Table of Contents
Title page – – – – – – – – – i
Approval Page – – – – – – – – ii
Dedication – – – – – – – – – iii
Certification – – – – – – – – – iv
Acknowledgement – – – – – – – – v
Table of Contents – – – – – – – – vi
List of Tables – – – – – – – – viii
Abstract – – – – – – – – – ix
CHAPTER ONE: Introduction
Background to the Study – – – – – – – 1
Statement of the Problem – – – – – – – 9
Purpose of the Study – – – – – – – 10 Research Questions – – – – – – – 10
Hypotheses – – – – – – – – 11
Significance of the Study – – – – – – – 11
Scope of the Study – – – – – – – – 13
CHAPTER TWO: Review of Related Literature
Conceptual Framework – – – – – – – 15
International initiatives to PMTCT of HIV – – – – 21
Factors affecting PMTCT of HIV and AIDS services – – 22
Theory and Evaluation Models – – – – – – 23
Theory of reasoned action (TRA) – – – – – 24
Health belief model (HBM) – – – – – – 25Evaluation model – – – – – – 26
Empirical Studies on PMTCT of HIV and AIDS – – – – 28
Summary of Literature – – – – – – – 32
CHAPTER THREE: Methods
Research Design – – – – – – – – 35
Population of the Study – – – – – – – 35
Sample and Sampling Techniques – – – – – – 35
Instruments for Data Collection – – – – – – 36
Validity of instruments – – – – – – 36
Reliability of instruments – – – – – – 37
Method of Data Collection – – – – – – 37
Method of Data Analysis – – – – – – – 37
CHAPTER FOUR: Results and Discussions
Results – – – – – – – – – 39
Summary of Major Findings – – – – – – 48
Discussions – – – – – – – – 50
CHAPTER FIVE: Summary, Conclusions and Recommendations
Summary – – – – – – – – – 56
Conclusions – – – – – – – – – 58
Recommendations – – – – – – – – 59
Suggestions for Further study – – – – – – 60
Limitations to the Study – – – – – – – 60
References – – – – – – – – – 62
A Questionnaire for HIV Positive pregnant Women – – – – 69
B Questionnaire for PMTCT Service Providers – – – 71
C Focus Group Discussion Guide (FGDG) – – – – 75
D Reliability Analysis of the Questionnaires – – – – 76
E SPSS Analysis of the Questionnaires – – – – – 77
F Letter of Introduction from the Department – – – – 85
G Letter of Research Approval from FMC Umuahia – – – 86
H Letter of Invitation for Focus Group Discussion – – – 87
List of Tables
PMTCT Services Available – – – – – – – 39
Extent to which Qualified PMTCT Service Providers are Available – – 40
Extent of Availability of PMTCT Materials – – – – – 41
Adequacy of PMTCT Service Providers – – – – – 42
Adequacy of PMTCT Materials – – – – – – 43
Level of Utilization of VC, HIV Testing, ART, CS and
Safer Infant Feeding Counseling – – – – – – 44
Factors Influencing the Utilization of PMTCT Services – – – 45
Result of One-Way ANOVA Verifying the Utilization Level of
PMTCT Services Based on Level of Educational of HIV
Positive Pregnant Women – – – – – – – 46
Result of t-Test for level of utilization of PMTCT Services Based
On Location of HIV Positive Pregnant Women – – – – 47
Result of One-Way ANOVA Verifying the Utilization Level of PMTCT
Services Based on Age of HIV Positive Pregnant Women – – – 48
The study was to evaluate the PMTCT of HIV and AIDS programme in Umuahia hospitals. The study evaluated the availability of PMTCT service, availability and adequacy of qualified service providers and materials, the level of utilization of PMTCT services and factors that influenced the utilization of PMTCT service. The factors evaluated in relation to the utilization of the services were educational level, location and age of HIV positive pregnant women. To achieve the purpose of the study, eleven research questions were posed and four null hypotheses were postulated. The study adopted a cross sectional survey research design. It covered the only PMTCT site (FMC Umuahia) and 5 private hospitals providing VC. All the HIV positive pregnant women that attended ANC at the period of study (4 weeks) were used. All the 14 PMTCT service providers in FMC Umuahia and the 8 PMTCT trained staff in 5 private hospitals were also used as respondents. Data collected were both quantitative and qualitative. Fifty eight HIV positive pregnant women who attended ANC at the period of study responded to the questionnaire for HIV positive pregnant women (QHPPW) while 22 PMTCT service providers responded to the questionnaire for PMTCT service providers (QPSPs). Seven PMTCT service providers were also the participants of the focus group discussion. For the purpose of reaching a valid conclusion, data from the 58 respondents who completed the QHPPH and 22 respondents who completed the QPSPs were analyzed quantitatively. Frequency distribution and percentages were used to answer research questions one and seven, while mean and standard deviation were used to answer research questions two to six. T-test and ANOVA were used to verify the three null hypotheses formulated for the study at 05 level of significance. Data generated from the FGD with PMTCT service providers were used to substantiate the findings. The study revealed that