Factors associated with uptake of services to prevent mother-to-child transmission of HIV in a community cohort in rural Tanzania

Sexually Transmitted Infections, Volume 91, No. 7, Year 2015

Interpretation

Objectives This study aimed to identify factors associated with access to HIV care and antiretroviral (ARV) drugs for prevention of mother-to-child transmission (PMTCT) of HIV among HIV-positive pregnant women in a community cohort in rural Tanzania (Kisesa). Methods Kisesa-resident women who tested HIVpositive during HIV serosurveillance and were pregnant (while HIV-positive) between 2005 and 2012 were eligible. Community cohort records were linked to PMTCT and HIV clinic data from four facilities (PMTCT programme implemented in 2009; referrals to city-based hospitals since 2005) to ascertain service use. Factors associated with access to HIV care and ARVs during pregnancy were analysed using logistic regression. Results Overall, 24% of women accessed HIV care and 12% accessed ARVs during pregnancy (n=756 pregnancies to 420 women); these proportions increased over time. In multivariate analyses for 2005-2012, being married, prior voluntary counselling and testing, increasing age, increasing year of pregnancy and increasing duration of infection were independently associated with access to care and ARVs. Residence in roadside areas was an independent predictor of access to care but not ARVs. There was no evidence of an interaction with time period. Conclusions Access to PMTCT services was low in this rural setting but improved markedly over time. There were fairly few sociodemographic differentials although support for young women and those without partners may be needed. Further decentralisation of HIV services to more remote areas, promotion of voluntary counselling and testing and implementation of Option B+ are likely to improve uptake and may bring women into care and treatment sooner after infection. Kisesa is a rural community in north-western Tanzania, 20 km east of Mwanza city in Magu district. Approximately 30 000 individuals inhabit the DSS area of roughly 150 km2 that includes a trading centre and five other villages (roadside, or rural, where housing is fairly dispersed). There are three village dispensaries and a health centre in the trading centre (government-run). Implementation of PMTCT services started in 2009, including provider-initiated HIV testing and counselling and provision of ARV prophylaxis at ANCs, with referrals to the HIV care and treatment clinic (CTC) in the health centre for long-term care and ARV therapy (ART) (see figure 1 and see online supplement 1 for PMTCT protocols). From 2005 to 2009, pregnant women diagnosed with HIV at voluntary counselling and testing (VCT) services in the health centre were referred to hospitals in Mwanza city for PMTCT services. At the health centre, ANC, CTC and VCT services are carried out in separate buildings. Antenatal HIV prevalence in Magu district has declined from 10.7% in 2000 to 8.9% in 2008.8 9 Cascade of prevention of mother-to-child transmission (PMTCT) services available in the dispensaries and/or health centre in Kisesa in 2009–2012, as well as referral services to city-based hospitals from 2005. ANC, antenatal clinic; PITC, provider-initiated testing and counselling; ARV, antiretroviral; CTC, care and treatment clinic; VCT, voluntary counselling and testing. From 2005 to 2009, pregnant women diagnosed with HIV at VCT services in the health centre were referred to hospitals in Mwanza city for PMTCT services. *In 2005–2011, HIV-positive pregnant women with CD4 counts <200 cells/mm3 were eligible for antiretroviral treatment (ART) for their own health (lamivudine (3TC) or emtricitabine, plus azidothymidine (AZT) or tenofovir, with efavirenz or nevirapine), otherwise ARV prophylaxis was provided: in 2005–2006 single-dose nevirapine at onset of labour; in 2007–2011 AZT from 28 weeks gestation (single-dose nevirapine, AZT and 3TC during labour) until 7 days postpartum (AZT plus 3TC). The treatment threshold was raised to 350 cells/mm3 in 2012 (ARV prophylaxis from 14 weeks (drug regimens remained unchanged), ‘Option A’).30 **In 2005–2006 infants received nevirapine within 72 h of birth; 2007–2011, infants received nevirapine for 1 week after birth and AZT for up to 4 weeks. Under ‘Option A’ in 2012 they received nevirapine prophylaxis until 1 week after cessation of breastfeeding (4–6 weeks if replacement feeding). Infant dried blood spot samples were sent for HIV testing to the national referral hospital in Mwanza city. The Kisesa cohort study started in 1994,10 with DSS enumeration of the entire population every 6 months. Enumerators visit households to record all births, pregnancies, migrations and deaths. HIV serological surveys are conducted approximately every 3 years (seven to date, most recently in 2013) within each village among resident adults aged ≥15 years. Participants consent to give blood for HIV research testing without results disclosure, are offered VCT, and are interviewed about economic activities, childbearing, use of health services, and knowledge of HIV. Routine clinic data were collected retrospectively from all four Kisesa facilities (approximately 10% of women in the seventh serosurvey