THE PROBLEM AND ITS SETTING
The global community has set a global target to reduce new paediatric HIV infections by over 90%, and reduce the number of HIV-related maternal deaths by 50%. HIV prevention, barriers to improving Maternal Child Health (MCH)/ Prevention of Mother to Child Transmission of HIV (PMTCT) outcomes are often interlinked, so that an intervention approach targeting attitudes, norms, and knowledge levels at different spheres of social organization (community and individual) may be more effective than interventions operating on a single barrier. A peer is a person who belongs to the same social group as another person or group. The social group may be based on age, sex, sexual orientation, occupation, socio-economic and/or health status, in this case study it is pregnant women. Education refers to the development of a person’s knowledge, attitudes, beliefs or behaviour resulting from the learning process. The Global Plan (formally called ‘The Global Plan towards the Elimination of new HIV infections among children by 2015 and keeping their mothers alive’) recognizes that in order to achieve the elimination of pediatric AIDS, significant investments must be made to address the various barriers that limit optimal uptake, retention and adherence by pregnant women, particularly those living in the most highly affected countries.
1.2 Background to the Study
The WHO 2010 Option A guidelines recommended HIV ‘positive pregnant women to be on antiretroviral (ARV) prophylaxis from as early as 14 weeks gestation or initiated on antiretroviral therapy (ART) if they are eligible for treatment. These guidelines also require follow-up of mothers and babies for a longer period, including the breastfeeding period which, according to the Zimbabwean guidelines, goes up to 24 months post-delivery. Data from Zimbabwe Demographic and Health Survey (ZDHS) (2010-11), however, showed that approximately 10% of the women did not register their pregnancies for antenatal care (ANC) and only 19% of those who registered, did so in the first trimester. The ZDHS also showed that only about 65% of the women attended the recommended four ANC visits during their pregnancy. If Zimbabwe’s PMTCT program is to achieve the national goal of eliminating new paediatric HIV infections by 2020, there is need to ensure that all women book for ANC and do so early on or before 12 weeks. To ensure that those identified to be HIV positive can receive appropriate interventions. There is also need to increase retention of mothers and infants in HIV care through the longer follow-up period of postnatal care (PNC).
Demand for maternal and child health (MCH)/prevention of maternal to child transmission (PMTCT) services is often limited by critical social barriers such as low motivation to seek health services; lack of knowledge or understanding of health issues; lack of information on available services and the importance of these services for healthy families; misconceptions about HIV testing and treatment; fear of disclosure of HIV test results; pernicious HIV/AIDS stigma and the fear of its social effects; harmful gender norms, attitudes, and behaviours which manifest as poor decision-making ability; limited partner support and participation among males; and community norms that often preclude open discussion of sexual and reproductive health issues within the family.
The peer group discussions are to envisage the solidarity and support for these women at the vulnerable times of pregnancy and lactation. The groups act as a vehicle for education about maternal and child health, leading to enhancements in knowledge of and changes in attitudes towards ANC health seeking behaviour. Health promotion, aid in generation of self-efficacy that would enable women to seek antenatal and postnatal care services.
1.3 Statement of the Problem
In 2011, 330,000 children were infected with HIV, the virus that causes AIDS (UNAIDS 2012). Whilst much progress has been made in low- and middle-income countries, 57% of at-risk mothers and babies receive antiretroviral medications to prevent perinatal transmission from mother to child (2011 estimates). Without any preventative intervention, up to 30% of children born to HIV positive women will acquire the virus during pregnancy, labor and delivery, and breastfeeding.
To attain virtual elimination of pediatric HIV and achieve the best possible outcomes for themselves and their infants, women need to be tested for HIV, and to start antiretroviral drugs as early as 14 weeks gestational age. They also need to return for ANC visits throughout pregnancy, deliver their babies at health facilities, and continue to adhere to the prevention recommendations throughout breastfeeding. Women who are tested and found to be HIV negative need to maintain safer sexual practices vigilantly, throughout pregnancy and breastfeeding, in order to remain HIV free.
In addition to grappling with these concerns, knowledge, attitudes, practices and behaviors of pregnant women on seeking health advice, health institutional management on pregnancy and institutional deliveries are only vivid means of preventing mother to child transmission of HIV (Watts et al. 2010). Cultural practices and briefs as well knowledge gaps perverts the attainment of HIV free born babies therefore hurling down on myths and misconceptions will have a significant influence in women’s utilization of health services, acceptance of HIV test results, adherence to antiretroviral drug regimens, and infant feeding decisions (WHO, 2012).
Critical barriers to accessing PMTCT include: low motivation to seek health services; lack of knowledge or understanding of health issues; lack of information on available services and the importance of theseservices for healthy families; misconceptions about HIV testing and treatment; fear of disclosure of HIV test results; pernicious HIV/AIDS stigma and the fear of its social effects; harmful gender norms, attitudes, and behaviors which manifest as poor decision-making ability; reduced access to financial resources, limited mobility for women, limited partner support and participation among males; and community norms that often preclude open discussion of sexual and reproductive health issues within the family. Many of these barriers reinforce each other; for example, lack of knowledge on health issues increases poor health seeking behavior.
Much efforts has been put by government and civic organization to reverse these barriers in attaining Zero new infection in pediatrics hence the desire to carry out a study, an analysis into the effects of health promotion educationi.e.engaging community leaders in PMTCT; community health fairs (henceforth referred to as community days); and peer-led health groups discussionsin Maternal Child Health, with focus on of PMTCT, case of Hwedza District.
1.4 Objectives of the Study
The general objective of the study is to assess the efficacy health promotion education has brought about to Hwedza communities on the demand for, uptake of, and retention on MCH/PMTCT services. The specific objectives are to:
1. Assess knowledge gaps amongst women of child bearing age regarding demand for, uptake of and retention of HIV positive pregnant/postpartum women in MCH/PMTCT services
2. Understanding if any external force outside women knowledge that has a contribution on demand for, uptake of and retention of HIV positive pregnant/postpartum women in MCH/PMTCT services
3. Assess the self- efficacy of community health days, community leadership engagements and peer group education in narrowing or closing knowledge, attitude, practices and behaviours on issues of demand for, uptake of and retention of HIV positive pregnant/postpartum women in MCH/PMTCT services.
1.5 Research Questions
Main research questions
1- Does health promotion education bring behaviour change on issues of maternal child health?
2- To what extend can health promotion create demand for, uptake and retention of MCH/PMTCT services amongst communities?
3- The significance of stakeholders in health promotion education buy-in, for sustainability and replication of such MCH/ PMTCT strategies.
1.5.1 Sub- questions for the research
‘ -Do MCH peer group discussions provide leverage on the demand creation, uptake and retention of MCH/PMTCT services?
‘ To assess practices, briefs, norms and social effects that perverts pregnant women from meeting behaviour change in positive direction for the elimination of HIV.
‘ To identify KAPB gaps that undermines women of Hwedza District from creating demand and having retention of health services on MCH/PMTCT
‘ In what ways can support group education provokes and or maintains a culture/ behaviour of health service seeking behaviour with regards to MCH/ PMTCT?
‘ To what degree of influence can community health days and dialogue sessions promote issues of MCH?
‘ Does community leadership engagement foster adoption of health promotion education strategies.
‘ How did the project impact on the community?
The researcher hypothesize that improving individual and community knowledge on MCH/PMTCT and HIV, and addressing individual, family, and community socio-cultural and behavioral norms through health promotion education is key in elimination of HIV paediatric new infections. These selected community based interventions will increase the number of HIV-positive pregnant and post-partum women who are initiated and retained in PMTCT services.
According to the Diffusion of Innovation Theory, the sustained spread of a behavior (or set of behaviors) within a social network is determined by adoption among individuals who are central and influential within the network. Mobilizing communities by working through community leaders to mobilize others in their social networks can result in improved health-seeking behaviors.
These community mobilization activities are informed by Rothman’s Framework which illustrates three approaches to involving communities in health promotion work: social planning, locality development and social action.
‘ Social planningis a task-oriented method stressing rational problem solving, usually by an outside party, to address community concerns. Outside change agents gather facts about community problems and recommend the most appropriate responses.
‘ Locality development is a more process oriented approach that attempts to build a sense of group identity and community, a broad cross-section of people will come together to learn about MCH/PMTCT and discuss community barriers to health services uptake and retention.
‘ Social action seeks to address imbalances of power between marginalized community groups and dominant segments of the community.
Community mobilization also draws from the Transtheoretical (Stages of Change) Model of Behavior Change which postulates behavior change is an ongoing process, not an event, and that individuals have varying levels of motivation or readiness to change. The theory identifies five stages of change:
– pre-contemplation: where individuals are not considering changing their behaviors, or are consciously intending not to change;
– contemplation: the stage at which a person considers making a change to a specific behavior;
– preparation: where a person makes a serious commitment to change and begins to make the necessary preparations to do so;
– action: the stage at which a change is initiated; and
– maintenance: sustaining the change over time.
Peer education has a strong theoretical basis. The peer education draws elements from Social Learning Theory and the Theory of Reasoned Action. Social Learning Theory states that people learn from each other through observation, imitation and modeling and some people (significant others) are capable of eliciting behavioral change in certain individuals, based on the individual’s value and interpretation system. The Theory of Reasoned Action asserts that an influential element for behavior change is an individual’s perception of social norms or beliefs about what people who are important to the individual think or do about particular behavior. Diffusion of innovations theory: This theory argues that social influence plays an important role in behaviour change. The role of opinion leaders in a community, acting as agents for behaviour change, is a key element of this theory. Their influence on group norms or customs is predominantly seen as a result of person to person exchanges and discussions.
1.8 Significance of the Study
The MCH classes will involve transfer of information on MCH/PMTCT to pregnant women utilizing peer facilitators. This intervention involves health literacy and peer education. Health literacy has been defined by WHO (1998) as: ‘The cognitive and social skills which determine the motivation and ability of individuals to gain access to understand and use information in ways which promote and maintain good health’. There are multiple definitions of health literacy, and Sorenson et al., have developed a comprehensive definition: ‘Health literacy is linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course. In 2011, 330,000 children were infected with HIV, the virus that causes AIDS (UNAIDS 2012). Whilst much progress has been made in low- and middle-income countries, 57% of at-risk mothers and babies receive antiretroviral medications to prevent perinatal transmission from mother to child (2011 estimates). Without any preventative intervention, up to 30% of children born to HIV positive women will acquire the virus during pregnancy, labor and delivery, and breastfeeding.
Building on the foundation laid by the publication of the WHO 2010 guidelines on prevention of mother-to-child transmission (PMTCT) of HIV. A variety of social, behavioral, and structural barriers operate beyond the influence of the health system, limiting HIV and AIDS service demand from target individuals and communities (Auerbach et al. 2007). They include pervasive stigma and discrimination, disempowerment, gender based violence, gender inequity, limited education, low health literacy, poor/limited social safety nets, lack of political will, among other factors (Seeley et al. 2009). These factors are embedded in community structures and norms, and there has been limited exploration of how to optimally intervene on these to improve PMTCT outcomes. Also, it is acknowledged that over the last decade, the global AIDS response has under-funded programs and research on the social, behavioral and structural program barriers (Schwartlander et al.2011). As a result, there is limited concrete evidence to inform the implementation of demand-side PMTCT interventions at the scale necessary to achieve elimination of pediatric HIV.
The process of peer education is perceived more like receiving advice from a friend ‘in the know’, who has similar concerns and an understanding of what it’s like to be pregnant women in this case. Peer education clearly goes beyond information sharing into the realm of behaviour change. It is essential to learn about the principles of comprehensive, skills-based health education and behaviour change interventions, and to understand how they relate to peer education.
1.9 Assumptions of the Study
The researcher anticipates that institutional records of pregnant women shall be well documented for utilisation of desk data since it provides evidence on time of pregnancy booking, male involvement, number of ANC visits made as well postpartum services. It is positively assumed that pregnant women who attended health promotion education will consent for the study.
1.10 Definition of Terms
Health: ‘has been considered less as an abstract state and more as a means to an end which can be expressed in functional terms as a resource which permits people to lead an individually, socially and economically productive life .health is a resource for everyday life, not the object of living it is a positive concept emphasising social and personal resources as well as physical capabilities’. (WHO 1986:1)
Health promotion: ‘any planned combination of educational, political, environmental, regulatory or organisational mechanisms that support actions and conditions of living conducive to the health of individuals, groups and communities’. The 2000 Joint Committee on Health Education Terminology (Gold & Miner 2002:4)
Maternal health: refers to the health of women during pregnancy, childbirth and the postpartum period. While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death. (WHO 2002)
Education refers to the development of a person’s knowledge, attitudes, beliefs or behaviour resulting from the learning process.