voluntary counseling, HIV testing, antiretroviral therapy, caesarean section and safer infant feeding counseling services were available in the government hospital. Majority of the PMTCT service providers and materials were moderately available and adequate. Four out of the five PMTCT services available were highly utilized by the clients. The study also revealed that majority of the respondents indicated that majority of the factors influenced the utilization of these services. The study further revealed that the utilization of these PMTCT services did not differ by level of education, location and age of clients except the use safer infant feeding counseling which differed based on the location of the clients. Based on the major findings and conclusions, it was recommended among others that Social workers and Health Educators should be employed and trained for PMTCT programme to sensitize, educate and encourage HIV positive pregnant women to avail themselves of PMTCT programme. To educate and encourage rural women who are HIV positive to strictly practice safer infant feeding after delivery.
Background to the Study
Everyday, approximately 5,000 women are newly infected with HIV (Human Immunodeficiency Virus), and more than 3,000 die from AIDS (Acquired Immune Deficiency Syndrome) – related illnesses (UNAIDS, 2000a). In most parts of the world, HIV infection is increasing faster among women than men. Nowhere is the trend more apparent than in sub – Saharan Africa where women comprise 58 per cent of existing HIV infection (UNAIDS, 2000b). These differences in infection rates are due to a combination of factors. Women and girls are commonly discriminated against in terms of access to education, employment and land inheritance. With increasing poverty levels, African women have found themselves in casual relationship with men as this can serve as a conduit for financial and social security. Women, therefore, find it difficult to demand for safe sex, as they become subordinates or dependents of mainly older men. Women are also biologically prone to infection and HIV is easily transmitted from men to women than the reverse.
This has led to the increase in women living with HIV. Results of initial early studies analyzing progression and survival in HIV syndrome suggested a difference based on gender. Most of these studies indicated that the prognosis for women was worse than for men. This reflected late access to limited care (Bastian, Bennet, Adams, Waskin, Divine & Edlin, 1993; Melnick, Sherer, Louise, Hillman, Rodriguez, Lackman, Capps, Brown, Caryln & Korvick 1994). Lack of access to care, minimal self – motivation, and attention to the health care of their children over that of themselves all contributed to decreased rates of early detection and intervention. HIV and AIDS for women, therefore, is an issue of access to health care (UNAIDS, 2003). Furthermore, at the end of 2004, UNAIDS reported that women made up almost half of the 37.2 million adults (aged 15 to 49) living with HIV and AIDS worldwide. The hardest-hit regions are areas where heterosexual contact is the primary mode of transmission. This is most evident in sub-Saharan Africa, where close to 60 per cent of adults living with HIV and AIDS are women. Women and girls make up a growing proportion of those infected by HIV and AIDS (UNAIDS/WHO, 2005a).
AIDS is a disease of the immune system that makes the individual highly vulnerable to life-threatening infections such as tuberculosis (TB) and certain types of cancer. AIDS is caused by a retrovirus known as Human Immunodeficiency Virus (HIV) which attacks and impairs the body’s natural defence system against diseases and infections (Piwoz & Preble, 2000). They further stated that HIV is a slow-acting virus that may take years to produce illness in a person. HIV is transmitted via three primary routes: having unprotected sex with a person already carrying the HIV virus; transfusions of contaminated blood and its by-products or use off non-sterilized instruments, such as shared needles, razor, and other surgical tools; and from an infected mother to her child (MTCT) during pregnancy, labour, childbirth or breastfeeding.
According to UNAIDS/WHO (2000), the principal mode of transmission of HIV in Africa is heterosexual. The second is mother – to – child transmission, which is the main mode of acquisition of HIV infection in children under 15 years. The number of children living with HIV infection is estimated at 2.5 million since the epidemic began. Each year, around half a million children aged under 15 become infected with HIV. Almost all of these infections occur in developing countries, and more than 90 per cent are the results of mother – to – child transmission during pregnancy, labour and delivery or breast – feeding. Without interventions, there is a 20 – 45 per cent chance that a baby born to an HIV – infected mother will become infected (De Cock, Fowler, Mercier, de Vincenzi, Saba & Hoff, 2000).