attended ANC outside Kisesa). All records from 2005 to 2012 were abstracted from ANC pregnancy registers (some records (<10%) from different clinics and time periods were missing), PMTCT programme registers and the CTC (including patients who enrolled at city-based CTCs and transferred back to Kisesa). Data were double-entered, apart from CTC data. Community cohort data were linked to clinic data sets by matching on personal attributes (eg, age, sex, village of residence and pregnancy dates), using an algorithm developed from a gold standard of ANC numbers captured from women's ANC cards during DSS round 27 (2012). The algorithm had a sensitivity of 70% and positive predictive value of 98% for matching ANC clinic records, with a similar algorithm used to match CTC data (algorithms were based on a similar approach to Kabudula et al).11 12 PMTCT register records were linked to ANC and CTC records using ANC or CTC registration numbers, respectively. Sources of pregnancy data were child birth dates in the DSS (linked to mothers), mothers’ self reports of pregnancies or births in the DSS or serosurveys, and clinic pregnancy records. Women residing in Kisesa in 2005–2012, testing HIV-positive during any serosurvey, and pregnant during this interval were eligible. HIV seroconversion dates were estimated using the midpoint between first positive and last negative test dates. Prevalent cases were assumed to have seroconverted 3 years prior to their first positive test date (based on average duration of infection for seroincident cases). The denominator comprised HIV-positive pregnancies, excluding pregnancy records that lacked serosurvey interview data within 5 years. Two outcomes were assessed: (1) enrolled in a PMTCT programme and/or CTC (‘HIV care’) during or before pregnancy, and (2) accessed ARV drugs during pregnancy. Enrolment in HIV care was defined as linkage of a DSS record to a PMTCT or CTC clinic record. Dates of clinic registration were aligned with pregnancy dates to verify service access during each pregnancy. Maternal ARV access was defined as receipt of ARV drugs documented on any ANC visit in PMTCT registers, or a CTC record indicating initiation or continuation of ART during pregnancy (before the recorded or estimated delivery date). Data on infant ARVs or HIV diagnoses could not be linked to mothers’ records. Explanatory variables were constructed using DSS data or serosurvey questions, taking information from the round closest to the pregnancy. Knowledge of HIV transmission was assessed by asking respondents to mention any modes of HIV transmission. ART knowledge was assessed using the number of correct answers to five true or false statements about ART (detailed in table 1). Responses to knowledge questions after the pregnancy date were distinguished, as knowledge was hypothesised to change as a result of attending the clinic. Death of a child was defined as any self-reported miscarriage, stillbirth or child death after birth. VCT use prior to pregnancy was based on attendance at VCT in an earlier serosurvey, or self-reported VCT use before the pregnancy date. HIV status of partners was determined using DSS line numbers of the spouse and spousal serosurvey HIV test data. Age was modelled as a continuous variable; all other quantitative variables were categorised. Characteristics of pregnancies (n=756) to HIV-positive women in Kisesa and proportions accessing HIV care/ARVs by factor Missing values: education (1); religion (13); ethnicity (1); income (3); children died (17); relatives died (17); know someone on ART (38). *No prior report: knowledge data point after pregnancy, or from an earlier serosurvey questionnaire lacking the same question. †Statements: “Drugs can only slow down HIV illness not stop it”; “ART drugs are very dangerous and can kill people”; “ART drugs have to be used for life”; “ART drugs are available free of charge in Tanzania”; “Everyone who is infected with HIV needs drugs”. ‡Unknown to the study investigators. ART, antiretroviral treatment; ARV, antiretroviral; MTCT, mother-to-child transmission; P1–4, primary level 1–4 years; P5, primary level 5 years; VCT, voluntary counselling and testing. Descriptive analyses, followed by bivariate and multivariate logistic regression analyses (deemed appropriate given the short and homogeneous follow-up time per pregnancy) were performed using Stata V.12 (StataCorp LP, Texas, USA) to identify independent predictors of access to HIV care or ARVs. All factors associated with the outcome (p≤0.1) in bivariate analyses were assessed in multivariate models, using a forwards stepwise approach. Variables were retained if they significantly improved the model fit (p≤0.1, based on likelihood ratio tests). Clustering due to multiple pregnancies per woman was accounted for using random effects, checking for quadrature stability. Interactions with calendar year of pregnancy or age were assessed. For continuous variables, departure from linearity was assessed using likelihood ratio tests. Informed consent was obtained from all serosurvey participants. Data typists and managers received ethics training. Names of patients with HIV were not visible to data typists. Data sets were stored on password-restricted computer networks.

AI Digest

Study Justification:

This study aimed to identify factors associated with access to HIV care and antiretroviral (ARV) drugs for prevention of mother-to-child transmission (PMTCT) of HIV among HIV-positive pregnant women in a rural community in Tanzania. The study is important because it provides insights into the barriers and facilitators of accessing PMTCT services in a rural setting, which can inform the development of interventions to improve uptake of these services.

Study Highlights:

– Overall, 24% of women accessed HIV care and 12% accessed ARVs during pregnancy.
– Factors associated with access to care and ARVs included being married, prior voluntary counselling and testing, increasing age, increasing year of pregnancy, and increasing duration of infection.
– Residence in roadside areas was associated with access to care but not ARVs.
– Access to PMTCT services improved over time.
– There were few sociodemographic differentials, but support for young women and those without partners may be needed.
– Decentralization of HIV services to more remote areas, promotion of voluntary counselling and testing, and implementation of Option B+ are recommended to improve uptake of PMTCT services.

Recommendations for Lay Reader:

– The study found that access to services to prevent mother-to-child transmission of HIV was low in a rural community in Tanzania but improved over time.
– Being married, prior voluntary counselling and testing, increasing age, increasing year of pregnancy, and increasing duration of infection were factors associated with accessing HIV care and antiretroviral drugs during pregnancy.
– Residence in roadside areas was associated with accessing HIV care but not antiretroviral drugs.
– The study suggests that decentralizing HIV services to more remote areas, promoting voluntary counselling and testing, and implementing Option B+ can improve uptake of services to prevent mother-to-child transmission of HIV.

Recommendations for Policy Maker:

– The study highlights the need to improve access to services to prevent mother-to-child transmission of HIV in rural communities.
– Decentralization of HIV services to more remote areas should be considered to ensure that pregnant women in these areas can easily access care and antiretroviral drugs.
– Promoting voluntary counselling and testing is important to identify HIV-positive pregnant women early and link them to appropriate care and treatment.
– Implementation of Option B+, which involves providing lifelong antiretroviral therapy to all HIV-positive pregnant women, can improve uptake of services and ensure that women receive timely and effective treatment.
– Additional support may be needed for young women and those without partners to ensure that they can access and benefit from PMTCT services.

Key Role Players:

– Healthcare providers: They play a crucial role in delivering PMTCT services and should be trained and supported to provide high-quality care.
– Community health workers: They can help raise awareness about PMTCT services, provide education and counseling, and support pregnant women in accessing and adhering to care and treatment.
– Community leaders and influencers: They can help promote PMTCT services and address any cultural or social barriers that may prevent women from accessing care.
– Government agencies and policymakers: They are responsible for developing and implementing policies and programs to improve access to PMTCT services.
– Non-governmental organizations: They can provide additional resources and support to strengthen PMTCT programs and reach underserved populations.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers and community health workers.
– Development and dissemination of educational materials and awareness campaigns.
– Infrastructure and equipment for decentralized HIV services in remote areas.
– Support for transportation and logistics to ensure the availability and delivery of antiretroviral drugs.
– Monitoring and evaluation of PMTCT programs to assess their effectiveness and identify areas for improvement.

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 used logistic regression analysis to identify factors associated with access to HIV care and antiretroviral drugs for prevention of mother-to-child transmission (PMTCT) of HIV among HIV-positive pregnant women in a rural community in Tanzania. The study had a large sample size (756 pregnancies to 420 women) and analyzed data from 2005 to 2012. The study found that being married, prior voluntary counseling and testing, increasing age, increasing year of pregnancy, and increasing duration of infection were independently associated with access to care and ARVs. However, there are some limitations to consider. The study did not provide information on the representativeness of the sample or the generalizability of the findings. Additionally, the study did not assess the statistical significance of the associations. To improve the strength of the evidence, future studies could include a more diverse sample and assess the statistical significance of the associations.

Abstract

Kisesa is a rural community in north-western Tanzania, 20 km east of Mwanza city in Magu district. Approximately 30 000 individuals inhabit the DSS area of roughly 150 km2 that includes a trading centre and five other villages (roadside, or rural, where housing is fairly dispersed). There are three village dispensaries and a health centre in the trading centre (government-run). Implementation of PMTCT services started in 2009, including provider-initiated HIV testing and counselling and provision of ARV prophylaxis at ANCs, with referrals to the HIV care and treatment clinic (CTC) in the health centre for long-term care and ARV therapy (ART) (see figure 1 and see online supplement 1 for PMTCT protocols). From 2005 to 2009, pregnant women diagnosed with HIV at voluntary counselling and testing (VCT) services in the health centre were referred to hospitals in Mwanza city for PMTCT services. At the health centre, ANC, CTC and VCT services are carried out in separate buildings. Antenatal HIV prevalence in Magu district has declined from 10.7% in 2000 to 8.9% in 2008.8 9 Cascade of prevention of mother-to-child transmission (PMTCT) services available in the dispensaries and/or health centre in Kisesa in 2009–2012, as well as referral services to city-based hospitals from 2005. ANC, antenatal clinic; PITC, provider-initiated testing and counselling; ARV, antiretroviral; CTC, care and treatment clinic; VCT, voluntary counselling and testing. From 2005 to 2009, pregnant women diagnosed with HIV at VCT services in the health centre were referred to hospitals in Mwanza city for PMTCT services. *In 2005–2011, HIV-positive pregnant women with CD4 counts <200 cells/mm3 were eligible for antiretroviral treatment (ART) for their own health (lamivudine (3TC) or emtricitabine, plus azidothymidine (AZT) or tenofovir, with efavirenz or nevirapine), otherwise ARV prophylaxis was provided: in 2005–2006 single-dose nevirapine at onset of labour; in 2007–2011 AZT from 28 weeks gestation (single-dose nevirapine, AZT and 3TC during labour) until 7 days postpartum (AZT plus 3TC). The treatment threshold was raised to 350 cells/mm3 in 2012 (ARV prophylaxis from 14 weeks (drug regimens remained unchanged), ‘Option A’).30 **In 2005–2006 infants received nevirapine within 72 h of birth; 2007–2011, infants received nevirapine for 1 week after birth and AZT for up to 4 weeks. Under ‘Option A’ in 2012 they received nevirapine prophylaxis until 1 week after cessation of breastfeeding (4–6 weeks if replacement feeding). Infant dried blood spot samples were sent for HIV testing to the national referral hospital in Mwanza city. The Kisesa cohort study started in 1994,10 with DSS enumeration of the entire population every 6 months. Enumerators visit households to record all births, pregnancies, migrations and deaths. HIV serological surveys are conducted approximately every 3 years (seven to date, most recently in 2013) within each village among resident adults aged ≥15 years. Participants consent to give blood for HIV research testing without results disclosure, are offered VCT, and are interviewed about economic activities, childbearing, use of health services, and knowledge of HIV. Routine clinic data were collected retrospectively from all four Kisesa facilities (approximately 10% of women in the seventh serosurvey attended ANC outside Kisesa). All records from 2005 to 2012 were abstracted from ANC pregnancy registers (some records (<10%) from different clinics and time periods were missing), PMTCT programme registers and the CTC (including patients who enrolled at city-based CTCs and transferred back to Kisesa). Data were double-entered, apart from CTC data. Community cohort data were linked to clinic data sets by matching on personal attributes (eg, age, sex, village of residence and pregnancy dates), using an algorithm developed from a gold standard of ANC numbers captured from women's ANC cards during DSS round 27 (2012). The algorithm had a sensitivity of 70% and positive predictive value of 98% for matching ANC clinic records, with a similar algorithm used to match CTC data (algorithms were based on a similar approach to Kabudula et al).11 12 PMTCT register records were linked to ANC and CTC records using ANC or CTC registration numbers, respectively. Sources of pregnancy data were child birth dates in the DSS (linked to mothers), mothers’ self reports of pregnancies or births in the DSS or serosurveys, and clinic pregnancy records. Women residing in Kisesa in 2005–2012, testing HIV-positive during any serosurvey, and pregnant during this interval were eligible. HIV seroconversion dates were estimated using the midpoint between first positive and last negative test dates. Prevalent cases were assumed to have seroconverted 3 years prior to their first positive test date (based on average duration of infection for seroincident cases). The denominator comprised HIV-positive pregnancies, excluding pregnancy records that lacked serosurvey interview data within 5 years. Two outcomes were assessed: (1) enrolled in a PMTCT programme and/or CTC (‘HIV care’) during or before pregnancy, and (2) accessed ARV drugs during pregnancy. Enrolment in HIV care was defined as linkage of a DSS record to a PMTCT or CTC clinic record. Dates of clinic registration were aligned with pregnancy dates to verify service access during each pregnancy. Maternal ARV access was defined as receipt of ARV drugs documented on any ANC visit in PMTCT registers, or a CTC record indicating initiation or continuation of ART during pregnancy (before the recorded or estimated delivery date). Data on infant ARVs or HIV diagnoses could not be linked to mothers’ records. Explanatory variables were constructed using DSS data or serosurvey questions, taking information from the round closest to the pregnancy. Knowledge of HIV transmission was assessed by asking respondents to mention any modes of HIV transmission. ART knowledge was assessed using the number of correct answers to five true or false statements about ART (detailed in table 1). Responses to knowledge questions after the pregnancy date were distinguished, as knowledge was hypothesised to change as a result of attending the clinic. Death of a child was defined as any self-reported miscarriage, stillbirth or child death after birth. VCT use prior to pregnancy was based on attendance at VCT in an earlier serosurvey, or self-reported VCT use before the pregnancy date. HIV status of partners was determined using DSS line numbers of the spouse and spousal serosurvey HIV test data. Age was modelled as a continuous variable; all other quantitative variables were categorised. Characteristics of pregnancies (n=756) to HIV-positive women in Kisesa and proportions accessing HIV care/ARVs by factor Missing values: education (1); religion (13); ethnicity (1); income (3); children died (17); relatives died (17); know someone on ART (38). *No prior report: knowledge data point after pregnancy, or from an earlier serosurvey questionnaire lacking the same question. †Statements: “Drugs can only slow down HIV illness not stop it”; “ART drugs are very dangerous and can kill people”; “ART drugs have to be used for life”; “ART drugs are available free of charge in Tanzania”; “Everyone who is infected with HIV needs drugs”. ‡Unknown to the study investigators. ART, antiretroviral treatment; ARV, antiretroviral; MTCT, mother-to-child transmission; P1–4, primary level 1–4 years; P5, primary level 5 years; VCT, voluntary counselling and testing. Descriptive analyses, followed by bivariate and multivariate logistic regression analyses (deemed appropriate given the short and homogeneous follow-up time per pregnancy) were performed using Stata V.12 (StataCorp LP, Texas, USA) to identify independent predictors of access to HIV care or ARVs. All factors associated with the outcome (p≤0.1) in bivariate analyses were assessed in multivariate models, using a forwards stepwise approach. Variables were retained if they significantly improved the model fit (p≤0.1, based on likelihood ratio tests). Clustering due to multiple pregnancies per woman was accounted for using random effects, checking for quadrature stability. Interactions with calendar year of pregnancy or age were assessed. For continuous variables, departure from linearity was assessed using likelihood ratio tests. Informed consent was obtained from all serosurvey participants. Data typists and managers received ethics training. Names of patients with HIV were not visible to data typists. Data sets were stored on password-restricted computer networks.

Materials

Innovations

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

1. Mobile Clinics: Implementing mobile clinics that travel to rural areas, including roadside areas, to provide maternal health services. This would bring healthcare closer to women in remote areas and increase access to services.

2. Telemedicine: Introducing telemedicine services that allow pregnant women in rural areas to consult with healthcare professionals remotely. This would enable women to receive medical advice and guidance without having to travel long distances.

3. Community Health Workers: Training and deploying community health workers in rural areas to provide basic maternal health services, such as prenatal care and education. These workers could also assist with referrals to healthcare facilities when necessary.

4. Awareness Campaigns: Conducting targeted awareness campaigns to educate women and their families about the importance of maternal health and the available services. This could help reduce stigma and increase demand for maternal health services.

5. Strengthening Referral Systems: Improving the referral systems between village dispensaries, health centers, and city-based hospitals to ensure seamless access to comprehensive maternal health services. This could involve streamlining communication and transportation between facilities.

6. Integration of Services: Integrating maternal health services with other existing healthcare programs, such as HIV care and treatment. This would ensure that pregnant women living with HIV have access to both PMTCT services and antiretroviral therapy.

7. Task Shifting: Training and empowering non-physician healthcare providers, such as nurses and midwives, to deliver a wider range of maternal health services. This could help alleviate the shortage of healthcare professionals in rural areas.

8. Incentives for Healthcare Providers: Implementing incentive programs to attract and retain healthcare providers in rural areas. This could include financial incentives, professional development opportunities, and improved working conditions.

9. Infrastructure Development: Investing in the development of healthcare infrastructure in rural areas, including the construction of additional health centers and upgrading existing facilities. This would ensure that there are enough healthcare facilities to meet the needs of the population.

10. Collaboration with NGOs and International Organizations: Collaborating with NGOs and international organizations that specialize in maternal health to leverage their expertise and resources. This could help accelerate the implementation of innovative solutions and improve access to maternal health services.

AI Innovations Description

The study mentioned in the description focuses on factors associated with access to HIV care and antiretroviral (ARV) drugs for the prevention of mother-to-child transmission (PMTCT) of HIV in a rural community in Tanzania. The study found that access to PMTCT services was low initially but improved over time. Factors such as being married, prior voluntary counseling and testing, increasing age, increasing year of pregnancy, and increasing duration of infection were independently associated with access to care and ARVs. Residence in roadside areas was also found to be a predictor of access to care. The study suggests that further decentralization of HIV services to more remote areas, promotion of voluntary counseling and testing, and implementation of Option B+ could improve uptake of PMTCT services and bring women into care and treatment sooner after infection.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health in the rural community of Kisesa, Tanzania:

1. Decentralization of HIV services: Expand the availability of HIV care and antiretroviral therapy (ART) to more remote areas within the community. This can involve setting up additional clinics or mobile health units to provide convenient access to maternal health services.

2. Promotion of voluntary counseling and testing (VCT): Increase awareness and encourage pregnant women to undergo VCT for early detection and management of HIV. This can be done through community outreach programs, educational campaigns, and integration of VCT services into existing healthcare facilities.

3. Implementation of Option B+: Adopt the Option B+ strategy, which involves providing lifelong ART to all pregnant and breastfeeding women living with HIV, regardless of CD4 count. This approach simplifies the treatment process and ensures that women receive continuous care and support throughout their pregnancy and beyond.

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 specific indicators that measure access to maternal health services, such as the percentage of pregnant women accessing HIV care, the percentage of pregnant women accessing ARVs, and the time from HIV diagnosis to initiation of treatment.

2. Collect baseline data: Gather data on the current status of access to maternal health services in the community. This can be done through surveys, interviews, and analysis of existing health records.

3. Develop a simulation model: Create a mathematical model that simulates the impact of the recommendations on access to maternal health services. The model should take into account factors such as population size, geographical distribution, healthcare infrastructure, and the effectiveness of the proposed interventions.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to estimate the potential impact of the recommendations. Vary the parameters and assumptions to explore different scenarios and assess the robustness of the results.

5. Analyze the results: Analyze the simulation results to determine the projected changes in access to maternal health services. Assess the effectiveness of each recommendation individually and in combination. Identify any potential barriers or limitations that may affect the implementation and impact of the recommendations.

6. Refine and validate the model: Refine the simulation model based on feedback from stakeholders and experts in the field. Validate the model by comparing the simulated results with real-world data and conducting sensitivity analyses to assess the model’s reliability and accuracy.

7. Communicate the findings: Present the findings of the simulation study to relevant stakeholders, including policymakers, healthcare providers, and community members. Use the results to inform decision-making and prioritize interventions that have the greatest potential for improving access to maternal health services.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions and make informed decisions to improve access to maternal health in the rural community of Kisesa, Tanzania.

Author

Dima Health

Statistics:

Citations: 17

Identifiers:

DOI: 10.1136/sextrans-2014-051907

ISSN: 13684973

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

Study Countries:

Tanzania

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female