Impact: Measure of the tangible and intangible effects (consequences) of one thing’s or entity’s action or influence upon another.
Peer support: is any organised support provided by and for people with similar conditions, problems or experiences. Peer support is sometimes known as self-help, mutual aid or mutual support.
Behaviour : is an overt action conscious or unconscious with a measureable frequency, intensity and duration.
Health behaviour : ‘those personal attributes such as beliefs, expectations, motives, values, perceptions and other cognitive elements personalising characteristics including effective and emotional states and traits, and behaviour patterns, actions and habits that relate to health maintenance to health restoration and to health improvement’.David.G (1982 :167)
PMTCT: As defined in the UNAIDS terminology guidelines (October 2011), PMTCT refers toa four-pronged strategy for stopping new HIV infections in children and keeping mothers aliveand families healthy.
1.11Delimitations of the Study
The study is to be carried out in Hwedza District, Mashonaland East Province, Zimbabwe. Hwedza district is predominately rural, with farming as the major economic activity. The district has 15 wards and to its boarders are farmers and communal lands of Sadza District. The population of the district stands at 45000, gender aggregation of males and females, a total of 15000 women of child bearing age with annual pregnancy expectations of 1830 and an average of 1560 new-borns annually. The study will call for people who were in Hwedza for the past three years. The participants of this study shall also be those who are between 16 and 45 years since these are the people who are sexual active and were the intended beneficiaries of the programme.
Anticipated challenges on accessing library due to work commitments as well periodically consultations with the supervisor are some of the limitations the researcher might interface with. The study demands much of travelling and funds, there a chances of financial strain though the research shall maximise through application of mixed research techniques. According to (Creswell 2003) this design needs a lot of time. It involves qualitative data collection and quantitative data on its own. At times there is also a problem when it comes to resolve discrepancies between different types of data. To resolve this issue, the instruments used to collect data shall glean same information but using quantitative questions for quantitative information and qualitative questions for qualitative data.
According to NAC (2006), perceptions on vulnerability and basic knowledge about HIV and AIDS as well as prevention were reported to be well established in the middle of 1990s. The adequacy of practical knowledge related to prevention practices was questionable. The community appears lacked more information on Testing and Council (T &C), Prevention of Mother to Child Transmission (PMTCT), knowledge on option B+ as a long-life solution on elimination of HIV pideatric infections. Can the availability of health promotion education steer communities to create demand for, uptake and retention of MCH/PMTCT services. The problem and its setting had been explained in this chapter, scientific justified scholars publications shall be contained in chapter two accrediting the research worthiness. Research design methodology stating the design adopted and justifying the choice, shall be contents in chapter 3, followed by findings from the study, data presentation, analysis and interpretations. The final chapter is on summary, recommendations and conclusions.
2. 0 Purpose of the Review
Reviewing of other scholar’s contributions and critics helps the researcher to align the study in acceptable and applicable academia perceptive that are of relevance. Literature review aims to give researched pedigree, academic support on subject being understudy.
2.1 Source of the review
The types of literature reviewed included journal articles; published and unpublished reports, evaluations and reviews; and abstracts and desk data. In line with the health promotion education in maternal child health and PMTCT, the focus was largely on sub-Saharan Africa, but case studies were identified from other regions as well. The review was limited to literature related to health promotion education in PMTCT regarding pregnant or postpartum women or women of childbearing age and their partners. This literature review concentrated on three key areas these include:
‘ significance of health promotion education looking into the following outcomes on:
-community health fairs/ days
-MCH peer education
‘ stakeholder and institutional support/ buy-in
‘ Self- efficacy of MCH promotion education in creating demand for, uptake of, and retention on MCH/PMTCT services.
2.2 Statistical presentation
Zimbabwe is one of the 22 HIV high burden countries with an adult HIV prevalence of 15% and an ANC sero-prevalence of 16.1%. Mother to child HIV transmission (MTCT) is the main cause of HIV infection in newly infected children in the country every year, accounting for >90% of all Paediatric HIV infections. Nation-wide, MTCT is the second major mode of transmission next to heterosexual transmission, contributing to 7% of all new HIV infections.
In Zimbabwe, 21% of the Under 5 Mortality Rate (<5MR) is attributed to HIV/AIDS as the underlying cause (MIMS 2009) while 26% of all Maternal Mortality is HIV/AIDS related
In 2012, an estimated 70,000 mothers where in need of PMTCT and there were about
11,000 new HIV infections in Children, a 50% decrease since 2009.In addition, about
110,000 children are in need of ART but the coverage of paediatric ART remains low at about 45% compared to 85% for the adult population. With references to above statements, it is cogent to find the significance of health promotion education into:
2.3 Maternal Child Health barriers in communities
Women living with HIV must confront stigmatizing and discriminatory attitudes towards people living with HIV (Watts et al.2007). The resultant feelings of isolation and self-stigmatization are associated with poor mental health and depression during pregnancy and the postpartum period, with important implications for subsequent care seeking, and adherence to clinical and preventive recommendations (Psaros et al 2004.). At the household level, male partners have a significant influence in women’s utilization of health services, acceptance of HIV test results, adherence to antiretroviral drug regimens, and infant feeding decisions (WHO, 2012). Women who disclose their status to a male partner are more likely to adhere to antiretroviral therapy and to infant feeding recommendations (Peltzer et al. 2008). limited but growing body of peer-reviewed literature indicates that providing structured social support throughout pregnancy and the breastfeeding period can effectively address shortcomings in medical models of care in high HIV burden settings, helping mothers overcome barriers to care-seeking and adherence (Thyleskaar et al.2011; Futterman D et al.2010; Mushi et al.2010). Critical barriers to accessing PMTCT include: low motivation to seek health services; lack of knowledge or understanding of health issues; lack of information on available services and the importance of these services for healthy families; misconceptions about HIV testing and treatment; fear of disclosure of HIV test results; pernicious HIV/AIDS stigma and the fear of its social effects; harmful gender norms, attitudes, and behaviors which manifest as poor decision-making ability; reduced access to financial resources, limited mobility for women, limited partner support and participation among males; and community norms that often preclude open discussion of sexual and reproductive health issues within the family (Nassal et al 2009). Many of these barriers reinforce each other; for example, lack of knowledge on health issues increases poor health seeking behavior.
A number of interventions to address these barriers have been implemented, for example, mother mentors and health promoters (UNAIDS 2008). Many of these interventions however, have focused narrowly on HIV, rather than more broadly on HIV in relation to MCH, and they have underestimated the role of men in overcoming the barriers. The interventions have also generally focused on increasing knowledge, without sufficient attention to transforming social norms, galvanizing collective agency and leveraging existing traditional and social structures. Few of these interventions have been systematically tested in multiple settings, and none of these interventions have been tested jointly. As with combination HIV prevention, barriers to improving MCH/PMTCT outcomes are often interlinked, so that an intervention approach targeting attitudes, norms, and knowledge levels at different spheres of social organization (community and individual) may be more effective than interventions operating on a single barrier.
The researcher seeks to systematically evaluate the impacts on HIV and health outcomes, of a social-behavioral package comprised of three interventions. These interventions are: a) engaging community leaders in MCH/PMTCT; b) community health fairs (henceforth referred to as community days); and c) peer-led health groups. These health promotion interventions were implemented in Hwedza District and evaluation on performance in order to generate evidence that assesses their effect to communities.
2.4 Empowering Communities – Community Leadership engagement
Community engagement: community engagement is the process of working collaboratively with and through groups of people with diverse characteristics who are linked by common ties, social interaction or geographical location (Centers for Disease Control and Prevention, 1997).According to the Diffusion of Innovation Theory, the sustained spread of a behavior (or set of behaviors) within a social network is determined by adoption among individuals who are central and influential within the network. Mobilizing communities by working through community leaders to mobilize others in their social networks can result in improved health-seeking behaviors.
Drawing from the theories of Participatory Education and Diffusion of Innovation, the implemented health promotion interventions built a critical mass of adopters by equipping community leaders from various sub-sections of the population to serve as opinion leaders, disseminating information and influencing attitudes and norms in their communities. These leaders will create opportunities for discussion, to enable the target communities of this intervention to collectively plan and implement responses to MCH, HIV, and challenge and change harmful gender norms, attitudes, and behaviors related to women’s access and uptake of PMTCT services. Providing training and mentorship to community leaders on MCH, PMTCT and gender issues will alter perceptions around the value of these services for the larger community, will increase community action around MCH and PMTCT, will promote positive gender norms, attitudes, and behaviors, and will eventually increase demand for and uptake of MCH and PMTCT services.
2.4.1 Community engagement improves programmes:
Since the Alma Ata Conference in 1978, when primary health care was ratified as a key strategy and policy of WHO Member States, there has been a growing recognition and body of literature on the right of communities to participate in their health care and the added value of that participation (Rosato et al., 2008). In 2001, Leonard and colleagues presented persuasive evidence from 40 years of development projects in various sectors and concluded that projects with substantial community engagement are more likely to succeed. They convincingly extend the argument to community engagement in PMTCT programmes (Leonard et al., 2001; Rutenberg et al., 2003). This review accepts as a foundational principle that community engagement, as broadly called for in The Global Plan, will be essential to scaling up PMTCT and achieving the goals set for 2015.
2.4.2 Community and facility interventions PMTCT scale-up:
Strong linkages between community and facility services are the foundation of an effective PMTCT programme, and fully integrating PMTCT services includes developing linkages between the two, (Israel & Kroeger, 2003). A second underlying assumption of this review is that neither community engagement nor facility interventions alone will suffice. Community engagement for PMTCT must work hand in hand with efforts to improve PMTCT services at health facilities. Demand created within communities must be linked to adequate, stigma-free, client-sensitive service delivery. Facilities must also engage with communities to address demand-side barriers and ensure provision of the full PMTCT continuum to every client. Although the focus of this review is solely on community engagement, it is understood that elimination of new infections among children and keeping their mothers alive will require harmonized scale-up of promising practices in both community engagement and facility services.
2.5 Community health days and dialogues
Community Days are community mobilization events, where communities are brought together for health promotion activities and dialogues supported by selected health services and disease screening. These community mobilization activities are informed by Rothman’s Framework which illustrates three approaches to involving communities in health promotion work: social planning, locality development and social action seeking behavior change.
2.5.1 Theory and conceptual framework
As its theoretical basis, the researcher draws upon the concept of empowerment education as embodied extensively in the literature, and notably in Paulo Freire’s work on participatory education. According to the Theory of Participatory Education, empowerment results from the full participation of the people who are affected by a problem or condition. This posits that through active learning in which participants draw from their own knowledge and experience, communities can transform themselves. Health promotion education interventions implemented in communities will make communities come together for reflective dialogue to build critical awareness of the pressing health issues; to identify problems, critically analyze the social and cultural roots of the problems; to develop strategies to positively change their lives and their communities; and to take collective action in this regards, (Paulo .F 1973). This cycle encompasses three processes to stimulate critical thinking and change: listening (which will be initiated at community-wide scale by community leaders equipped for this purpose), dialogue (which will be catalyzed through facilitated group dialogues at supported community days), and collective action (which will be potentiated and sustained through ongoing peer-facilitated groups for men and for women). This approach is critical for conscientizing communities on the constructive roles that men can play in family and community health, by confronting the underlying gender norms, attitudes, and behaviors that drive individual and social HIV risk.
2.6 Constructive Engagement of Men in PMTCT
While countries recognize the importance of engaging men in PMTCT, there is a lack of consensus on how to engage define and measure this. Existing efforts have largely involved encouraging men to attend ANC with their female partners as in Kenya. Yet, despite various facility-based efforts such as invitation letters, special evening programs, and promotion of couples counseling (Rwanda is the only country that has seen improved male attendance nationally) male ANC attendance (as a proxy for male involvement/support) has remained extremely low in most countries. This lack of success in increasing and sustaining male participation in ANC in most African settings demands a different approach’one that tackles the underlying gender norms, attitudes, behaviors, in order to improve discussion and decision-making around health issues at the household level.
The theoretical basis for the utilization of male discussion groups draws from Paulo Feire empowerment education; where through learning people can transform themselves. In this methodology groups identify problems, critically analyze the roots of the problems, and develop strategies to positively change their lives and their communities (Paulo .F 1973).