Mother to child transmission (MTCT) also known as vertical transmission occurs when HIV positive woman passes the virus to her baby. This can occur during pregnancy, labour and delivery or breastfeeding, (Msellati, Leroy & Lepage, 1992). The most effective means of reducing mother – to – child transmission is to provide fully suppressive Antiretroviral therapy (ART) to the mother in long term, thereby not only reducing the risk of vertical transmission, but also sustaining the life and health of the mother while the child is growing up. In high income countries, MTCT has been virtually eliminated thanks to effective prevention programmes (Preble & Piwoz, 2002).
According to Hornby, (2001), prevention is the act of stopping something bad from happening. Prevention of mother to child transmission (PMTCT) of HIV and AIDS therefore, is the act of stopping a mother from passing or transmitting HIV and AIDS to her child during pregnancy, labour, delivery and breastfeeding. The member states of the United Nations set target for PMTCT in 2001, as part of a landmark agreement called the UNGASS (United Nations General Assembly) declaration. In this document, the world leaders made the following pledge: by 2005, reduce the proportion of infants infected with HIV by 20 per cent, and by 50 per cent by 2010, by: ensuring that 80 per cent of pregnant women accessing antenatal care have information, counseling and other HIV prevention services available to them (UNGASS, 2001). The goals of PMTCT programme go beyond decreasing the MTCT risk to a minimum, and aim to achieve the strategic goal of virtual elimination of HIV infection in infants (Malyuta, Newell, Ostergren, Thorne & Zhilka, 2006).
Effective PMTCT, according to UNAIDS/WHO (2000), requires a three – fold strategy – (1) preventing HIV infection among prospective parents, (2) avoiding unwanted pregnancies among HIV positive women, and (3) preventing the transmission of HIV from HIV positive mothers to their infants during pregnancy, labour, delivery and breast feeding. UNAIDS (2000) added that PMTCT of HIV consists of a core package of interventions which includes, (1) voluntary counseling (VC), (2) HIV testing, (3) antiretroviral therapy (ART), (4) obstetric intervention or caesarean section (CS), and (5) safe infant feeding counseling. Zaman and Thorne-Lyman (2004) added ARV (antiretroviral vaccine) prophylaxis given to the baby within 72 hours of birth (a one time dose). But this study shall settle on the first five.
Voluntary counseling (VC) is the cornerstone of the PMTCT programme and provides critical information to pregnant women about HIV testing and prevention. Counseling is also necessary to help HIV- infected women to adjust to their diagnosis and reduce transmission to their children. Thus, counseling can enhance not only the possibility of reducing HIV vertical transmission but also the quality of antenatal care and other health services in addition to the prevention of HIV MTCT (Perez-Then, Peňa, Tavarez-Rojas, Peňa, Quiňonez & Buttler, 2003).
HIV testing of pregnant women is to identify which women are infected so that increased precautions could be taken to reduce exposure of health care workers to HIV during deliveries (Stringer, Stringer & Phanuphak, 1999). For pregnant women, the benefit of HIV testing is to learn their HIV status so they could decide about pregnancy continuation, subsequent birth control, and prevention of HIV transmission to partners.
Women who have reached the advanced stages of HIV disease require a combination of antiretroviral drugs for their own health. This treatment, which must be taken every day for the rest of a woman’s life, is also highly effective at reducing the risk of mother to child transmission. Women who require treatment will usually be advised to take it, beginning either immediately or after the first trimester. Their newborn babies will usually be given a course of treatment for the first few days or weeks of life, to lower the risk even further (Kanabus & Nobel, 2006).
Caesarean section is an operation to deliver a baby through its mother abdominal wall. When a mother is HIV positive, a caesarean section may be done to protect the baby from direct contact with her blood and other fluids. However, there is a need to weigh the risk of HIV transmission against the risk of harm due to intervention (Kanabus & Nobel, 2006).
Safe infant feeding counseling is the advice given to pregnant mothers especially those who are HIV positive on safer feeding option of their infant to avoid postpartum transmission of HIV. According to UNICEF, UNAIDS and WHO (2000), they are advice on the following different feeding methods during the first six months of postpartum: use of breast milk substitute exclusively, mixed feeding strategy (breast milk substitutes and breastfeeding) and exclusive breastfeeding.
