Perceptions and experiences of pregnant women about routine HIV testing and counselling in Ghimbi town, Ethiopia: A qualitative study

BMC Research Notes, Volume 10, No. 1, Year 2017

Interpretation

Background: Ethiopia has implemented routine HIV testing and counselling using a provider initiated HIV testing (‘opt-out’ approach) to achieve high coverage of testing and prevention of mother-to-child transmission of HIV. However, women’s perceptions and experiences with this approach have not been well studied. We conducted a qualitative study to explore pregnant women’s perceptions and experiences of routine HIV testing and counselling in Ghimbi town, Ethiopia, in May 2013. In-depth interviews were held with 28 women tested for HIV at antenatal clinics (ANC), as well as four health workers involved in routine HIV testing and counselling. Data were analyzed using the content analysis approach. Results: We found that most women perceived routine HIV testing and counselling beneficial for women as well as unborn babies. Some women perceived HIV testing as compulsory and a prerequisite to receive delivery care services. On the other hand, health workers reported that they try to emphasise the importance HIV testing during pre-test counselling in order to gain women’s acceptance. However, both health workers and ANC clients perceived that the pre-test counselling was limited. Conclusions: Routine HIV testing and counselling during pregnancy is well acceptable among pregnant women in the study setting. However, there is a sense of obligation as women felt the HIV testing is a pre-requisite for delivery services. This may be related to the limited pre-test counselling. There is a need to strengthen pre-test counselling to ensure that HIV testing is implemented in a way that ensures pregnant women’s autonomy and maximize opportunities for primary prevention of HIV. Ethiopia has adopted the WHO/UNICEF/UNAIDS 4-pronged PMTCT strategy as a key entry point to HIV care for women, men and families in 2001. In 2007, Ethiopian government issued revised PMTCT guideline that promotes integrated and “Opt-Out” approaches as the most appropriate strategy for expanding national access and sustainability of PMTCT services in the country. Routine provider-initiated HIV counselling and testing using the opt-out approach is recommended for all clients seen within the context of maternal care. According to the guideline, clients are given pre-test information in a group or individually on HIV/AIDS and PMTCT and are told that their routine antenatal laboratory tests will include HIV test. The provider also must inform the client that she has the right to say “no” (to opt out), and this decision by no means affects the services she will get from the health facility. Compared to other approaches, routine provider-initiated HIV counselling and testing using the opt-out approach for all pregnant women has resulted in greater acceptability, and increased opportunity to prevent MTCT [11]. As compared to the 2006 figures, the proportion of ANC clients provided with HIV counselling services at PMTCT sites and the number of HIV positive pregnant mothers identified and the proportion of have increased by more than threefold in 2010. The prevalence of HIV among those pregnant mothers who underwent HIV testing has decreased from 8% in 2006 to 2% in 2010 [12]. The study was conducted among pregnant women attending ANC clinics of one health center and one hospital in Ghimbi town. Ghimbi town is situated in West Wollega Zone of Oromia Regional State, 441 km west of Addis Ababa, the capital city of Ethiopia. Ghimbi town is the capital of Ghimbi district, which is one of the 21 districts in the Zone. Based on the 2007 National census the total population of the district was about 74,623, of which 30,981 were from Ghimbi town. Women of reproductive age (15–49 years) constitute about 28% of the total population in the town [20]. In 2013, there were two public health institutions, including one primary hospital and one health center, providing HIV testing and counselling for pregnant women and offering ART and other necessary care for HIV positive women and their infants in Ghimbi town and surrounding areas. A qualitative research design using in-depth interviews (IDIs) was employed to explore perceptions and experiences of pregnant women with routine HIV testing and counselling provided as part of ANC. IDIs was considered to be an appropriate method as the aim of the study was to elicit individual experiences and perceptions with HIV testing and counselling process. Key informant interviews were conducted with health workers who were involved in routine HIV testing and counselling to explore their views on PITC with particular emphasis on pertest counselling and consent process. The study population included women who were attending ANC for the first time during the current pregnancy and tested for HIV at the two public facilities in May 2013. We conducted a total of 28 IDIs until we reached information saturation where we felt that adding more interviews would not bring forth any new information. Women were selected purposively to consider the variety of participants in terms of parity, educational level and experience of routine antenatal HIV testing. They were interviewed after going through HIV counselling and testing but before receiving the test result. Four IDIs were conducted with ANC staffs who were involved in routine HIV testing and counselling. Three of the interviewees were midwives and one was a clinical nurse. Two health workers were recruited from public hospital and two from health center. The interviews were conducted in Afaan Oromo (the local language) at a place that provided optimum privacy and tape recorded after consent was received. A pretested interview guide was used to explore women’s perceptions and experiences with routine HIV testing and counselling. The guide included questions related to knowledge and perceptions about routine HIV testing and counselling, and experiences with pre-test counselling and consent process. Probing questions were included in the interview guide in case the responses of the participants are superficial and/or the answers are conflicting (Additional file 1). Interviews took between 20 and 45 min to complete. The interviews were moderated by the first author and attended by one health professional who took notes, both fluent in the local language and familiar with qualitative research methods. Preliminary data analysis was concurrent with data collection and evolved throughout the data collection and analysis period. Debriefing was conducted at the end of each data collection day to share preliminary findings and identify areas to be explored more. Tape recordings were transcribed verbatim in local language and translated into English. Further data analysis was conducted by two members of the research team. The analysis involved multiple reading of transcripts to understand the data to identify emerging themes. The first and the last authors independently coded the transcribed data using an inductive approach and the codes were compared for consistency. Transcripts were coded line by line and data were analyzed through thematic content analysis using the qualitative research analysis software, Open Code 3.6.2.0. The codes were compared for similarities and differences, and themes were developed. Salient quotes were used to express the experiences and perceptions of women in the study findings.

AI Digest

Study Justification:

– The study aimed to explore pregnant women’s perceptions and experiences of routine HIV testing and counseling in Ghimbi town, Ethiopia.
– This study is important because it provides insights into the acceptability and effectiveness of routine HIV testing and counseling in preventing mother-to-child transmission of HIV.
– Understanding women’s perceptions and experiences can help improve the implementation of HIV testing and counseling programs and ensure women’s autonomy in decision-making.

Highlights:

– Most women perceived routine HIV testing and counseling as beneficial for themselves and their unborn babies.
– Some women felt that HIV testing was compulsory and a prerequisite for receiving delivery care services.
– Health workers emphasized the importance of HIV testing during pre-test counseling to gain women’s acceptance.
– Both health workers and ANC clients felt that the pre-test counseling was limited.
– Routine HIV testing and counseling during pregnancy is well accepted among pregnant women in the study setting.

Recommendations:

– Strengthen pre-test counseling to ensure that pregnant women have a clear understanding of the purpose and implications of HIV testing.
– Provide comprehensive information about HIV/AIDS and prevention of mother-to-child transmission during pre-test counseling.
– Ensure that women have the right to opt out of HIV testing without affecting the services they receive.
– Maximize opportunities for primary prevention of HIV by integrating HIV testing and counseling with other maternal care services.

Key Role Players:

– Health workers involved in routine HIV testing and counseling
– ANC clients
– Policy makers and government officials responsible for implementing and monitoring HIV testing and counseling programs
– Community leaders and organizations involved in promoting HIV/AIDS awareness and prevention

Cost Items for Planning Recommendations:

– Training and capacity building for health workers on comprehensive pre-test counseling
– Development and dissemination of educational materials on HIV/AIDS and prevention of mother-to-child transmission
– Integration of HIV testing and counseling services with existing maternal care services
– Monitoring and evaluation of the implementation of routine HIV testing and counseling programs
– Community engagement and awareness campaigns on the importance of HIV testing and prevention

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is qualitative, which limits the generalizability of the findings. However, the study conducted in-depth interviews with a diverse group of pregnant women and health workers, which provides valuable insights into their perceptions and experiences of routine HIV testing and counseling. The study also used a content analysis approach to analyze the data. To improve the strength of the evidence, future research could consider using a mixed methods approach to gather both qualitative and quantitative data. This would allow for a more comprehensive understanding of the topic. Additionally, expanding the sample size and including participants from multiple health centers or hospitals would increase the generalizability of the findings. Finally, conducting follow-up interviews with the same participants after they have received their test results could provide further insights into their experiences and perceptions.

Abstract

Ethiopia has adopted the WHO/UNICEF/UNAIDS 4-pronged PMTCT strategy as a key entry point to HIV care for women, men and families in 2001. In 2007, Ethiopian government issued revised PMTCT guideline that promotes integrated and “Opt-Out” approaches as the most appropriate strategy for expanding national access and sustainability of PMTCT services in the country. Routine provider-initiated HIV counselling and testing using the opt-out approach is recommended for all clients seen within the context of maternal care. According to the guideline, clients are given pre-test information in a group or individually on HIV/AIDS and PMTCT and are told that their routine antenatal laboratory tests will include HIV test. The provider also must inform the client that she has the right to say “no” (to opt out), and this decision by no means affects the services she will get from the health facility. Compared to other approaches, routine provider-initiated HIV counselling and testing using the opt-out approach for all pregnant women has resulted in greater acceptability, and increased opportunity to prevent MTCT [11]. As compared to the 2006 figures, the proportion of ANC clients provided with HIV counselling services at PMTCT sites and the number of HIV positive pregnant mothers identified and the proportion of have increased by more than threefold in 2010. The prevalence of HIV among those pregnant mothers who underwent HIV testing has decreased from 8% in 2006 to 2% in 2010 [12]. The study was conducted among pregnant women attending ANC clinics of one health center and one hospital in Ghimbi town. Ghimbi town is situated in West Wollega Zone of Oromia Regional State, 441 km west of Addis Ababa, the capital city of Ethiopia. Ghimbi town is the capital of Ghimbi district, which is one of the 21 districts in the Zone. Based on the 2007 National census the total population of the district was about 74,623, of which 30,981 were from Ghimbi town. Women of reproductive age (15–49 years) constitute about 28% of the total population in the town [20]. In 2013, there were two public health institutions, including one primary hospital and one health center, providing HIV testing and counselling for pregnant women and offering ART and other necessary care for HIV positive women and their infants in Ghimbi town and surrounding areas. A qualitative research design using in-depth interviews (IDIs) was employed to explore perceptions and experiences of pregnant women with routine HIV testing and counselling provided as part of ANC. IDIs was considered to be an appropriate method as the aim of the study was to elicit individual experiences and perceptions with HIV testing and counselling process. Key informant interviews were conducted with health workers who were involved in routine HIV testing and counselling to explore their views on PITC with particular emphasis on pertest counselling and consent process. The study population included women who were attending ANC for the first time during the current pregnancy and tested for HIV at the two public facilities in May 2013. We conducted a total of 28 IDIs until we reached information saturation where we felt that adding more interviews would not bring forth any new information. Women were selected purposively to consider the variety of participants in terms of parity, educational level and experience of routine antenatal HIV testing. They were interviewed after going through HIV counselling and testing but before receiving the test result. Four IDIs were conducted with ANC staffs who were involved in routine HIV testing and counselling. Three of the interviewees were midwives and one was a clinical nurse. Two health workers were recruited from public hospital and two from health center. The interviews were conducted in Afaan Oromo (the local language) at a place that provided optimum privacy and tape recorded after consent was received. A pretested interview guide was used to explore women’s perceptions and experiences with routine HIV testing and counselling. The guide included questions related to knowledge and perceptions about routine HIV testing and counselling, and experiences with pre-test counselling and consent process. Probing questions were included in the interview guide in case the responses of the participants are superficial and/or the answers are conflicting (Additional file 1). Interviews took between 20 and 45 min to complete. The interviews were moderated by the first author and attended by one health professional who took notes, both fluent in the local language and familiar with qualitative research methods. Preliminary data analysis was concurrent with data collection and evolved throughout the data collection and analysis period. Debriefing was conducted at the end of each data collection day to share preliminary findings and identify areas to be explored more. Tape recordings were transcribed verbatim in local language and translated into English. Further data analysis was conducted by two members of the research team. The analysis involved multiple reading of transcripts to understand the data to identify emerging themes. The first and the last authors independently coded the transcribed data using an inductive approach and the codes were compared for consistency. Transcripts were coded line by line and data were analyzed through thematic content analysis using the qualitative research analysis software, Open Code 3.6.2.0. The codes were compared for similarities and differences, and themes were developed. Salient quotes were used to express the experiences and perceptions of women in the study findings.

Materials

https://efashare.b-cdn.net/materials/21ded81281760106db0e7ca43f2c9154949af95263e6869aded0e5be3a0ef741/13104_2017_2423_MOESM1_ESM.docx

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Strengthening pre-test counseling: Enhance the quality and comprehensiveness of pre-test counseling for pregnant women undergoing routine HIV testing. This could include providing detailed information about the testing process, addressing any concerns or misconceptions, and ensuring that women fully understand their rights and options.

2. Improving consent process: Develop strategies to ensure that pregnant women fully understand the importance of HIV testing and have the opportunity to provide informed consent. This could involve using visual aids, simplified language, and culturally appropriate materials to facilitate understanding and decision-making.

3. Community-based education and awareness: Implement community-based programs to raise awareness about the benefits of routine HIV testing during pregnancy and address any stigma or misconceptions associated with HIV. This could involve engaging community leaders, healthcare providers, and local organizations to disseminate accurate information and promote acceptance of testing.

4. Integration of services: Explore opportunities to integrate routine HIV testing with other maternal health services, such as antenatal care and delivery services. This could streamline the testing process and ensure that pregnant women have access to comprehensive care in a single setting.

5. Mobile health (mHealth) interventions: Utilize mobile technology to deliver information, reminders, and support to pregnant women regarding routine HIV testing and other maternal health services. This could include SMS or voice messages with educational content, appointment reminders, and links to resources or support groups.

6. Task-shifting and training: Train and empower a wider range of healthcare providers, such as nurses, midwives, and community health workers, to conduct routine HIV testing and counseling. This could help to increase the availability and accessibility of testing services, particularly in remote or underserved areas.

7. Quality improvement initiatives: Implement quality improvement initiatives to ensure that routine HIV testing and counseling services are consistently delivered in a patient-centered and culturally sensitive manner. This could involve regular monitoring and evaluation, feedback mechanisms, and ongoing training and support for healthcare providers.

It is important to note that these recommendations are based on the specific context and findings of the study mentioned. Further research and consultation with relevant stakeholders would be needed to determine the feasibility and effectiveness of these innovations in improving access to maternal health in other settings.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the provided description is to strengthen pre-test counseling for routine HIV testing and counseling during pregnancy. This recommendation is based on the findings of the qualitative study conducted in Ghimbi town, Ethiopia, which revealed that while routine HIV testing and counseling was well accepted among pregnant women, there was a sense of obligation as women felt that HIV testing was a prerequisite for delivery services. This perception may be related to the limited pre-test counseling provided.

By strengthening pre-test counseling, pregnant women can be better informed about the importance of HIV testing and the benefits it provides for both themselves and their unborn babies. This can help address the sense of obligation and ensure that HIV testing is implemented in a way that respects women’s autonomy. Additionally, maximizing opportunities for primary prevention of HIV can be achieved through comprehensive pre-test counseling that provides information on HIV/AIDS and prevention of mother-to-child transmission.

To implement this recommendation, healthcare providers can receive training on effective pre-test counseling techniques and communication skills. They can be encouraged to provide individualized counseling sessions that address the specific concerns and questions of pregnant women. Information materials, such as brochures or pamphlets, can also be developed to supplement the counseling sessions and provide additional resources for pregnant women.

Furthermore, the innovation can involve the use of technology to enhance pre-test counseling. For example, interactive mobile applications or websites can be developed to provide pregnant women with accessible and user-friendly information about routine HIV testing and counseling. These platforms can also allow women to ask questions and receive personalized responses from healthcare professionals.

Overall, by strengthening pre-test counseling, pregnant women can make informed decisions about HIV testing and feel empowered in their healthcare journey. This innovation can contribute to improving access to maternal health services and ensuring the successful implementation of routine HIV testing and counseling during pregnancy.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen pre-test counseling: Enhance the quality and comprehensiveness of pre-test counseling for pregnant women undergoing routine HIV testing. This can include providing detailed information about the benefits and importance of HIV testing, addressing any concerns or misconceptions, and ensuring that women have the opportunity to ask questions and make informed decisions.

2. Improve provider communication: Train healthcare providers to effectively communicate with pregnant women about routine HIV testing and counseling. This can involve using clear and simple language, actively listening to women’s concerns, and addressing any fears or anxieties they may have.

3. Enhance privacy and confidentiality: Ensure that pregnant women feel comfortable and safe during the HIV testing process by providing private spaces for counseling and testing, as well as maintaining strict confidentiality of their test results.

4. Increase community awareness: Conduct community awareness campaigns to educate pregnant women and their families about the importance of routine HIV testing and counseling. This can involve disseminating information through various channels such as community meetings, radio programs, and posters.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific group of pregnant women who would benefit from improved access to maternal health, such as those attending antenatal clinics in a particular region or healthcare facility.

2. Collect baseline data: Gather information on the current state of access to maternal health services, including the percentage of pregnant women receiving routine HIV testing, their perceptions and experiences, and any existing barriers to access.

3. Develop a simulation model: Create a mathematical or computational model that represents the target population and simulates the impact of the recommendations on access to maternal health. This model should take into account factors such as the number of pregnant women, the effectiveness of the recommendations, and any potential interactions between different factors.

4. Input data and parameters: Input the baseline data and parameters into the simulation model, including information on the current state of access to maternal health and the expected impact of the recommendations.

5. Run simulations: Run multiple simulations using different scenarios and assumptions to explore the potential impact of the recommendations on access to maternal health. This can involve varying factors such as the level of improvement in pre-test counseling, the extent of provider communication training, and the reach of community awareness campaigns.

6. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on access to maternal health. This can include quantifying the increase in the percentage of pregnant women receiving routine HIV testing, assessing changes in perceptions and experiences, and identifying any remaining barriers to access.

7. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data or expert input. This can help ensure the accuracy and reliability of the model in predicting the impact of the recommendations.

8. Communicate findings and recommendations: Present the findings of the simulation study to relevant stakeholders, such as healthcare providers, policymakers, and community organizations. Use the results to advocate for the implementation of the recommendations and inform decision-making processes related to improving access to maternal health.

Author

Dima Health

Statistics:

Citations: 8

Identifiers:

DOI: 10.1186/s13104-017-2423-1

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study, Exploratory Study, Grounded Theory

Study Approach:

Qualitative

Participants Gender:

Male & Female