Most programmatic efforts related to reproductive health, child health, and PMTCT are directed toward women, disregarding the gender norms that often determine women’s participation in these programs, (Peacock .D etal 2009). In addition the ‘feminization’ of the health system and limited roles of men and fathers present significant obstacles to the constructive engagement of men. To effectively strengthen the uptake of services and retention into care, it is necessary to address the ‘demand side’ of uptake of services by addressing underlying gender norms preventing the successful completion of the PMTCT cascade, as well as to make the system more ‘male’ friendly.
Traditional perceptions of masculinity enable and often encourage men to refrain from seeking health care services, with grave implications for women’s’ risk of HIV during pregnancy and lactation, when they are highly vulnerable. Women who are diagnosed with HIV often do not receive any significant support for disclosing their HIV diagnosis to their male partners. Anecdotal and research evidence has suggested that in spite of facility-based efforts to provide peer support for women who test positive, many women are afraid to disclose their status to their partner for fear of violence or abandonment and consequently are less likely to attend future ANC visits, adhere to ARV prophylaxis, or initiate treatment for their own health,( Bwirire et al 2008).
Numerous communities have undertaken efforts to address these issues through increasing constructive engagement of men in PMTCT. Literature supports that addressing gender attitudes and norms can have an influence on uptake of PMTCT services.
In a cohort study conducted between 1999 and 2005 in Nairobi, Kenya, the risk of vertical transmission was lower among women who attended an ANC clinic with a partner compared to those attending alone, adjusting for maternal viral load. Risk of vertical transmission or infant death was also lower among women reporting partner HIV testing, adjusting for maternal viral load and breastfeeding, (Aluisio.2011). The woman’s ability to disclose her HIV status and have her partner’s support for ARV treatment was likely the facilitating factor in reducing HIV transmission. Partner attendance at ANC was also likely a proxy for male support, interpersonal level, reinforcing MCH/PMTCT knowledge self-efficacy, HIV risk perception, and the perceived PMTCT benefits (of life-long ART and HIV status disclosure).
2.6.1Conceptual Framework on peer education
The components of the project interventions are presented, along with the mechanisms through which the researcher hypothesize achieving the immediate and project endpoints. hypothesize that in order to attain the desired study endpoints (early ANC attendance, testing and retesting for HIV, uptake of antiretroviral drugs (ARV) for prophylaxis and antiretroviral treatment (ART) by HIV positive mothers and infants, PNC attendance, and completion of the PMTCT cascade by HIV pregnant women), community attitudes around pregnancy and childbirth norms and gender equity must be modified, and group efficacy strengthened to address the social and cultural barriers to optimal health outcomes. To accomplish this, community leaders will rely on influencing, community organization and behavior modeling. In addition assume the potential changes brought by the community leaders, the community days, through conscientization, will enhance MCH and HIV reproductive knowledge, and gender-equitable attitudes to achieve the study endpoints.
2.7 Women’s peer-led MCH classes
The MCH classes will involve transfer of information on MCH/PMTCT to pregnant women utilizing peer facilitators. This intervention involves health literacy and peer education. Health literacy has been defined by WHO (1998) as: ‘The cognitive and social skills which determine the motivation and ability of individuals to gain access to understand and use information in ways which promote and maintain good health’. (Nutbeam.1998). There are multiple definitions of health literacy, and (Sorenson et al.2012), have developed a comprehensive definition: ‘Health literacy is linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course,’stated ,Sorensen et al (2012). According to Nutbeam (2000), a proposed a conceptual model of health literacy of having three levels:
Level 1: Functional literacy; sufficient basic literacy skills to function on a day-to-day basis, such as being able to read health-related materials, for example, health information flyers, labels on a pill bottles.
Level 2: Communicative/interactive literacy. Building upon functional literacy, focuses on the development of advanced cognitive skills and the ability to operate in a social environment, such that patients, from their reading, are able to express their understanding of a health condition to peers.
Level 3: Critical health literacy. At this level, health literacy includes analysis skills that allow individual and group empowerment that supports social action participation in health-related issues.
The classes will build upon the information that is delivered in health facilities, which usually leads only to functional literacy. In addition the classes, being led by peer facilitators, may make the information more relevant and more understanding to the participants. The implementers believe that through the MCH classes, the women will be able to attain at least level 2 in their understanding of MCH/PMTCT issues and their ability to act upon them.
Peer education has a strong theoretical basis. The peer education draws elements from Social Learning Theory and the Theory of Reasoned Action. Social Learning Theory states that people learn from each other through observation, imitation and modeling and some people (significant others) are capable of eliciting behavioral change in certain individuals, based on the individual’s value and interpretation system, (Bandura.1986). The Theory of Reasoned Action asserts that an influential element for behavior change is an individual’s perception of social norms or beliefs about what people who are important to the individual think or do about a particular behavior.
2.7.1 Behaviour Change
Behaviour change communication has its roots in behaviour change theories that have evolved over the past several decades. These theories are valuable foundations for developing comprehensive communication strategies and programs. These include the Stages of Change model (Prochaska, DiClemente and Norcross) and the Health Belief Model which of course originated from psychologist but was later publicised by Becker in 1974 as cited by,(Glanz 2008). The Health Belief Model has four main constructs. These are perceived seriousness, perceived susceptibility, perceived benefits, and perceived barriers. It also includes cues to action, motivating factors and self-efficacy. This is one of the most used models in health promotion (Glanz etal 2002). Perceived seriousness is how an individual views the effects that the disease might have on someone. This is based on medical information that one has and personal beliefs. Perceived susceptibility is seeing oneself in the danger of contracting a disease. Such a person is likely to take prevention measures e.g. condom promotion was also part of this project. If people perceive themselves as out of danger, then risky practices come into being. Perceived benefits are when one sees the value of the new behaviour. The value encourages someone to go for that behaviour. Janz and Becker (2008), they believe that perceived barriers determine one’s behaviour adoption. One has to believe the benefits of a new behaviour outweigh the results of continuing with the old behaviour.
According to Janz and Becker (1984) the Stages of Change Model by Prochaska, Di Clemente and Norcross are as follows:
Since concerted knowledge transfer and attitudinal change will take place in the small group peer-lead MCH classes (and potentially discussion and action through informal group discussion) at an intensity higher than any of the community level interventions, there may be more ability to impact the more sensitive PMTCT/HIV issues, increasing the HIV positive pregnant on ARV/ART and improving the completion of the PMTCT cascade. At high enough coverage levels amongst eligible pregnant women and men, the peer group intervention also is likely to have community-wide impact through social diffusion
2.7.2Health Education for Empowerment Approaches
Health education for empowerment refers to explicitly participatory approachesthat promote social responsibility and social justice and have an ultimate goal of community empowerment. While participation and empowerment have become ubiquitous and sometimes appropriated terms in health education, these educational approaches are differentiated from others in their distinctive use of certain theories and emphasis on societal values.
2.7.3Critiques on Empowerment Education Approaches
Health communicators have not critiqued empowerment approaches in the same consistent way as conventional education, although Braun et al. (1994) write that community participation and mobilization models do not represent a complete model needed for health communication. Rather, some health communication proponents have appropriated the discourse of empowerment education, citing the participatory nature of their methodologies. For example, Lefebvre et al. (1995) claim that social marketing is a method of empowering people to be totally involved and responsible for their well-being as well as a comprehensive strategy for effecting social change because of the continual dialogue with consumers.
2.7.4NGO Health Education Approaches in Developing Countries
A large range of health education and related data collection activities exist within NGO health programs. These activities may include anything from peer education for AIDS prevention, to training of government health workers in growth monitoring and promotion, to educating village caretakers in oral rehydration therapy, to social marketing of child feeding behaviors, or to community mobilization for safe motherhood practices. The particular health education approach underlying a health educationintervention may be undefined or vague, may refer to an eclectic mix of educational and communication theories, or may be more strictly linked to a particular theory and its accompanying educational and research methodologies. Furthermore, many NGO health educators claim that their approaches promote participation and empowerment of participants while others focus primarily on issues of efficiency and the behavioral results achieved. Two main issues emerge from a review of NGO health education in practice and in literature. The first issue has to do with the implications of whether or not NGO health education practice is explicitly linked to theoretical, conceptual and philosophical frameworks. The second issue involves debate and the existence of tensions among proponents of different health education approaches.
2.8Stakeholders participation and programme buy-in
Creating an enabling environment for PMTCT scale-up, an enabling environment for PMTCT scale-up is considered into perspectives whereby firstly ,communities engage in advocacy and activism to improve policies and actions around PMTCT and maternal, neonatal and child health. Second, governments and their developmentpartners promote policies and frameworks that encourage community engagement in PMTCT.
This chapter gave substantial empirical scholars evidence through various publications on how health promotion education is understood and or being relevant on elimination of HIV/AIDS with regard to PMTCT prevention strategies. The literature review contents looked into three key areas these include, significance of health promotion education looking into the following outcomes on: community health fairs/ days, leadership engagement, MCH peer education and male involvement. Also to effectively evaluate the impact of health promotion education stakeholder and institutional support/ buy-in as well as self- efficacy of MCH promotion education in creating demand for, uptake of, and retention on MCH/PMTCT services.
This research is geared towards understanding of the implementation of the health promotion education in MNCH particularly focusing on PMTCT programme in Hwedza district hence the philosophical basic thought of this research is constructivism. According to Burke and Onwuegbuzie (2004) constructivism tenets are that multiple constructed realities are plentiful, time and context free generalisation are undesirable, explanations are inductively generated that is form specific to general and the researcher can be involved with research participants. . Under this chapter, the following were looked at, the research design, study population and sample size. To be discussed as well is sampling design and procedure, instrument design, data collection procedures, data presentation, and analysis and interpretation. At the end of this chapter a summary will be given.The end product of this study was to generate theory which is supported by facts from the ground.
3.2 Research Design
Polit and Hungler (1991) describe the researchers overall plan for obtaining answers to the research questions as the research design. Glatthorn (1998) defines the research design as a specific plan for studying the research problem. Babbie (1986) highlighted that the special details of a research design differs according to what the research wants to do. The type of data that the research wants to collect also dictates the research methodology.
In this study, the mixed methods research design was used. This means that the researcher had to gather both qualitative and quantitative data during the research process.The study has sequential exploratory design in which the quantitative results was to be used to enhance qualitative data. This approach is especially useful when the researcher’s interest is in enhancing generalizability of results, (Burke and Onwuegbuzie 2007).
According to (Greene 2007) the mixed method design is an opportunity to compliment the weakness of quantitative and qualitative research. Actually Caracelli and Greene (1997) came up with the following uses of a mixed methods study: (1) it tests the congruency of findings got from different measuring instruments, (2) clarifying and building on one method with another method results, and (3) Showing how the results from one method can impact subse-quent methods or inferences drawn from the results.
According to Creswel (2003), mixed methods involve philosophical assumptions pointing to the data collection and analysis using a mixture of qualitative and quantitative methods in a single or series of studies. The argument being when quantitative and qualitative research designs are put together they tend to produce better results. Quantitative methods result in the voices of the participants not being heard and researcher bias is also common. Qualitative research enables the voices of the participants to be heard but limits generalisation of findings, in case point, gender norms and cultural-social challenges can be researchable.
Creswel (ibid), further says quantitative data includes closed information which may include behaviour. An instrument like a checklist may be used in the process. Quantitative data may also be from records such as reports. In this study, the researcher had to go through such reports from the health institutes and NGOs (EGPAF & Community Working Group) implementing partners for Hwedza district. In data analysis statistical methods had to be used.
Qualitative research methods are methods of data inquiry which aim to gather an in-depth understanding of behaviour and reasons that govern such behaviour. Quantitative methods are totake the form of a survey which used a semi-structured questionnaire to collect the data. A survey is a systematic attempt to collect information from a sample of individuals in order to describe and explain their beliefs attitudes, values, behaviour as well as their experiences.
3.3 Study population
The population of the district stands at 45000, with a total of 15000 women of child bearing. The study will call for people who were in Hwedza for the past two years. The participants of this study are those who were between 16 and 49 years since these were the people who were the target group for health promotion education programme. Extension population target group were district stakeholders and NGOs district staff.
The following were study populations of the selected communities:
1. The community leaders (formal and informal)
2. Pregnant and lactating women normally resident in the selected communities and their babies
3. Male partners of pregnant and lactating women/fathers of the babies, including other resident men
4. Health care workers from the study health facilities
5. Men and women in the selected communities
Polit and Hungler (1991) say sampling is the process of selecting a portion of a population to represent the entire population. Hwedza has 15 wards of which 3participated in this study.The researcher had to make use of purposive sampling technique. Creswell (2009:178) proffers that ‘the idea behind purposive or judgement sampling is to decisively select participants or sites that will best help the investigator comprehend the problem.’
The purposive sample for the purposes of this research comprised of key stakeholders at district level, thesefive key informants shall were interviewed and at ward level also two key informants from each ward shall wereinterviewed, a councillor, nurse in charge, community leader implementing the intervention, 2 peer facilitators a male and a female, 10 peers (5 female and 5 males) targeted with MNCH education were interviewed. A total 40 participants was targeted for in-depth interviewing and focus group discussions. For Focus Group Discussions each group had 10 participants for the 3 wards planned 16-49 age group.
In this study a Focus group guide was used to solicit information from the local leaders and community members. An interview guide was used to get information from key informants. A questionnaire for community members was designed and used to get information from them.
3.5.1 Questionnaire: A questionnaire with both open and closed questions had to be administered to selected respondents by researcher. It had an introduction which basically introduces the researcher and informs respondents about the purpose of research and assuring the participants about ethical considerations and seeking the participant’s consent.These were the categorised sections;Section Acovered the demographical and socio-economic information. Section B had focus on individual MNCH knowledge, attitudes, perceptions and barriers. Section C reflected on community MNCH perception, attitudes, beliefs and gender norms. Section Dwas on gleaning information on PMTCT knowledge and Behaviour. Section E focused on self- efficacy of health promotion education and formative assessments in creating on demand for, retention and uptake of PMTCT services.Then lastly, Section F. Programme goals and stakeholders involvement (sustainability and ability of replication)
3.5.2 In-depth Interviews
According to Litherhood (2000:12) in-depth interviews are used to help the investigator to enquiry and apt for further elucidation of ambiguous and blurred answers by the respondent. Targeted for the interviews were community leaders and peer facilitators,implementing, community engagement, community health days and peer education in health promotion of MNCH in Hwedza district. The in-depthsinterviews were directed tocommunity participants from the three selected health institutes to assess efficacy and relevance of these implemented health education promotional.
3.5.3 Key Informant Interviews
The purpose of key informant’s interviews tasked to collect reliable information from the professionals who had been implementing health promotion. Civic organisation district staff was interviewed .Key informants interviews provided insight on the nature of the problem of how health education has been implemented its positivity and shortfalls, thereby reducing biased information to the researcher.
3.5.4 Focus Group Discussion
FGDshad been conducted with peers to obtain first-hand information on the implementation of the health promotion education in district. FDGs informed the researcher on the various facets, strength and limitation of health promotion education. They also allowed time to gather how these cadres viewed the model, their experiences and recommendations
The study ,assessment of knowledge, attitudes, practices and beliefs (KAPB) on MCH/PMTCT among women peer group members through focus group discussions using semi- structured questionnaireat baseline, (prior to training/induction into the groups), and at end-line. The researcher also carried out participant-observation, during group discussions.
3.6. Data collection procedures
The permission study to carry out the research wassoughted from the District Administrator as well as the District Nursing Officer. The participants were consented before the interviews were done, as a requirement of research ethical considerations. Pre-testing of the questionnaire so as to fine tune the instrument was done. After that the participants were to be interviewed face to face.
Data collected from study participants, using pre-tested semi-structured questionnaires. Key informative interviews wereinterviewed first at district stakeholder’s level, NGO implementing personnel and nurse in charge at three of the selected health institutes. Three focus group discussions were held with female and male peers with regards to health promotion education. Exit interviews using the questionnaire were as well conducted to the above targeted peer group members, to collect information on their knowledge, attitudes and practice regarding MNCH. An in-depth interview with community health workers (peer facilitators and community leaders) were done, aimed on exploring limitations and strength of these health promotion education strategies.
According to Joppe (2000), defines reliability as the extent to which results are consistent over time and are an accurate representation of the total population under study. This calledfor scientific methods in coming up with a sample. Charles (1995) states that questionnaire answers should remain relatively the same and this can be achieved through test and retest method at two different times. This can answer the question of whether the results are replicable. These statements were linked to quantitative research and it was part of this study since mixed methods will be employed.
The scholar Joppe (2000) simply defines validity as whether the research truly measures that which it was intended to measure. The researcher had to closely examine the link between the data gathering tool and the research objectives. Validity is also after measuring how truthful the research results are?
Seale (1999) cited by Golafshani (2003) emphasises the discussion of quality in qualitative research and it subsumes reliability and validity which were initiated from the concerns of reliability and validity traditionally in quantitative research.
To ensure reliability and validity in this study a pilot study was done in another ward that implemented these health promotion education strategies. Seaman (1987) defines pilot study as small scale dress rehearsal done before the actual study. The idea was on testing questions that were to be used as part of this study. Questions that had ambiguitywere then identified and corrected.
The fact that mixed methods research design was used in this study that enabled triangulation to take place. Quantitative data assisted in verifying the quality of qualitative data. During the course of the study the research had to re-visit the same key informant’s at different intervals to verify the consistency of responses.
3.8 Data management
The data gathered during the study was quantitative and qualitative in nature since the mixed methods approach shall be used. A note book shall be used to record useful information from documents which are perused during the desk review process. A questionnaire per key informant shall be filled in and they are shall be coded. A notebook for each Focus Group Discussion shall be maintained.Qualitative data shall be transcribed into coded category. Quantitative data shall also be organised under subheadings related to questions from the question.
3.9 Data analysis and presentation
In the study quantitative data hadpresentations on tables, pie charts and graphs, qualitative /data analysed using thematic analysis. According to Creswell (2003), the analysis can be Sequential Exploratorywhich is characterized by collection and analysis of qualitative data followed by a collection and analysis of quantitative data as complimentary. This was done to use quantitative results to assist in explaining and also to interpret the findings of a qualitative study. This is how the study unfolded. Quantitative data had to be analysed using a statistical tastings techniques. Differences between categorical groups were tested using the Chi-Square test and for this analysis significance level was set at 0.05.
3.9.1 Data Analysis Methods
Data analysis is the process of making meaning from the data.Thematic data analysis was used by the researcher. The researcher analysed data gathered through identification of intermittent themes during the period of the study. The information collected and gathered by the researcher had to be arranged in thematic headings based on similarities of information. Content analysis was deployed in the research as a method of examining the information collected qualitatively. Coding of gathered information was done by way ofimposing order on the data and doing pattern recognition. Coding, guided by research objectives allowed the researcher to quickly retrieve relevant parts on the research topics.The researcher had to analyse qualitative data by using descriptive narratives, this had to identify the common issues coming out of the data collected to come out with a pattern or relationship. Qualitative data has to be presented descriptively as a way of summarising the findings from the interviews before interpreting the meaning within the context of the phenomenon understudy.
Constant comparative analysis was used by the researcher to analyse the data in the research. The research made use of case study in which contemporary phenomenon was used to provide context and narratives behind particular results about what actually transpired during implementation of health promotion education in MCH model .
3.9.2 Data interpretation
In interpreting this study the overall aims of the research objectives the theoretical framework and the literature that was reviewed was taken into consideration. Considered also was the limitations to the study that is the foreseen and unforeseen.
3.10 Ethical considerations
The permission to carry out the research was issued from the District Administrator of Hwedza District, study place. The participants’ consent was sought before the interviews were done. Those willing to be part of the research had to sign consent forms after explanations from the researcher. To ensure anonymity, data collection tools used in this research, no names were to be written but participants were allocated a participant number. The filled in data collection tools shall be kept under lock and key.
The chapter discussed on the methodology that had been used in conducting the study. A mixed approach for the study design adopted. The chapter deliberated on justifications of research instruments, the target population, data management and ethical protocols. Validity and reliability on researched data had been presented herein as well highlighting on data presentation and interpretation and discussions that has to follow in the next chapter.
Data Presentations, Interpretations and Discussions
The chapter presents data, deliberate on study outcomes qualitatively and quantitatively, giving meaning supported with other scholar’s opinions on the same subject matter. The data collected focuses on answering the study research questions, which are:
‘ Does health promotion education bring behaviour change on issues of maternal child health?
‘ To what extend can health promotion create demand for, uptake and retention of MCH/PMTCT services amongst communities?
‘ The significance of stakeholders in health promotion education buy-in, in issues of MCH/ PMTCT services
A total of 47 participants were reached, 8 being key informants and 39 included community leaders, Peer Facilitators and peers targeted with in-depth interviews and Focus Group Discussions.
4.1 Health promotion strategy framework:
The thrust of the implementing organization was to access the feasibility of community leadership engagement, community health days and peer education in creating demand for, retention and uptake of PMTCT services.
The knower is enticed to study effectiveness of these interventions as they try to bring down the fight of pediatric infection to Zero infection, Zero deaths, Zero stigma and discrimination the national goal in elimination of HIV, a resultant of behavior change and stakeholder buy-in. Figure 1 outlines the conceptual framework of the three health promotion education.
Figure 1: Conceptual Framework
4.2 Intervention 1: Engagement of community leaders:
The engagement of community leaders’ intervention had the following elements: training and capacity building on gender norms, stigma and MNCH/PMTCT; mentorship on influencing for social action and development of community action plans. The development of a community action plan (CAP), which aimed to provide a framework for action on how to overcome the barriers and enhance the facilitators to improve MCH/PMTCT outcomes in the particular communities and provide a platform for continuing community advocacy of MCH/PMTCT issues.
Principles of community engagement,which was published by CDC and ATSDR Principles defined community engagement as ‘the process of working collaboratively with groups of people who are affiliated by geographic proximity, special interests, or similar situations with respect to issues affecting their well-being’ (CDC, 1997,: 9)
The rationale for community-engaged health promotion, policy making, and research is largely rooted in the recognition that lifestyles, behaviors, and the incidence of illness are all shaped by social and physical environments (Hanson, 1988; Institute of Medicine, 1988) This ‘ecological’ view is consistent with the idea that health inequalities have their roots in large socioeconomic conditions (Iton, 2009). If health is socially determined, then health issues are best addressed by engaging community partners who can bring their own perspectives and understandings of community life and health issues to a project And if health inequalities are rooted in larger socioeconomic inequalities, then approaches to health improvement must take into account the concerns of communities and be able to benefit diverse populations
4.2.1: Analyzing the effect of community leader engagement on the demand for, uptake of and retention of HIV positive pregnant/postpartum women in MCH/PMTCT services
The feedback from key informants and general participants was in agreement that community leaders scored 40% in community organizing mechanism, 35% on influencing and 25% on modeling. The FDGs pointed out that more of modeling was on peer education the men’s groups and MCH groups since much was based on interactive and empowerment. On community organizing it was highlighted that they organized village PMTCT dialogues so by virtue of them being generally leaders their level of influence to health promotion uptake did not face headways even much resistance. This suggests the highest level of stakeholder buy-in from low level grassroots development structures.
Figure 3 Coverage on advocacy by community leaders
The statistics in figure 3 present advocacy meetings held by community leaders whose efforts were to demystify unsafe behaviours that catalyse transmission of HIV from mother to child. Feedback from health institutes personnel and community leaders pointed that the campaigns help to move downtrend on home deliveries, as shown in figure 3. The responds from Community Leaders give an estimation of 60-75% of women in their respective communities were reached with information on MCH/PMTCT.
In concurrence with the effectiveness of community leadership engagement the researcher’s findings match, Community Change (C-Change) another proven intervention that is an adaptation of the community conversation model introduced and disseminated by other non-governmental organisations (NGOs) and the United Nations Development Programme. World Vision adapted this approach to empower communities to transform cultural behaviours and social norms that have a negative influence within the areas of health, and HIV and AIDS. The C-Change methodology engages communities in a broad dialogue focused on identifying common goals, transforming harmful cultural barriers and planning positive actions. C-Change is a vehicle for disseminating knowledge about PMTCT and also for reducing stigma and mobilising community support for PMTCT interventions.
4.2.2: Community leader’s feedback
The community leaders reported that as a result of health promotion education, pregnancies were being booked on time, people where no longer afraid of being tested for HIV and many were being tested as couples, an increased number of women were now delivering at health centers, and mothers were bringing back their children for postnatal care. In some cases, however women were not quick to participate, the hesitant ones worried about material benefits and some thought it was only for HIV positive women. A reflection that behavior change is not an event rather a process, submerged in compassionate and passion.
Meaningful community engagement requires a capacity-building approach: Communityengagement is not a one-off event, but rather is a rights-based process that ultimately leads
to greater empowerment. Governments, donors and other development partners should planfor sustained financial and technical investment in community engagement as part of theirnational plan towards the elimination of new HIV infections in children by 2015 and keepingtheir mothers alive,UNAIDS (2012).The study findings were supported by Jones & Bartlett (2009),scholarsstated that engaged leadership at all levels is an important key for success: whether at the clinic, community,district, national or global level, an engaged leadership will help to ensure the successof any PMTCT programme. Encouraging national- grassroots level leadership and the expression of thisleadership in policies, strategies, frameworks and tools for greater community engagement will be vital to the way forward study of Nigeria, 2011.
4.2.3:Development of a Community Action Plan (CAP): These advocacy meeting had a philosophy of developing an Community Action Plan (CAP).CAP elements: The leaders were encouraged to advocate broadly among their stakeholders for improved uptake of MCH and PMTCT services, encourage open community discussion and promote an environment where the community is motivated to take action. The Community Action Plans were explicitly stating barriers to desired MCH outcomes, develop actions and targets to overcome these barriers, and identify the activities and contributions necessary. The community leaders developed and disseminate the plans widely with their stakeholders and constituencies to promote buy-in and elicit action at the grassroots level.
The findings from the study concurred with, the Government of Botswana’s Department of HIV/AIDS Prevention and Care cites community mobilization as one of three main strategies for the national PMTCT programme.Communities are encouraged to take the lead in promoting the importance of HIV testingand PMTCT enrolment. Communities are also encouraged to prevent health problemsrelated to PMTCT through their own efforts. As cited by the Government of Botswana, themain lesson learnt is that ‘political commitment is necessary’. Other lessons include thatall stakeholders, especially nongovernmental organizations, must collaborate; and thatcommunity ownership is enhanced through community capacity development (Departmentof HIV/AIDS Prevention and Care, 2009).
Listed below are some of the barriers and recommended solutions from CAP
Table4.1presentation on identified PMTCT barriers and recommendations
Barriers Solutions recommended
Low male involvement Village heads agreed that community cadres to given platforms at every gathering to disseminate knowledge on PMTCT with particular focus on HIV partner testing and screening
‘ fontanel management
‘ traditional practices on new-borns/ pregnant women
‘ bewitching of pregnancy hindering early pregnancy booking
‘ polygamies Health education on myths and misconceptions regarding such issues
Poor health institute and community working relations. Health staff created an unfriendly environment Local leadership and health centre committee to hold meetings of amending relations and creating an idle environment
Poor road network infrastructure Village heads to organise repairing of roads
No mothers waiting homes at the health institutes Multi-stakeholders approach, the community will mould bricks and provide labour
Lack of knowledge from traditional births attendant It was commendable that they undergo a refresh course that will highlight to them dangers of home pregnancy deliveries in this advent of pandemic
‘ domestic violence
‘ unsafe sexual practices Continuous advocacy and education.
Empowering the disadvantaged group, women and girls.
Local leadership to summon men who perpetuate domestic violence.
The following scholars, (Lopez, Jones et al. 2010, Trimble, Nava et al. 2013) reported that, both the IMAGE project and the Stepping Stones project were found to reduce IPV, and other risk behaviors for HIV transmission and negative gender norms which are drivers of both the HIV and gender violence pandemics.
The Stepping Stones program, which was originally developed in Uganda and has now been implemented in more than forty countries in Africa, Asia, and Latin America, takes a participatory gender transformative approach involving critical reflection on gender inequality as a means of encouraging safer sexual practices. Peer groups (stratified by age and gender) work separately and then together to analyze factors that affect their lives and behavior, and to define how they could implement positive change to reduce HIV and AIDS vulnerability in their life and community. Program evaluations from India, Gambia, South Africa, Ethiopia, Angola, Tanzania, Uganda and Fiji involving 14,630 people have also shown varied but generally positive results with reduction in IPV and other behavioral risk factors for HIV acquisition such as abusing alcohol and having multiple sexual partners (Skevington, Sovetkina et al. 2013). Participation in the Stepping Stones program has also been correlated with increases in HIV knowledge and measures of gender equity and reductions in HIV-related stigma (Skevington, Sovetkina et al. 2013). The South African randomized controlled trial of the Stepping Stones program, which measured biological outcomes, had a number of interesting findings. First, the study identified a statistically significant reduction in herpes infections among the intervention group. Second, while not statistically significant, there were 15% fewer new HIV infections among young women in the intervention group (Jewkes, Nduna et al. 2008).
4.2.4: Knowledge level on benefits of institutional delivery
The Ministry of Health Child Welfare had made it a rule of thump that no women should deliver outside the institute to easy management of pediatric HIV elimination. All the three health promotion interventions aimed at eliminating home deliveries. The graph below presents trends before implementation (2013), during implementation (2014-2015) and after, showing a positive growth to the call.
Fig 4: Trends on Home deliveries from the 3 sample health institutes
The major hindrance in an effort of elimination of HIV in pediatrics is the fact that untrained birth attendant facilitates the birth delivery. Study participants cited, a cause to water mouth intervention failure in eliminating HIV if all stakeholders fail to deal with untrained birth attendants.
On the question to request participants to highlight barriers to elimination of HIV, the issue of traditional births attendants that came top. The stakeholders feedback on which areas they view the intervention managed to close knowledge gaps, 6/8 (75%) pointed out during community health days the District Administrator’s office, District AIDS Coordinator, Chief or Headman had a prerogative duty to condemn home deliveries with much focus on religious groups and traditional births attendants.
Discussions from FDGs directed the conclusions that community leaders, key note address was on discouraging home deliveries. It clearly reflects that leaders in community have a certain level of power to manipulate and or composite communities to follow their view. Participants further highlighted that some village heads and headmen whom are described ‘as overzealous’ enshrined a policy at their levels that any man those women delivery at home is suppose to pay a goat.
The study outcomes highlighting on the knowledge gap of HIV management in PMTCT of traditional births attendant since they service providers, is important. A programme in the mountainous areas of rural Lesotho has realized improvements at each point in the PMTCT continuum of care through a combined effort of training traditional birth attendants and other community members as maternal mortality reduction programme assistants (MMRPAs);
The MMRPAs are responsible foridentifying and counselling women in their own villages about the importance of comprehensiveantenatal care and delivery at the health centre. Womenmake a greater number of antenatal care visits during each pregnancy, and facility deliverieshave dramatically increased. (Partners in Health personalcommunication, Nov 2011).
4.2.5 Evaluation on Behaviour Change under community leadership engagement
The researcher understood that community leadership engagement posses the hidden force in communities to force behavior change. As community leaders trained by the implementing organization recruited other local leaders like Village Health Workers (VHW), village heads and headmen to impose an attentive PMTCT behavior in demand, retention and uptake of ANC and PNC services.
4.2.6Evaluation on self-efficacy PMTCT services.
The power within community leaders pushed for the services of institutional delivery, they came out strongly in condemning traditional births attendant. They went astepped up to extend that they gazette fine for traditional attendants as a measure to discourage pregnant women to be assisted by untrained community attendants.
4.2.7 Summation on stakeholder buy-in regarding community leadership engagement.
The day to day custodians of laws and regulations are the local community leadership. The health promotion intervention managed to win support of grassroot leadership. Village heads and headmen coiled in their societal by-laws that traditional attendants be discarded or if possible be trained in this advent of HIV transmission to manage the pandemic. Some enshrined in their societal constitutions that any women who gave births at home the male responsible or parent in case of single mother shall be obliged to pay a goat price.
In summary the intervention had greater drive in winning stakeholder buy-in both primary stakeholders who are the product consumers and secondary stakeholder as well the interested parties like the Ministry of Health Child Welfare. Assessing on creation of demand and behavior,the intervention had moderate stamina since these are individual socially molded.Community engagement is relevant and needed in all four prongs of PMTCT: The need forcommunity engagement in PMTCT scale-up was a guiding assumption of this review study and wasrevalidated in the strength of the promising practices identified and results achieved. Communityengagement should be viewed by all stakeholders as an integral feature of any comprehensivePMTCT programme.
4.3: Intervention 2: Community health days:
These were a large catch platform for health education dissemination targeting all age groups; the other two health promotions were streamlines of community health fairs. Key informants participants involved in the study all 8/8 their responses agreed that community health days was the most effective. MoCHW further affirmed in collaboration with National AIDS Council district representative they are in a process of establishing a district committee that will be tasked to continue the idea of conducting such foras of health magnitude.
District AIDS Coordinator acknowledged that their provincially approved programme ongoing of PMTCT community dialogues was through lessons learnt from community health days that were implemented in Hwedza and Goromonzi districts by NGO (EGPAF).
Fig 5: Attendance figures for community health (CD) days
Similar such programs of engaging communities on health promotion education were highlighted, in a participatory communication programme, particularly for stigma reduction. By tacklingharmful attitudes and norms ‘from within’, programmes can inspire uniquely strong andrelevant responses. For example, a participatory process undertaken with a rural communityin the Eastern Cape of South Africa led to the adoption of a community declaration on HIV.This declaration distinctively reflects the voice of the community it intends to influence andin so doing increases relevance and engenders ownership (Parker & Birdsall, 2005):
Participant Group Male Adults Mother in laws Women child bearing age Male Youths Female Youths totals
CD 1 278 21.1% 258 19.6% 683 51.9% 54 4.1% 43 3.35% 1316
CD 2 211 17.3% 256 21% 626 51.4% 89 7.3% 37 3% 1219
CD 3 193 16.4% 291 24.7% 564 48% 59 5% 69 5.9% 1176
CD 4 280 21.3% 302 23% 584 44.5% 63 4.8% 84 6.4% 1313
962 19.1% 1107 22% 2457 49% 265 5.3% 233 4.6% 5024
Table4.2 above is on community health days attendance statistics
Women of child bearing are most affected and at risk population group in this advent of HIV. It could make greatest impact if they are reached with health promotion education. The table presents that 49% of the total community health day’s participants were women of child bearing age. As in curtailing down the spread on HIV in new born, this is a plus to the efforts. Chambers. R (2002), it is the horse that knows how hot the ground is not the rider. The phenomena that knowledge + power = empowerment is reflective of the figures hence conclude that learning took place particularly with the most affected group. The researcher highly optimistic that knowledge, attitudes, practices and briefs changed for the positive.
Furthermore, rates of uptake, linkage between MCH and HIV care, retention and ART adherence are suboptimal. Reducing HIV-related stigma and gender discrimination, including violence against women, increasing social support for women during pregnancy and the extended postpartum period, and mobilizing communities to promote respectful, high quality HIV and MCH services are promising interventions for creating an enabling environment for women to access and remain in care, Nassali et al (2009).
UN Commission on the Status of Women to eliminate preventable maternal mortality will not be achieved unless HIV among women of reproductive age is addressed and care of pregnant women living with HIV is improved (United Nations 2010). Changing the negative synergies between HIV and poor maternal health outcomes into opportunities to promote the health and well-being of women of reproductive age, both those who are living with HIV and those who are not, is an urgent international public health priority.
Women of child bearing age as well pointed out in FGDs that participation of their mother and father in laws was a springboard to clear unscientific knowledge that are a cause to a flaccid to zero infection in pediatrics . The issue of NO support to exclusive breastfeeding came out strongly, verbatim record ‘the myth that infants are not satisfied with the mother’s milk until 6 months of age should be demystified and the Ministry of health and child welfare and NGOs gave a scientific explanation regarding nutrition and hormones, thumps up as this provoke discussions with mother in laws, father in laws and husbands. It is a platform then for a woman to self liberate from such practices.’ UNAIDS (2012), report points that mothers should be enlightened on why they are encouraged to exclusively breastfeed if they are found to be HIV positive and the male counterparts should also be educated on the benefits of Exclusive breastfeeding. However, limitations of the study were that Social and cultural beliefs have an influence on an individual’s perception hence some mothers had challenges of opening up. Incidence of exclusive breastfeeding is declining in almost all parts of the world despite all its benefits.
World Health Organisation recommends exclusive breastfeeding for the first six months of life and this reduces child mortality rate by 13% which rose from 8.2% in 2009 to 8.6% currently in Zimbabwe.
4.3.2 Community health day service provisions
Adult learning is by practice, all facets that were advocated for regarding demand for, retention for PMTCT services where provided, Provision of general health and HIV related services: including: HIV counseling and testing, TB (clinical) screening, blood pressure and glucose (urine dipstick) testing, pregnancy testing and information about ANC services and facility delivery, contraceptive counseling, information on medical male circumcision and child nutrition screening. Other implementing partners may were invited to participate in the event, if they offer services that may add value to the Community Day event. For instance, Population Services International (PSI), may carry out HIV counseling and testing or distribute information on voluntary male medical circumcision, ZiChire targeting behavior change and Family Planning services. The table below shows figures reached during community health days.
4.3 Table of figures of service provisions at community health days
HIV testing & counselling Pregnancy testing ANC information Child nutrition education CD4 count Sexual reproductive health education
CD 1 263 36 654 312 54 376
CD 2 211 16 441 143 101 231
CD 3 134 23 306 266 94 332
CD 4 286 44 516 348 126 491
In view of service provision during community health days, the idea demanded action on positive behavior from communities as such, a similar activity, Men Taking Action was a communication strategy undertaken in Zambia to promote maleinvolvement in PMTCT.9 Male community leaders took part in formative research to identifythe specific male attitudes and practices that negatively impact women accessing HIVcounseling and testing and PMTCT. Messages were delivered through faith-basedhealth institutions and trained traditional and cultural leaders. After each session, men wereencouraged to test for HIV in an opt-out manner. In the first 5 months, 65% of the 2261 menreached by the programme tested for HIV, compared with a baseline rate of 11%. There wasa fourfold increase for same-day pregnant couples counseling and testing. Antenatal clinicclients’ acceptance of HIV counseling and testing rose from 60% to 95%, and acceptancerates for antiretroviral prophylaxis or treatment rose from 40% to 70% among womenwho tested positive. PEPFAR (2011) findings suggest thatcommunity-led communication is a powerful tool for transforming attitudes and reducingstigma, engendering local leadership, and increasing service uptake.
4.3.3 Improved PMTCT services uptake through male involvement
The graphic presentation above figure 6 highlights to the fact that gender disparities are a negation to elimination of HIV in newborns. Responds from the in-depth interviews, a sample of 39 participants 33 respond that male partners are afraid of being tested for HIV, causing poor adherence to women who test positive as disclosure becomes a challenge. All the three health promotions were advocating ‘sheketsa perekedza mimba yako’, which had a positive outcome on male involvement in PMTCT particularly HIV testing and counseling.
A responses from key informants particularly MoHCW (Nurses in Charge) they pointed out it was now their strategy on community health days to announce statistics on male involvement and benefits the institute give to couple HIV testing, marriage and social benefits. On the same platform they could ask communities to respond on their views regarding low male involvement. The respondent was in strong agreement that males were doing such behaviours in ignorance hence the health promotions closed such knowledge gaps resulting in a positive trend recorded.
Numerous communities have undertaken efforts to address these issues through increasing constructive engagement of men in PMTCT. Literature supports that addressing gender attitudes and norms can have an influence on uptake of PMTCT services. In a prospective cohort study conducted between 1999 and 2005 in Nairobi, Kenya, the risk of vertical transmission was lower among women who attended an ANC clinic with a partner compared to those attending alone, adjusting for maternal viral load. Risk of vertical transmission or infant death was also lower among women reporting partner HIV testing, adjusting for maternal viral load and breastfeeding. Aluisio,A. et al (2011). The woman’s ability to disclose her HIV status and have her partner’s support for ARV treatment was likely the facilitating factor in reducing HIV transmission, although this was not measured directly in the study. Partner attendance at ANC was also likely a proxy for male support.
4.3.4 Stakeholder buy-in, in health promotion education
Knowledge decentralized result in a big catch of targeted population hence behavior change will be positive.A mounting body of evidence over the past 10 years strongly supports the importance of engagingcommunities in PMTCT to better understand and address sociocultural and other barriers and toengender local ownership and sustainability while decentralizing services and scaling up coverage(Israel & Kroeger, 2003; Leonard et al., 2001; Rutenberg et al., 2003). Both the UNAIDS InvestmentFramework for HIV/AIDS through 2020 (Schwartlander et al., 2001) and The Global Plan promoteincreased community engagement as a priority.Arandomized field experiment on increasing community-based monitoring conducted in Uganda provides significant insight on this promising practice (Bjorkman & Svensson, 2007).
4.4 Assessing the additional effect of community peer groups on the demand for, uptake of and retention of HIV positive pregnant/postpartum women in MCH/PMTCT services
After informed consent, the men were invited to attend a series of group discussion sessions. These sessions normally lasted about 2 ‘ 3 hours, and over a period of 2 ‘ 4 months, a total of 4 sessions were held. Feedback from FDGs concluded that the focus of the discussions were on change of behaviors that can and should be changed to meet the goal of improving mother and child health in relation to PMTCT.Pregnant women (both HIV negative and HIV positive) were recruited to the MCH classes (as early as possible in their gestation) from a variety of sources. Health facilities were referring women and men to the classes, as well community/village health workers, traditional birth attendants (TBAs), the community leadership, and staff/facilitators at the Community Days.
The table4.4 below shows statistics on ANC booking
< 12 weeks 12-27 weeks 28 week+ Total
Garaba Goto Mukamba Garaba Goto Mukamba Garaba Goto Mukamba
2013 13 7 21 133 89 183 144 117 67 774
2014 84 39 58 202 96 140 79 23 61 782
2015 97 43 58 225 88 117 41 21 48 738
2016 53 11 08 50 36 31 7 2 14 212
247 100 145 610 309 471 271 163 190 2506
The critical column in management of MCH / PMTCT is ANC booking with gestation period less 12 weeks. For the three institutions,overly its 19.6% of the total 2506 pregnant women who booked for ANC where on timeline according to recommended WHO HIV guidelines on elimination of HIV in pediatrics. The figure’s upward trend positively alerts on importance the health promotion education impacts to communities on ANC early booking. It demands more on researchable topics, probably the issue distances to health facilities is a drawback and many more factors.
FGDs participants strongly agree greatly that community health days and peer group intervention positively influenced behaviours of Hwedza communities. With member checking technique the verbatim record is as follows ‘community health days in particular group PMTCT dialogues had a breakthrough to the following target groups ,mother in laws , father in laws and males as they were given technical explanations. These groups would impose traditional and cultural practice to women of child bearing age but now they are in the forefront demanding we seek medical attention in earliest time.’
Feedback from Key informants alluded to the fact the PMTCT dialogues provoked male involvement not merely the husband responsible for the pregnancy and postnatal care management but the entire community’s responsibility and obligation.’ It was religiously advocated that pregnancy is not an emergency, never to be, it is planned hence all poverty and economic barriers raised by males are a flaw.’
The study outcomes are complimented with, data from a South African study suggests that antenatal and postpartum visits by trained peer mothers benefit women living with HIV and HIV-negative women. Women living with HIV who were visited by a peer mother were significantly less likely to have birth-related medical complications and more likely to administer infant antiretrovirals, practice exclusive infant feeding, and have infants with healthy height-for-age scores (le Roux, Tomlinson et al. 2013).
The table below suggests that the barriers to PNC which includes lack of commitment from male were ironed out
Table4.5 of figuresPNC service retention
< 3 days 7 days 6 weeks Total
Garaba – Mukamba Garaba – Mukamba Garaba Mukamba
2013 76 97 114 135 120 141 683
2014 59 110 79 95 50 80 473
2015 76 142 90 125 74 129 636
2016 34 49 34 42 39 31 229
245 398 317 397 283 381 2021
Analysis the data with time series regression Mukamba health center
2013 2014 2015 2016
X 1 2 3 4
Y 97 110 142 ?
Prediction 94 116 149 161
Regression equation Y=71.3+22.5X
The FGD discussions raised issues to do with field work commitments, distances to health centers for uptake of PNC services, but mostly low male knowledge on importance of PNC services hence the health promotion leveraged a step up the uptake of postpartum services.
The discussions to the findings agreed to one of the interventions which had been successful at engaging men and obtaining high rates of treatment uptake and retention for men, women and children is the MTCT-Plus model of ‘family-focused care’ which aimed to enroll the pregnant woman and other HIV-infected family members. In a cohort from the Ivory Coast, 95% of the eligible women began treatment and, of those, 98% were still in care two-years later. Additionally, 78% of those living with HIV and more than half of the HIV-negative male partners participated in the program and 95% of the male partners on ART and 100% of the HIV-positive and HIV-negative children, as well as the HIV negative male partners were still in the program at the two year follow-up (Tonwe-Gold, Ekouevi et al. 2009).
4.4.1 Evaluation of social learning theory
The theoretical framework of peer education through Social Learning Theory states that people learn from each other through observation, imitation and modeling and some people (significant others) are capable of eliciting behavioral change in certain individuals, based on the individual’s value and interpretation system. In depth interview with Peer Facilitators, they acknowledged that peer sharing of pregnancy experiences provided milestones to model and sharp other peers on issues of MCH/PMTCT. Accordingly, peers discussions provided solutions on haddock issues clears myths and misconceptions in most receptive mood.
As alluded by some scholars that a variety of social, behavioral, and structural barriers operate beyond the influence of the health system, limiting HIV and AIDS service demand from target individuals and communities. During FGDs the question: what challenges that are into existence that prevents women from getting services of ANC and PNC. Through use of thick description peers point out that,’ the issue that we don’t have proper clothing, nurses request us to undress, poverty is a challenge, l better go for ANC booking when the husband bought me a new dress and a paint.’ This is beyond the health delivery system since they provide education that pregnancy should be planned in essence the issues of poverty are manageable if pregnancy is planned. The challenge on demand service is cultural and societal enshrined because maternity booking and delivery is fee free, peer education impact knowledge.
To identify KAPB gaps that undermines women of Hwedza community from creating demand and having retention of health services on MCH/PMTCT. FDGs highlighted the following presented in a table4.6 below
Question /topic Responses Category
What briefs and traditional practices done to pregnant women Among all of us here include you the researcher your fontanel had been managed the traditional way, also people have their culture health should not destroy our culture.
These young women of first pregnancy the birth canal only opens with these traditional practice otherwise at health facility they will be operated. Without these practices more maternal deaths could have been recorded
Concern that these challenges were and are still manageable the traditional way even in this advent of pandemic
Concern of death or operation
How do these briefs and practices a negation to behaviour change in an effort to eliminate HIV Mother in laws insists the practices must be done
These challenges like fontanel management can only be reversed when administered the traditional way otherwise the child will die
Baby’s body is built up through early introduction of solid food stuffs. Elders insists on solid foods
Failure to trust the health management means on fontanel
Elders coercive strategies
Coding and categorizing ideas and concepts have identified words/phrases used frequently, as well as ideas coming from the participants how they expressed themselves their understanding of subject matter. This reflects that there are other issues that retard demand for PMTCT services as health facilitates are rendered second option. The intergenerational gap with the advent of HIV and AIDS is showing effects of elimination of the pandemic to the unborn and new-born particularly through fontanel management whereby rubbing exposes the baby to infected milk from the HIV infected mother. The service for PNC is being catapulted down by the elders and mothers in law as they are strongly and continually engulfed in their traditional briefs and practices that they want done to their grandsons and daughters. Women of child bearing age will comply to save their marriages. Stewart-Knox et al (2003) stated almost a decade ago, “culture profoundly influences health knowledge, attitudes and behaviour; and this is particularly true of infant feeding practices” (p265). Known demographic factors that influence breastfeeding duration rates are race, age, marital status and socioeconomic status (Grassley, 2010; McGregor & Hughes, 2010; Thulier & Mercer, 2009).
More broadly in the field of maternal and child health, participatory women’s groups that identified problems, developed locally-feasible plans to address the priority issues, implemented, and then assessed the results of their actions were shown to dramatically improve health outcomes (Prost, Colbourn et al. 2013). Exploratory data above has similar findings from meta-analysis of program results from seven randomized controlled trials in four countries found that women’s groups resulted in a 37% reduction of maternal mortality; if more than 30% of pregnant women in the community participated in a women’s group, the impact on women’s and children’s health was estimated to be even larger’55% reduction in maternal mortality and 33% reduction in neonatal deaths (Prost, Colbourn et al. 2013). The authors hypothesized that maternal mortality was reduced through improved uptake of ANC, better hygiene during and after delivery, and small changes in the rapidity of response and care-seeking which contributed to maternal survival (Prost, Colbourn et al. 2013). The Malawian study correlated establishing a women’s group in the community with a 74% reduction in the maternal mortality rate and a 28% reduction in the infant mortality rate (Lewycka, Mwansambo et al. 2013).
The peer group intervention was targeted at the individual level, unlike the other interventions which are at community level. To assess its effect on women attending the MCH classes, researcher compared home delivery and institutional deliveries at Mukamba health center. A positive growth trend on institution delivery at the same time witness a downward gradient on home births a commendable effort of health promotion.
4.7Statistical testing with chi-square at 5% significance level of testing
2013 2014 2015 Total
Institute delivery 123 141 163 427
Home delivery 15 12 6 33
138 153 169 460
Q health promotion education can manage negative behaviours
The statistical testing showed an acceptance to the hypothesis that health promotion education can result into a positive behavior change in health seeking behaviours of communities in issues of PMTCT services uptake, since the test accepted outcomes at 6.04 with critical value of 10,6 as a decision point.
4.4.2 Opinions on community perceptions, attitudes and beliefs in seeking health institutional services
Q= institutional pregnancy delivery can help manage complications and vertical HIV transmission to pediatric?
Strongly agree agree disagree Strongly disagree Not sure
N of respondents 7 30 2 0 0
With the technique of member checking, in an effort to assess why two respondents disagree, they highlighted to the fact on poor level of working relationships between health staff and community but with triangulation on data collection. in FDGs participants deliberated to the fact that community should priorities things, working relations are not important as compared to my baby hence not mind the prevailing circumstances and have focus on making sure my child is HIV free. Secondly the health staffs have a responsibility and obligatory role which pushes him/her to do the job at hand to perfection level regardless of compromised relations. Such statements reflect the highest level of education impact on priorities of HIV management in elimination of pediatric infections.
Table4.8 below categorical data measuring knowledge intensity on HIV transmission in pediatrics
General transmissions Vertical HIV transmission (MTCT) N %
Having unprotected sex with an infected partner(s) Having multiple sexual partners Sharing of sharp objects
During pregnancy During labour and delivery During breastfeeding
Low knowledge ‘ ‘ ‘ x x x 8 20.5%
Moderate knowledge + anyone one from vertical transmission side ‘ ‘ x 26 66.7%
High knowledge x x x ‘ ‘ ‘ 5 12.8%
Totals 39 100%
PMTCT knowledge is critical in attaining the desired goal of eliminating new pediatric HIV infections. Therefore knowledge level gaps were identified through in-depth interviews the most expected responses were from the vertical transmission not the general. Family Health International (2010), states that HIV may be transmitted to the infants during pregnancy, at the time of delivery and through breastfeeding. For a known HIV ‘infected mother who becomes infected in the antenatal period, the additional risk of transmission of HIV to her infant through breastfeeding has been estimated at 16%, it may reach 29% for mothers who acquire HIV in the postnatal period, Newell (2010). To assess the effectiveness of these health promotion PMTCT knowledge level on managing vertical HIV transmission were discussed in FDGs, participates agreed to the fact that family and spouse support is greatly important to surpass the challenge on vertical HIV transmission. They cited safe sex practices during pregnancy and breastfeeding as gap to be bridged in HIV pediatric management, infant nutrition feeding and practices they should all be in support of eliminating changes of passing on infection to the baby. This calls for a total family support since custodian and feeding times are every member’s subject hence the need to adhere to health advised feeding practices that do not exacerbate new HIV infection in pediatrics.
4.4.3 Self ‘efficacy on PMTCT services demand, retention and uptake.
Table4.9 below show couple HIV testing at Garaba health centre
2013 2014 2015 Total
Couple HIV testing 31 25% 69 34% 74 33% 174 32%
Individual HIV testing 93 75% 133 66% 152 67% 378 68%
124 202 226 552
The statistical figures above are on couple / male involvement HIV testing showing that a total 32% of recorded ANC bookings for the past three years involved partners and 68% were individual pregnant women. The analysis is that capacity building and women empowerment is important for ANC booking. Some of the reasons that could have failed the raise in figures are male partners will be away in their urban workplaces, some women are single parent hence no couple. These findings are in agreement to those done in Tanzania.
An intervention which randomized pregnant women to individual voluntary counseling and testing (IVCT) for HIV or couple voluntary counseling and testing (CVCT) in Tanzania is a cautionary tale about the potentially negative impacts of certain ways of promoting male involvement on women’s uptake of services. Half of the women randomized to CVCT did not return to the clinic, only 16% completed CVCT, and only 43% of the women randomized to CVCT completed HIV testing during pregnancy (either alone or with their male partners) as compared to 78% of the women in the IVCT group (Becker, Mlay et al. 2010).
Hence clearly, women’s concerns about disclosure of HIV status to male partners needs to be addressed and options for confidentiality considered carefully in efforts to promote male engagement. Not requiring male involvement as a condition of service provision is critical given that, in many communities in sub-Saharan Africa, a significant proportion of pregnant women are single. Finally, interventions which seek to involve men must ensure that women’s autonomy, safety and choices are respected, if self-efficacy on PMTCT services are to scale up and utilised fully.
Finally, significant community, cultural and social as well stakeholders barriers to effective elimination of HIV in Maternal Child Health were addressed with the three health promotional education strategies. What is greatly questionable to the researcher is, will the reflected wholesome approach be integrative and sustainable years down the line when funders pull out since the community drivers of these efforts were voluntary agents. Documented barriers to women beginning HIV treatment for PMTCT and for their own health, Hwedza communities should find lasting solutions if they are to entertain hopes of Zero infections, Zero deaths Zero stigma and discrimination. Broader health systems issues such as poor quality of care and geographic and economic barriers are also associated with poor uptake and retention of women in PMTCT. The next and final chapter will dwell on findings, giving recommendations and conclusions.
Findings, Recommendations and Summary
This chapter will sum-up the findings of the study make-up some recommendations as well give summary of the analysis of the effectiveness of health promotion education in Hwedza communities and in general spheres.
5.1 PMTCT technicality on wholesome HIV management
To improve the effectiveness of PMTCT programs and to reap the benefit of PMTCT interventions, women need access to adequate antenatal, delivery, and postnatal care, which includes, the following, comments from District Medical Officer:
‘ Early access to antenatal care (before 28 weeks) but the recommended time for pregnancy booking is with the first trimester, less 16 weeks
‘ Voluntary counseling and testing
‘ A minimum package of antenatal care that includes vitamin supplementation and screening for and treatment of anemia and sexually transmitted diseases (to reduce both sexual and mother-to-child transmission of HIV)
‘ Delivery care by a skilled attendant, including optimal obstetric practices that may reduce the risk of transmission
‘ Counseling on infant feeding and care practices, and support of mother’s infant feeding choice
5.1.2 ANC booking delay
Exploratory findings on the importances for early ANC booking to pregnant women, it shows the women are knowledgeable on early detection of HIV if a pregnant woman books within 12weeks as recommended by ministry of health. However they shun frequent or regular visits this came out in the prior discussions. At finalized discussion it was hammered down as peers pointed out that the only minimum recommended visits are four, if the pregnancy progression is satisfactory according the health experts, Peer Facilitators concluded. The discussions brought out knowledge gap that are detracting pregnant women from creating service demand for ANC, avoiding monthly visits not knowing it’s not homogeneity it’s on individuality recommendations. The most frequently-mentioned reasons for delay included: lack of money for booking and transport to the health facility for those that required public transport, long distance to health facilities, and cultural beliefs that women should not announce their pregnancy before it was physically noticeable. Some participants felt that booking early would make them visit the health facility several times and they felt that this was unnecessary.
5.1.3 Gender inequality
To assess practices, briefs, norms and social effects that pervert pregnant women from meeting behaviour change in positive direction for the elimination of HIV. The researcher learnt from FDGs when it was vividly concurred that women don’t engage men on family planning issues. Verbatim sentiments from women ‘lam the one who decide when to have a birth and conceive.’ This was unexpected reactions from the question, in what ways does male involvement facilitate in demand creation and retention of health services? It point out that communities often do not understand how to encourage the positive role that men can play as fulfilling their role as head of the family in supporting their female partners and children to access services and practice healthy behaviors. In many settings, these traditional gender roles confer power on men to make decisions related to women’s participation in PMTCT programs, including whether they undergo HIV testing, return for follow up appointments, and adhere to ARV regimens. It was confirmed that men are afraid of HIV testing hence they assumes spouse results are a reflection of their HIV status. Women who are diagnosed with HIV often do not receive any significant support for disclosing their HIV diagnosis to their male partners. Observations and desk data provided evidence has suggested that in spite of facility-based efforts to advocate for couple HIV testing as mechanism supportive for women who test positive, many women face a dilemma to disclose their status to their partner for fear of violence or abandonment and consequently are less likely to attend future ANC visits, adhere to ARV prophylaxis, or initiate treatment for their own health.
5.1.4 Views on ANC/ PNC services
The researcher got that participant’s views about ANC services were very positive and they reported that nurses were usually available at health facilities and provided services. Participants indicated that attending PNC was important because it was an opportunity to check on the baby’s growth, provide HIV testing for mother and infant, receive immunizations, and protect child from HIV during breastfeeding.
‘ There is moderate rate of adherence to PNC visits mostly due to lack of knowledge on HIV pediatric management in postpartum phase. The health promotion strategies covered much ground on ANC and were weaker on PNC.
‘ Religious briefs are a confirmed stringent barrier in some few parts of Hwedza District with some apostolic sect members hence failing attainment of HIV elimination on MTCT.
5.1.5 Perceptions on health promotions interventions
Participants from community level felt the strategies were beneficial, as they enlightened women through information shared in community leadership engagement meetings, community health days and peer education. These brought about courage to disclose HIV status, encouraged women to book early and adhere to ANC recommended visits. A decrease in number of home deliveries, improved male partner participation and involvement of local community leaders was observed.
‘ Peer Education: the findings were that, Maternal Child Health peer groups accorded pregnant women platform to share experiences and correct myths, misconceptions and briefs that influence the spread of HIV in pediatrics. However some disregard the idea mixing older women with first time pregnant women because of old traditional and cultural ideology of MCH. Peer Facilitators pointed out that dealing with pregnant women who experienced negative attitudes from health workers when they advocated for demand, retention and uptake of PMTCT services was a challenge. Peers concluded that peer group discussions triggered partner HIV pregnancy management since their males could ask for feedback.
‘ Community leader engagement: engaging local leadership in dealing with community ills that are embedded in social and cultural dynamism proved effective. Community leaders harnessed challenges and crafted local solutions in narrowing HIV transmission in pediatrics. As community icons, most leaders’ educated communities at village meetings, ward meetings, water points, funerals and churches where the size of gathering ranged from five up to 60 people. The estimation is that 60-75% of women of reproductive age in their communities got information on Maternal Child Health on Prevention of Mother to Child Transmission of HIV.
‘ Community health days: all participants strongly agreed that health promotion education basing on community health fairs is an effective bridging scheme for correction of myths, misconceptions and briefs since technical experts will educate large volumes of participants. PMTCT group dialogues during community health days cherishes family dialogue on subject matter, they much entrenched eradications on traditional and cultural briefs and closing of knowledge gap on HIV between women of reproductive age and mother in laws. Males, be it a partner or father in law they were made to realize their highest role of influencing behavior change and adherence to health schemes in curbing down prevalence of HIV in pediatrics. Health staff pointed out that male involvement on couple HIV testing and screening is on positive growth, giving credit to education dissemination on community health days as this was an ideal platform to catch the mere men, who is mostly unreachable with efforts of addressing Maternal Child Health. Stakeholders indicated that their will adopt PMTCT dialogues in the whole District, to educate communities on their roles and responsibility on PMTCT.
5.1.6Community and Health cadres
‘ The findings of the study highlighted on aspects of integrity, maintaining core-values trustworthiness, reliability and credibility to Community Leaders, Peer Facilitators and health staff if ever demand, retention and uptake of PMTCT services are to scale to greater heights opinion leaders.
‘ The Community Leaders and Peer Facilitators role as educators is especially important in outreach work, where the target audience is not reached through formally planned activities but through everyday social contacts.
‘ Community engagement often involves building coalitions, defined by Cohen et al (2002) as ‘a union of people and organizations working to influence outcomes on a specific problem’ The goals of a coalition might range from sharing information and resources to advocating for specific policy changes (Cohen et al , 2002). Stakeholders must find mechanisms to maintain and adopt PMTCT dialogues and community health days.
‘ Relatively poor uptake and retention in MCH and HIV services and suboptimal ART adherence, particularly among postpartum women, must be better understood and overcome to promote women’s health. To achieve the desired results and truly support the health of women and communities, investments in ART scale-up must appropriately address the realities of women’s lives, which include gender discrimination and HIV-related stigma.
‘ The theoretical roots of ’empowerment’ as a critical element of community engagement can be traced back to Brazilian educator Paolo Freire (Freire, 1970;) as articulated by Kenneth Maton (2008), empowerment is ‘a group-based participatory, developmental process through which marginalized or oppressed individuals and groups gain greater control over their lives and environment, acquire valued resources and basic rights, and achieve important life goals and reduced societal marginalization ‘ Ideally, empowerment is both a process and an outcome of community engagement. Community of Hwedza must maintain such efforts since behavior change goes through a process otherwise gains on MCH will be short lived.