According to UNICEF, UNAIDS and WHO (2000), many countries are implementing pilot programmes, which are aimed at demonstrating the feasibility and effectiveness of integrating activities to prevent mother – to – child transmission of HIV into routine Maternal and Child Health (MCH) services in developing countries. Preble and Piwoz (2002) also stated that low utilization of Antenatal Clinic (ANC) and other MCH services is a major problem in many resources – poor Asian countries. Advocacy for improved MCH services and use at all levels (community to national) is critical for PMTCT and has direct and indirect benefits for all mothers. For example: reducing the incidence and severity of malaria, tuberculosis, reproductive tract, and other infections will improve an HIV-infected women’s chances of avoiding or delaying conditions that will compromise her health and survival; improving antenatal care will improve birth outcomes, such as stillbirths, low birth weight, preterm births, and infant mortality, regardless of HIV status of the mother; and malnutrition and HIV infection are inextricably linked. Improving HIV-infected mother’s nutritional status may help to slow the progression of HIV disease and prolong survival.
PMTCT is an ongoing programme. The Federal Ministry of Health (Nigeria) developed a national PMTCT of HIV Programme in 2001. Since then, sites providing PMTCT services have increased, involving partners such as UNICEF, Centers for Disease Control (CDC), APIN (AIDS Prevention Initiative in Nigeria) and USAID (United States Agency for International Development). PMTCT services have also been expanded from the initial tertiary health facilities to secondary and primary health facilities (UNICEF, 2007). According to National Agency for the Control of AIDS – NACA (2007), as at first of March, 2007, PMTCT sites in Nigeria was 195, out of which 53 are in private hospitals and the remaining ones are in government hospitals.
Malyuta et al (2006) noted that the PMTCT programme has been integrated into existing maternal and child health care services supervised by the ANC Department of Health Care for mother and child, with collaboration from HIV and AIDS specific services. Nobel (2007) opined that to achieve wide coverage, PMTCT programme must be integrated into existing public health systems, with services provided by all antenatal and delivery clinics. More so, a health system is a blend of public and private sector in both service delivery and funding organization. Therefore, PMTCT programme should be provided by both government and private hospitals.
Every programme endeavor, including prevention of MTCT of HIV and AIDS aims at maintaining its relevance through monitoring and evaluation of its activities. Evaluation is essential to identify shortcomings in PMTCT of HIV programme and to conceptualize approaches to improve services (Reithinger, Megazzini, Durako, Harris & Vermund, 2007). This in turn, will improve a programme’s cost effectiveness and long term sustainability and save the most infant lives.
Evaluation as defined by Trochim (2006) is the systematic acquisition and assessment of information to provide useful feedback about some object. UNICEF, UNAIDS and WHO (2000) also stated that monitoring and evaluation activities support implementation of PMTCT program in that they are systematic ways of learning from experience and using the lessons learned to improve health activities and promote better planning. They can provide information support for local management and strategy, policy and program formulation and budgeting, and program delivery through various services and institutions.
Stufflebeam (1990) defined evaluation as the systematic investigation of the worth or merit of some objects and that the merits of an evaluation is what one is examining or studying in a programme. Olaitan (2003) submitted that evaluation is the process of obtaining information on what one is doing towards achieving objectives, how far one could go in achieving the objectives, what constraints hinder the achievement of the objective, and what to do in order to overcome the constraints of achieving the objectives. This position seems to lend credence to the felt need for obtaining such information on the programme for prevention of MTCT of HIV and AIDS services in hospitals in Umuahia, Abia State.
Evaluation helps to emphasize the importance of evaluation participants, especially the client or users of a programme and stakeholders. Agency for Health Care Research and Quality- AHRQ (2007) observed that potential audiences for quality measurement report for child health care services are the providers and the consumers. In this case, pregnant women and health care providers’ perception measures as well as several measures of the delivery of preventive care may be used to assess the quality of the health plan or programme for PMTCT of HIV and AIDS services in government and private hospitals in Umuahia. WHO (2004) observed that the main providers of health care and their role in child health includes two main categories of government and public sector players.
Programme evaluation, according to Worthen (1990), consists of those activities undertaken to judge the worth or utility of a programme. Therefore, in the context of this study, evaluation of the PMTCT of HIV and AIDS services involve: