Health service barriers to HIV testing and counseling among pregnant women attending Antenatal Clinic; A cross-sectional study

BMC Health Services Research, Volume 14, No. 1, Year 2014

Interpretation

Background: HIV testing and counseling (HTC) remains critical in the global efforts to reach a goal of universal access to prevention and timely human immunodeficiency virus (HIV) treatment and health care. Routine HIV testing has been shown to be cost-effective and life-saving by prolonging the life expectancy of HIV patients and reducing the annual HIV transmission rate. However, these benefits of routine HIV testing may not be seen among pregnant women attending antenatal clinic (ANC) due to health facility related factors. This paper presents the influence of health facility related factors on HTC to inform HTC implementation. Methods. The study was cross-sectional in design and used structured questionnaire and interview guides to gather information from 300 pregnant women aged 18 to 49 years and had attended ANC for more than twice at the time of the study. Twelve health workers were interviewed as key informants. Respondents were selected from the five sub metro health facilities in the Kumasi Metropolis through systematic random sampling from August to November 2011. Pregnant women who had not tested after two or more ANC visits were classified as not utilizing HTC. Data was analyzed with STATA 11. Logistic regression was run to assess the odds ratios at 95% confidence level. Results: Twenty-four percent of the pregnant women had not undergone HTC, with “never been told” emerging as the most cited reason as reported by 29.5% of respondents. Decisions by pregnant women to take up HTC were mostly influenced by factors such as lack of information, perceptions of privacy and confidentiality, waiting time, poor relationship with health staff and fear of being positive. Conclusions: Access to HTC health facility alone does not translate into utilization of HTC service. Improving health facility related factors such as health education and information, confidentiality, health staff turnaround time and health staff-client relationship related to HTC will improve implementation. © 2014Kwapong et al.; licensee BioMed Central Ltd. The study was cross sectional in design with both qualitative and quantitative methods. These methods were chosen because combining qualitative and quantitative methods elicit in-depth information and generate extensive discussions on contextual explanations on women’s perceived barriers to HTC [13]. The study was conducted in the Kumasi metropolis because it accounts for a third of population in Ashanti region (2009 projection, 1,889,934) and second urbanized after Greater Accra in Ghana. It is located almost at the centre of Ghana, an economic nerve and has varying health facilities. The Metropolitan Health Services is decentralized and are organized around five (5) Sub Metro Health Teams; namely, Bantama, Asokwa, Manhyia North, Manhyia South and Subin. The Metro Health Team is led by its Director of Health Services who has the overall responsibility for planning, monitoring and evaluating the performance of the Health Sector in the metropolis. The city has many public and private health facilities with one teaching hospital, the Komfo Anokye Teaching Hospital (KATH), one of the three national autonomous hospitals, four (4) quasi health institutions, five (5) health centres owned by the Church of Christ and the Seventh-Day Adventist Church. In 2010 and 2011, a total of 97,852 and 122,708 ANC registrants were recorded in the Kumasi metropolis of which 79% and 88% respectively tested and received post-test counseling [14]. As at 2011, there were 285 counseling and testing (CT) and 268 PMTCT centres in the Ashanti region [14]. The study was conducted in five sub metro health facilities providing HTC services in the Metropolis. These were Kumasi South Government Hospital (62 respondents), Suntreso Government Hospital (68 respondents), Tafo Government Hospital (56 respondents), Maternal and Child Health Hospital (56 respondents) and Manhyia Government Hospital (58 respondents). Pregnant women who had attended ANC more than twice and HIV counsellors at ANC in the selected health facilities in the Kumasi Metropolis were studied. The sample size was determined following [15] as Where n is the sample size; z is the reliability co-efficient (1.96) at 95% confidence level, d the allowable error margin (0.05), p is the proportion of women in fertility age (WIFA) in the population (23%) and q = 1-p. This gave an approximate sample size of 300. Simple random sampling ballot in which health facilities offering PMTCT services in each sub-metro were numbered was used to select study facilities. Five facilities, one each of the five sub-metros were selected without replacement. In each of the selected health facility, the study was explained to all pregnant women presenting at the antenatal clinic after which pieces of papers with inscriptions, ‘YES’ and ‘NO”, were put in a box for pick by respondents. Respondents who picked ‘YES’ and consented to participate in the study were enrolled till the required sample size of 300 for the quantitative survey was reached. The data collection technique was interviewing where trained research assistants interviewed respondents with structured questionnaires. Data was collected from August to November 2011. Questionnaires and interview results were checked for completeness and internal errors during data collection. Questionnaires were then sorted, numbered and kept in files labeled per facility from which the participants were recruited. Data was then coded before entering into SPSS. The perception on quality of PMTCT services and its influence on HIV Counseling and Testing was analysed using logistic regressions. This was done using STATA 11. The dependent variable was utilization of HTC and independent variables were facility related factors that influence HTC and these included waiting time, privacy and confidentiality, feeling attended to, being listened to, being treated with respect and trust for health workers. Pregnant women who had not been tested for HIV after two or more ANC visits were classified as not utilizing HTC and this was coded as 1. Focus group discussions (FGDs) and in-depth interviews using interview guides and tape recorders were the data collection techniques and tools respectively. Five FGDs, involving 40 pregnant women (8 per group per FGD) were conducted. They involved three (3) groups of women who had not undertaken HTC and two (2) groups of pregnant women who had undergone HTC. Topics discussed involved various health facility barriers to HTC. Twelve health workers were also involved in the in-depth interviews. Qualitative data was analyzed using ATLAS.ti. Audio-recorded data from both FGDs and key informants interviews were transcribed verbatim and translated into English. Data was analysed thematically and salient quotes from the themes were presented as results. The Committee for Human Research Publication and Ethics of the School of Medical Science, Kwame Nkrumah University of Science and Technology (KNUST) gave ethical clearance. Participants were taken through consenting processes prior to enrolment into the study. There was full disclosure or discussion of relevant information and questions related to the study. Also participants who could not read were informed about the study by translating the consenting information into their local language for adequate comprehension. They were told that enrolment into the study was voluntary. No response was related to participants who were assigned study identification numbers.

AI Digest

Study Justification:

– HIV testing and counseling (HTC) is crucial for universal access to prevention and treatment of HIV.
– Routine HIV testing has been proven to be cost-effective and life-saving.
– However, pregnant women attending antenatal clinics (ANC) face barriers to accessing HTC.
– This study aims to identify and understand the health facility related factors that influence HTC utilization among pregnant women.

Highlights:

– 24% of pregnant women had not undergone HTC.
– The most cited reason for not testing was “never been told” (29.5% of respondents).
– Factors influencing the decision to take up HTC included lack of information, perceptions of privacy and confidentiality, waiting time, poor relationship with health staff, and fear of being positive.
– Access to HTC health facility alone does not guarantee utilization of HTC service.
– Improving health facility related factors such as health education and information, confidentiality, health staff turnaround time, and health staff-client relationship will improve HTC implementation.

Recommendations:

– Increase health education and information about HTC for pregnant women.
– Strengthen privacy and confidentiality measures in health facilities.
– Reduce waiting time for HTC services.
– Improve the relationship between health staff and pregnant women.
– Address the fear of being positive through counseling and support services.

Key Role Players:

– Director of Health Services: Responsible for planning, monitoring, and evaluating the performance of the health sector in the metropolis.
– Health Workers: Provide HTC services and play a crucial role in improving the health facility related factors.
– Research Assistants: Conduct interviews and collect data for the study.
– Pregnant Women: Play a vital role in utilizing HTC services and providing feedback on their experiences.

Cost Items for Planning Recommendations:

– Health Education and Information Materials: Budget for the development and distribution of educational materials about HTC.
– Training and Capacity Building: Allocate funds for training health workers on privacy, confidentiality, and improving relationships with pregnant women.
– Infrastructure and Equipment: Consider the need for additional infrastructure and equipment to reduce waiting time and improve HTC services.
– Counseling and Support Services: Allocate funds for counseling and support services to address the fear of being positive and provide emotional support to pregnant women.
Please note that the provided cost items are general suggestions and may vary depending on the specific context and resources available.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional study design, which provides a moderate level of evidence. The study used both qualitative and quantitative methods, which enhances the depth of information. However, the sample size of 300 pregnant women may be considered small for generalizing the findings to a larger population. To improve the strength of the evidence, future studies could consider increasing the sample size and using a longitudinal design to assess the long-term impact of health facility related factors on HIV testing and counseling among pregnant women.

Abstract

The study was cross sectional in design with both qualitative and quantitative methods. These methods were chosen because combining qualitative and quantitative methods elicit in-depth information and generate extensive discussions on contextual explanations on women’s perceived barriers to HTC [13]. The study was conducted in the Kumasi metropolis because it accounts for a third of population in Ashanti region (2009 projection, 1,889,934) and second urbanized after Greater Accra in Ghana. It is located almost at the centre of Ghana, an economic nerve and has varying health facilities. The Metropolitan Health Services is decentralized and are organized around five (5) Sub Metro Health Teams; namely, Bantama, Asokwa, Manhyia North, Manhyia South and Subin. The Metro Health Team is led by its Director of Health Services who has the overall responsibility for planning, monitoring and evaluating the performance of the Health Sector in the metropolis. The city has many public and private health facilities with one teaching hospital, the Komfo Anokye Teaching Hospital (KATH), one of the three national autonomous hospitals, four (4) quasi health institutions, five (5) health centres owned by the Church of Christ and the Seventh-Day Adventist Church. In 2010 and 2011, a total of 97,852 and 122,708 ANC registrants were recorded in the Kumasi metropolis of which 79% and 88% respectively tested and received post-test counseling [14]. As at 2011, there were 285 counseling and testing (CT) and 268 PMTCT centres in the Ashanti region [14]. The study was conducted in five sub metro health facilities providing HTC services in the Metropolis. These were Kumasi South Government Hospital (62 respondents), Suntreso Government Hospital (68 respondents), Tafo Government Hospital (56 respondents), Maternal and Child Health Hospital (56 respondents) and Manhyia Government Hospital (58 respondents). Pregnant women who had attended ANC more than twice and HIV counsellors at ANC in the selected health facilities in the Kumasi Metropolis were studied. The sample size was determined following [15] as Where n is the sample size; z is the reliability co-efficient (1.96) at 95% confidence level, d the allowable error margin (0.05), p is the proportion of women in fertility age (WIFA) in the population (23%) and q = 1-p. This gave an approximate sample size of 300. Simple random sampling ballot in which health facilities offering PMTCT services in each sub-metro were numbered was used to select study facilities. Five facilities, one each of the five sub-metros were selected without replacement. In each of the selected health facility, the study was explained to all pregnant women presenting at the antenatal clinic after which pieces of papers with inscriptions, ‘YES’ and ‘NO”, were put in a box for pick by respondents. Respondents who picked ‘YES’ and consented to participate in the study were enrolled till the required sample size of 300 for the quantitative survey was reached. The data collection technique was interviewing where trained research assistants interviewed respondents with structured questionnaires. Data was collected from August to November 2011. Questionnaires and interview results were checked for completeness and internal errors during data collection. Questionnaires were then sorted, numbered and kept in files labeled per facility from which the participants were recruited. Data was then coded before entering into SPSS. The perception on quality of PMTCT services and its influence on HIV Counseling and Testing was analysed using logistic regressions. This was done using STATA 11. The dependent variable was utilization of HTC and independent variables were facility related factors that influence HTC and these included waiting time, privacy and confidentiality, feeling attended to, being listened to, being treated with respect and trust for health workers. Pregnant women who had not been tested for HIV after two or more ANC visits were classified as not utilizing HTC and this was coded as 1. Focus group discussions (FGDs) and in-depth interviews using interview guides and tape recorders were the data collection techniques and tools respectively. Five FGDs, involving 40 pregnant women (8 per group per FGD) were conducted. They involved three (3) groups of women who had not undertaken HTC and two (2) groups of pregnant women who had undergone HTC. Topics discussed involved various health facility barriers to HTC. Twelve health workers were also involved in the in-depth interviews. Qualitative data was analyzed using ATLAS.ti. Audio-recorded data from both FGDs and key informants interviews were transcribed verbatim and translated into English. Data was analysed thematically and salient quotes from the themes were presented as results. The Committee for Human Research Publication and Ethics of the School of Medical Science, Kwame Nkrumah University of Science and Technology (KNUST) gave ethical clearance. Participants were taken through consenting processes prior to enrolment into the study. There was full disclosure or discussion of relevant information and questions related to the study. Also participants who could not read were informed about the study by translating the consenting information into their local language for adequate comprehension. They were told that enrolment into the study was voluntary. No response was related to participants who were assigned study identification numbers.

Materials

N/A

Innovations

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

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services to provide pregnant women with information about HIV testing and counseling, as well as reminders for appointments and follow-up care.

2. Community Health Workers: Train and deploy community health workers to provide education and counseling on HIV testing and antenatal care. These workers can reach women in their communities and address any concerns or misconceptions they may have.

3. Telemedicine: Implement telemedicine services to allow pregnant women in remote areas to access HIV testing and counseling remotely. This can help overcome geographical barriers and improve access to care.

4. Improved Health Facility Infrastructure: Invest in improving health facility infrastructure to create a welcoming and comfortable environment for pregnant women. This can include private counseling rooms, shorter waiting times, and improved confidentiality measures.

5. Health Education Campaigns: Launch targeted health education campaigns to raise awareness about the importance of HIV testing and counseling during pregnancy. These campaigns can address common misconceptions and provide accurate information to pregnant women and their families.

6. Strengthening Health Worker Training: Provide comprehensive training for health workers on HIV testing and counseling, including communication skills, confidentiality, and cultural sensitivity. This can help improve the quality of care and build trust between health workers and pregnant women.

7. Integration of Services: Integrate HIV testing and counseling services with other maternal health services, such as antenatal care and postnatal care. This can streamline the process for pregnant women and ensure they receive comprehensive care.

8. Peer Support Programs: Establish peer support programs where women who have undergone HIV testing and counseling during pregnancy can provide support and guidance to pregnant women who are hesitant or unsure about the process.

9. Public-Private Partnerships: Foster partnerships between public and private sectors to expand access to HIV testing and counseling services. This can involve collaboration with private clinics, pharmacies, and community organizations to reach more pregnant women.

10. Data Monitoring and Evaluation: Implement robust data monitoring and evaluation systems to track the uptake of HIV testing and counseling services among pregnant women. This can help identify gaps in access and inform targeted interventions.

These are just a few potential innovations that could be considered to improve access to maternal health, specifically in relation to HIV testing and counseling. It is important to assess the local context and engage stakeholders to determine the most appropriate and effective strategies for implementation.

AI Innovations Description

Based on the description provided, the recommendation to improve access to maternal health is to address the health facility related factors that act as barriers to HIV testing and counseling (HTC) among pregnant women attending antenatal clinics (ANC). The study found that factors such as lack of information, perceptions of privacy and confidentiality, waiting time, poor relationship with health staff, and fear of being positive influenced the decision of pregnant women to take up HTC.

To improve implementation of HTC and increase utilization among pregnant women, the following actions can be taken:

1. Health education and information: Provide comprehensive and accurate information about the benefits of routine HIV testing during ANC visits. This can include educating pregnant women about the importance of early detection, available treatment options, and the impact of HIV on maternal and child health.

2. Confidentiality: Ensure that strict confidentiality measures are in place to protect the privacy of pregnant women seeking HTC. This can be achieved by training health staff on the importance of confidentiality and implementing protocols to safeguard patient information.

3. Health staff turnaround time: Reduce waiting times for HTC services by improving efficiency in service delivery. This can be done by optimizing staff schedules, streamlining processes, and allocating adequate resources to ANC clinics.

4. Health staff-client relationship: Foster a positive and supportive environment between health staff and pregnant women. This can be achieved through training health workers on effective communication skills, empathy, and building trust with patients.

By addressing these health facility related factors, access to HTC services can be improved, leading to increased uptake of HIV testing and counseling among pregnant women attending ANC. This, in turn, will contribute to the goal of universal access to prevention and timely HIV treatment and healthcare.

AI Innovations Methodology

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

1. Increase health education and information: Provide comprehensive and accurate information about the importance of maternal health, including the benefits of routine HIV testing and counseling (HTC). This can be done through various channels such as community outreach programs, educational materials, and antenatal clinics.

2. Improve confidentiality and privacy: Address concerns about privacy and confidentiality by implementing measures to ensure that women feel comfortable and safe when accessing HTC services. This can include training healthcare providers on maintaining confidentiality, creating private spaces for counseling, and implementing strict data protection protocols.

3. Reduce waiting time: Take steps to minimize waiting times for HTC services by streamlining processes, improving appointment scheduling systems, and increasing the number of healthcare providers available to provide counseling and testing.

4. Enhance the relationship between health staff and clients: Foster a positive and supportive relationship between healthcare providers and pregnant women by promoting respectful and empathetic communication. This can be achieved through training programs for healthcare providers that focus on patient-centered care and effective communication skills.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the percentage of pregnant women who undergo HTC, the average waiting time for HTC services, and the satisfaction level of pregnant women with the quality of care received.

2. Collect baseline data: Gather data on the current status of these indicators before implementing the recommendations. This can be done through surveys, interviews, and data analysis of existing records.

3. Implement the recommendations: Roll out the recommended interventions, such as health education campaigns, training programs for healthcare providers, and improvements in facility infrastructure.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the indicators identified in step 1. This can be done through regular surveys, interviews, and data analysis.

5. Analyze the data: Use statistical analysis techniques to compare the baseline data with the data collected after implementing the recommendations. This will help determine the impact of the interventions on improving access to maternal health.

6. Draw conclusions and make adjustments: Based on the analysis of the data, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. If necessary, make adjustments to the interventions to further enhance their impact.

7. Communicate the findings: Share the findings of the impact assessment with relevant stakeholders, such as healthcare providers, policymakers, and community members. This will help create awareness and support for the interventions and encourage further improvements in access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for future interventions.

Authors & Co-Authors

Statistics:

Citations: 29

Authors: 4

Identifiers:

DOI: 10.1186/1472-6963-14-267

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Technology and Innovations

Study Countries:

Ghana

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female