‘ Participants recommended that peer education discussions should be fabricated with income generation activities such that poverty dimensions are addressed and a full throttle on PMTCT scheme will be effective. This is an effort to re-dress gender imbalances in finance such that mother waiting home will be utilized fully, home deliveries eliminated, transportation costs are covered. Empowered women will actively and fully compile with Health experts schemes of HIV management in elimination of pediatric new infections.Building capacity to improve health involves the development of sustainable skills and resources, because capacity building is deeply rooted in the social, political, and economic environment, it cannot be conducted without an understanding of the specific environment in which it will take place (Eng et al , 1994) When carried out with context in mind, capacity building is an integral part of community engagement efforts, necessary for challenging power imbalances and effectively addressing problems.The IMAGE project implemented in Southern Africa provided micro-finance to the poorest women in different communities alongside a participatory curriculum of gender and HIV education for the women and other community members. (Pronyk, Hargreaves et al. 2006).
‘ Reducing HIV-related stigma and gender discrimination, including violence against women, increasing social support for women during pregnancy and the extended postpartum period, and mobilizing communities to promote respectful, high quality HIV and MCH services are promising interventions for creating an enabling environment for women to access and remain in care, creating demand for, retention and uptake of PMTCT services.
‘ Establish formal community-facility linkages to strengthen a two-way referral system that improves uptake and follow-up services.
‘ Promote and facilitate formal facility-to-community linkages to strengthen the supervision of community iniatives.
‘ Intergenerational knowledge gap should be closed, it reviewed the health promotion education was such skewed to the reproductive age groups and the elders as the community health days attendance statistics reflects. There is need to catch them young the adolescent otherwise same costs incurred today in educating the current generation on MCH/PMTCT will be demand by poorly knowledge resourced younger ones who will in the reproductive gap group years to come. Given the importance of community prevention efforts to public health practice and policy, obtaining scientifically based evidence of the most effective ways of stimulating community change is essential for planning the next generation of health promotion programs and for advancing the nation’s prevention agenda, Prochaska et al (1992).
‘ Social influence plays an important role in behavior change. The role of Community Leaders, Peer Facilitators in a community, acting as agents for behavior change, is a key element of MCH/ PMTCT management. Their influence on group norms or customs is predominantly seen as a result of person-to-person exchanges and discussions enhancing self-efficacy.
‘ Finally, while an exhaustive discussion of human resource needs is beyond the substantive scope of this research and evaluation agenda, there is a clear need to address human resource shortages, inter-relations with community in the health systems.To eliminate preventable MTCT of HIV a, it is imperative not to miss the opportunities created when women attend health services during the continuum of maternity care (pregnancy, delivery, and postpartum) or when they seek HIV care. There is also a need to continue to improve quality of care and reduce barriers to women attending HIV and MCH services.
Transforming the Social Context to Improve Maternal Child Health, community leadership engagement, community health days and peer education as health promotion interventions that modify gender norms, reduce HIV-related stigma, mobilize communities to promote maternal health, and increase social support for pregnant and postpartum women have been shown to positively influence on behavior change context and demand, retention and uptake for and delivery of PMTCT services. There is also evidence that these interventions can improve (ANC & PNC) service utilization, ART adherence and maternal health outcomes in elimination of pediatrics HIV infections. The interventions prioritized for evaluation share a common mechanism of action: they seek to empower women of reproductive age by using participatory methodologies and to change the social context by engaging the broader community to transform social norms that undermine women’s health. To overcome poor rates of uptake and retention in MCH and HIV services and improve adherence, adoption of interventions which promote an enabling environment for women to use health services should be strongly considered by stakeholders working in MCH and HIV.
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Appendices 1 :Tool Guide: FDG
Ward;__________________ Date of interview: __ __ / __ __ / __ __ __ __
Institute: _________________ # of Participants: _Males ( ) Females ( )
Start time of the interview: __ __ . __ __
(Thank you again for agreeing to participate in my study)
1. Importance of ANC
‘ Why is it important for pregnant women to access ANC services
‘ What stage of pregnancy progression should women booked their pregnancy?
‘ What are the benefits of early ANC booking
‘ Why is important to be re-tested during pregnancy
‘ What are the challenges that deter from seeking ANC services?
3. Gender inequality
‘ What are the inequalities challenges that are a negation for demand of, retention and uptake of PMTCT?
‘ How does disclosure of HIV status becomes a hindrance to HIV positive tested pregnant women?
‘ What positives can be brought up through couple HIV testing?
‘ How is low male involvement/ participation a challenge towards efforts of elimination of HIV in peadtrics?
4 Community health days
‘ What benefits had community health days brought at individual level?
‘ Benefits at community level?
‘ How community health days addressed gender inequalities, gender norms, social norms which make HIV elimination in pediatric a pipedream?
‘ Evaluate group dialogue discussions during community health days?
‘ What recommendations could you point upon this health promotion in terms of effectiveness, sustainability and replication in curbing MNCH , MTCT of HIV.
5 Community leadership engagement.
‘ The cadres implementing this health promotion advocating for conducive environment that create demand for, retention and uptake of PMTCT, in your view how effective where they?
‘ How would you appreciate/ validate their level of knowledge in PMTCT issues?
‘ Cadre characteristics have a great contribution to impact of the intervention what is your comment?
6 Peer Education discussions
‘ In what ways did learning took place
‘ How did peer education managed to address MCH/ PMTCT issues?
‘ At household level what positives can be drawn from peer education/
‘ At community level, how do you evaluate its effectiveness?
‘ Could you recommend another pregnant women to attend peer group discussion and why?
7 Institutional pregnancy delivery
‘ Highlight benefits of institute pregnancy delivery in this advent of the pandemic?
‘ How can HIV positive mother transmit HIV to the baby?
‘ What dangers women face with home deliveries and being assisted by traditional birth attendants?
8 Behavior change
‘ In areas of safer sex during pregnancy and breastfeeding
‘ Breast feeding practice
‘ Fontanel management
‘ Child nutrition management
9 PNC services
‘ To what level did the health promotion impacts knowledge on postpartum management?
‘ Identify knowledge gaps that exist at individual and community level regarding PNC service?
‘ How important is knowledge gap closing in an effort to eliminate pediatric HIV new infections?
10 Stakeholders buy-in
‘ Evaluate the level of support the local leadership projected in PMTCT health promotion strategies?
‘ What activities or initiatives are they undertaking at village level and or ward, district level to sustain such efforts?
11 Recommendation and suggestions
End Time ____________
Thank you all. Good day stay blessed.
Appendice 2 :Tool Guide: Key informative interviews
Position;__________________ Date of interview: __ __ / __ __ / __ __ __ __
Institute: _________________ Participant Number: ___ ___ ___ ___
Start time of the interview: __ __ . __ __
(Thank you again for agreeing to participate in my study)
2. How long have you occupied the current office
3. What is your understanding on health promotion in general?
4. In your view, PMTCT health promotion in the District has it be coherent? Yes/no
5 As a stakeholder in MCH what is your opinion regarding any/ all of the interventions that were implemented in the District? Community health days_________________________________________________________________________________________________________________
Peer education ____________________________________________________________________________________________________________________
6 Evaluating the health promotion strategies what recommendations/ suggestions can you point regarding sustainability and replicability?
7 Where there any benefits the community realized in implementation of health promotion by the NGOs Yes/ No
8 In which of the three health promotion strategies did you participated Community days community leadership engagement dialogues peer education discussion
9 Which one could you point as workable to community Community days community leadership engagement dialogues peer education discussion
10 Which knowledge gaps / areas has been addressed through implementation of these health promotion strategies Community health days_________________________________________________________________________________________________________________
Community leadership engagement____________________________________________________________________________________________________________________________________________________________________
Peer education ______________________________________________________________________________________________________________________________________________________________________________
11 In your view knowledge, attitudes, practices and beliefs of negation effect were they corrected? Yes/ no
12 Service provision during community health days was it satisfactory? Yes/ no
How sustainable and replicability are these health promotion? Comments_________________________________________________________________________________________________________________________________
HEALTH & NGO STAFF INFORMATION
As is the recommendation that pregnant women should book for ANC within 12 weeks, are records positive to this call? Yes/ No
If yes can you attributes this to health promotion, why? -______________________________________________________________________
Viability and effectiveness of health promotion particularly male involvement is significant in MCH, what is the records reflection on couple HIV testing? Positive/ negative/ constant
Comment on the respond___________________________________________________________________________________________________________________________________
Regarding demand creation, retention and uptake for PMTCT service, comment on effects of the three health promotion strategies? Community health days_______________________________________________________________________________________
Community leadership engagement________________________________________________________________________________
Peer education discussions—————————————————————————————————————–
May you give attendance figures and services provided during community days General treatment
ANC Pregnancy booking
HIV testing and counseling
CD4 count service
End Time ____________
Thank you. Good day stay blessed.
Appendice 3: Tool Guide: Conducting In-depth interviews
Ward Number: __ __ Date of interview: __ __ / __ __ / __ __ __ __
Village Number: ___ ___ ___ Participant Number: ___ ___ ___ ___
Start time of the interview: __ __ . __ __
(Thank you again for agreeing to participate in my study)
1. In what month and year were you born?
2 Gender and martial status
3. What is the highest level of school you attended? Primary Secondary tertiary
4. How long have you lived here (in this community)?
Individual MCH Perceptions, Attitudes, and Beliefs
5. When is the BEST time to start antenatal care and why?
6 How many times should a woman attend/receive antenatal services during pregnancy? Less than 4 times
6 and above
Do not know
7 Can Option B+ ( ARVs) administration to pregnant women result in elimination of new infections in pediatrics Yes/No
8 What dangers are there if a woman delivers outside the health facility?
9 How are some of the practices, beliefs a negation to the elimination of MTCT of HIV
10. What are some of the challenges/ barriers women face in seeking ANC/ PNC services
11 What are the various ways or methods you have heard of, that can make one contracting HIV, the virus that causes AIDS?
Having unprotected sex with an infected partner(s)
Having multiple sex partners
Sharing of sharp objects with a infected person
Sharing of utensils and food with an infected person
During birth from mother to child
Tick all mentioned
12 Have you ever heard of any special care that health workers could give pregnant women? If yes, what have you heard of?
If yes what have you heard__________________________________________________________________________________________________________________________________________________________
13 Are you knowledgeable on HIV discorded couple
Community MCH Perceptions, Attitudes, and Beliefs
14 Maternal death is caused by evil spirits or breaking taboos. Yes / no
15 Complications during pregnancy can often be managed by rapid medical attention. Strongly agree
16 How some of the social and cultural practices and beliefs, an overt to transmission of HIV in pediatrics?
17 How can there be a breakthrough in curtailing these practices? How?________________________________________________________________________________________________________________________________________________________________________
18 In light of the implemented health promotion education , did such platforms managed to discuss community barriers towards elimination of HIV in newborns Yes/ no
If yes what was discussed_____________________________________________________________________________________________________________
19. It is possible for people to have a sexually transmitted infection without knowing it or showing any signs. true or false.
20. If a woman knows her husband/partner has an STI should she ask that they use a condom when they have sex? Yes/no
Health promotion education events
21. Did you participant in any of these events? Community health days, community leadership education, peer group discussions
List all participated in_________________________________________________________________________________________________________
Tick None ( if didn’t attend any)
22. How your participation did benefit you? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
23 How best can such strategies be more educational and appealing to communities __________________________________________________________________________________________________________
24 Which topics/ themes were of importance to you and why? Topic____________________________________
25 Where the facilitators knowledgeable Yes/no
26 Can such health promotion be replicable in other districts Yes/no
27 Could you recommend any community member to participate in these health promotion events? Yes/no
28. Are there any times that an HIV-positive woman can pass the HIV virus to her baby?
During deliver/ giving birth
Do not know
Tick all mentioned
29. How can an HIV-positive mother prevent passing the HIV virus to her baby?
30. Have you ever been tested for HIV?
31. Is it important for couples/ women to have an HIV test when pregnant?
Appendice 4 : Chi-square working
Hypothesis = health promotion triggers positive behaviours regarding PMTCT services demand, retention and uptake
Hypothesis’ health promotion triggers positive behaviours regarding PMTCT services demand, retention and uptake
O E (O-E)2 (O-E)2
123 128 25 .20
15 10 25 2.5
141 142 1 0.01
12 11 1 0.09
163 157 36 0.23
6 12 36 3
Critical value 10.6
Conclusion:accept the hypothesis that health promotion triggers positive behaviours regarding PMTCT services demand, retention and uptake
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