misbeliefs like malaria-typhoid co-infection and to enhance IPTp uptake and preventive behavior [6] [9] .

This involves holding structured discussions with village leaders, women’s groups, traditional birth attendants (TBAs), and church leaders, who play central roles in shaping community opinions. Since pastors and priests are respected voices of authority in rural Enugu, involving them in dispelling the malaria-typhoid concurrency myth ensures that accurate information is trusted and widely shared [19] . In addition, men and husbands will be actively encouraged to participate in malaria prevention activities. Through community meetings and faith-based programs, they can learn about the importance of IPTp, regular ANC visits, and the dangers of self-medication. Their involvement supports women in attending clinics, taking preventive drugs, and following health advice without delay.

Antenatal clinics (ANC) remain the primary platform for delivering malaria prevention measures such as IPTp, while also providing opportunities to educate pregnant women about malaria and dispel myths. In remote areas, community health workers (CHWs) can extend this service using models like TIPTOP, which has proven effective in neighboring Ebonyi State [3] [14] , ensuring that even women far from health centers receive preventive care. To further enhance uptake, collaboration with faith-based groups is encouraged. Religious leaders can motivate women to attend ANC, provide reassurance about preventive measures, and even organize transportation or offer encouragement during church services, thereby reinforcing medical advice with trusted religious endorsement.

Behavior Change Communication (BCC) uses culturally appropriate tools to influence knowledge, attitudes, and practices. In rural Enugu, interventions include Igbo-language radio messages, community dramas, and posters that clarify misconceptions about malaria-typhoid co-infection and promote preventive behaviors, such as ITN use and adherence to IPTp schedules. These campaigns are further strengthened by the involvement of faith leaders, who use pulpits, crusades, and women’s fellowships to reinforce prevention messages, encourage ITN use, and discourage reliance on the unreliable Widal test. Religious dramas and songs in Igbo during church events also serve as powerful reinforcements, ensuring that malaria-prevention messages are not only culturally relevant but also delivered through trusted community voices [18] .

Capacity building is central to improving malaria prevention and diagnosis in rural Enugu. Healthcare providers are trained to prioritize rapid diagnostic tests (RDTs) over the unreliable Widal test for malaria-typhoid diagnosis, and to counsel patients accurately on prevention, the proper use of IPTp, and the correct interpretation of test results. At the same time, faith leaders are given basic training on malaria prevention messages so they can reinforce accurate information within their congregations and communities. Evidence shows that when church leaders are directly engaged alongside trained health workers, communities are more likely to adopt preventive behaviors and reduce reliance on ineffective practices [20] .

To track the effectiveness of the interventions, measurable indicators are used. These include:

While the proposed health promotion framework is practical, some challenges may affect its success. Limited funds, few health workers, and poor roads in rural Enugu could make outreach difficult. Some community or faith leaders may resist new ideas because of cultural beliefs or mistrust. Getting husbands to take part may also be hard, as traditional gender roles often limit men’s involvement in maternal health. Sustaining the program after the initial phase could also be difficult without local and government support.

To overcome these issues, the framework promotes early engagement of community leaders, use of existing local structures, and integration into primary health care programs for long-term success. To make the impact last, the framework encourages communities to take ownership of activities. Trained faith leaders, health workers, and volunteers can keep sharing malaria-prevention messages during church events and local meetings. By using existing health and community systems, the program can continue even after outside support ends