The Tingathe programme: A pilot intervention using community health workers to create a continuum of care in the prevention of mother to child transmission of HIV (PMTCT) cascade of services in Malawi

Journal of the International AIDS Society, Volume 15, Year 2012

Ukuhunyushwa

Introduction: Loss to follow-up is a major challenge in the prevention of mother to child transmission of HIV (PMTCT) programme in Malawi with reported loss to follow-up of greater than 70%. Tingathe-PMTCT is a pilot intervention that utilizes dedicated community health workers (CHWs) to create a complete continuum of care within the PMTCT cascade, improving service utilization and retention of mothers and infants.We describe the impact of the intervention on longitudinal care starting with diagnosis of the mother at antenatal care (ANC) through final diagnosis of the infant. Methods: PMTCT service utilization, programme retention and outcomes were evaluated for pregnant women living with HIV and their exposed infants enrolled in the Tingathe-PMTCT programme between March 2009 and March 2011. Multivariate logistic regression was done to evaluate maternal factors associated with failure to complete the cascade. Results: Over 24 months, 1688 pregnant women living with HIV were enrolled. Median maternal age was 27 years (IQR, 23.8 to 30.8); 333 (19.7%) were already on ART. Among the remaining women, 1328/1355 (98%) received a CD4 test, with 1243/1328 (93.6%) receiving results. Of the 499 eligible for ART, 363 (72.8%) were successfully initiated. Prior to, delivery there were 93 (5.7%) maternal/foetal deaths, 137 (8.1%) women transferred/moved, 51 (3.0%) were lost and 58 (3.4%) refused ongoing PMTCT services. Of the 1318 live births to date, 1264 (95.9%) of the mothers and 1285 (97.5%) of the infants received ARV prophylaxis; 1064 (80.7%) infants were tested for HIV by PCR and started on cotrimoxazole. Median age at PCR was 1.7 months (IQR, 1.5 to 2.5). Overall transmission at first PCR was 43/1047 (4.1%). Of the 43 infants with positive PCR results, 36 (83.7%) were enrolled in ART clinic and 33 (76.7%) were initiated on ART. Conclusions: Case management and support by dedicated CHWs can create a continuum of longitudinal care in the PMTCT cascade and result in improved outcomes. The Tingathe-PMTCT pilot programme took place in Area 25 and Kawale, two large peri-urban communities in Lilongwe. The estimated population is 310,000 people, with 15,000 deliveries/year, 2000 HIV-exposed infants delivered/year and 12% adult HIV prevalence [16]. Over 96% of pregnant women attend at least one antenatal visit [17] and 99% of ANC attendees are tested for HIV [18,19]. All PMTCT clinical care was provided in accordance with MOH and WHO guidelines [20,21]. Figure 2a details all components of the PMTCT cascade available at the intervention sites. HIV testing, counselling and consent were conducted via opt-out testing per MOH guidelines. (a) Components of the PMTCT cascade available at programme intervention sites. (b) Curriculum of community health worker training. At the start of our programme, ART eligibility was defined as WHO Stage 3 or 4 or CD4≤250 cells/mm3 [21]. ART eligibility changed in August 2010 to CD4≤350 cells/mm3 for pregnant or lactating women living with HIV. For women who did not qualify for ART, single dose nevirapine for the mother and infant and a bottle of zidovudine (AZT) syrup for the infant was dispensed at the first ANC visit. AZT was dispensed beginning at 28 weeks, and mothers returned for monthly refills. A 1-week supply of AZT/lamivudine (3TC) tail was distributed during labour and delivery [21]. During the intervention period, the national infant feeding guidelines recommended exclusive breastfeeding until 6 months of age followed by gradual weaning [22,23]. Universal ART initiation for HIV-infected infants younger than 1 year of age was the standard of care. We used three sources for preintervention data. The first was a published report of maternal and infant utilization of PMTCT, EID and paediatric HIV services at five sites (including our two intervention sites) within Lilongwe between 2004 and 2008 [19]. This source contained preintervention comparison data for PMTCT prophylaxis, infant PCRs and ART initiation for HIV-infected infants. For information not included in this report, we used the 2004 Malawi Demographic and Health Survey, which provided national statistics for numbers of women accessing ANC, location of delivery and infant feeding choice after birth [17]. Finally, ANC CD4 log records documented CD4 test dates and whether or not results were returned to pregnant women. Consistent records were not kept at A25. At Kawale, records were available from March to October 2008. The main focus of this programme was CHW-based patient case management in both the health facility and community (Figure 1). The intervention began at ANC when pregnant women identified as living with HIV were assigned a dedicated CHW and voluntarily enrolled into the programme. CHWs ensured that mother-infant pairs received all necessary PMTCT services. They followed their clients at their homes and at health centres, from initial diagnosis up until confirmation of definitive HIV-uninfected status after cessation of breastfeeding or successful ART initiation for HIV-infected infants. Receipt of PMTCT was recorded only upon confirmation with the mother after delivery to verify that medication had actually been ingested, not just dispensed [7]. Women living with HIV who were identified at labour and delivery or after the birth of the infant were also followed up and provided services but were not included in this cohort. Criterion for CHW selection included living within the community, completion of primary schooling and ability to read and write in English and Chichewa, ability to ride a bicycle and HIV-infected or affected. Both men and women were recruited. Due to the large volume of applicants, we first conducted group interviews, inviting those who performed well in these for individual interviews. Once selected, CHWs earned a stipend for work-related transportation and food (2.50 USD/day). A specialized 2-week training, followed by a 2-week on-site orientation, was developed (Figure 2b). Trainees were monitored closely by supervisors and were only allowed to conduct unsupervised patient visits after competency had been verified. CHWs also received half-day quarterly refresher trainings by Baylor paediatricians. To help free up clinical staff for essential clinical care, specific tasks were shifted to CHWs, including patient registration, nutritional assessments, infant feeding counselling, pill counting and distribution of nutritional supplements. All CHWs were responsible for both health centre-based tasks (40% time) and community work (60% time). CHWs generally followed up to a maximum of 50 mother-infant pairs at one time. Prior to the programme intervention, consultative meetings were conducted with community leaders. CHWs conducted daily education sessions in the health centres and held ongoing sensitization meetings in the community. The main focus of education was promoting the utilization of PMTCT, EID and paediatric HIV treatment services. An individual patient mastercard was used to facilitate patient case management, and a patient register was used to monitor CHW activities. The mother-infant mastercard was opened on programme entry, updated after every visit and key data entered into registers weekly. Information from registers was entered into a Microsoft Access database bimonthly. CHWs were supervised weekly by site supervisors and monthly by the programme coordinator. Supervisors also conducted unscheduled visits with patients to ensure that they were satisfied with the services being provided. CHWs received bi-annual performance evaluations. Mother-infant pairs exited the programme if they reached one of the following outcomes: (1) maternal death; (2) miscarriage, stillbirth; (3) infant death; (4) transferred/moved outside the catchment area; (5) lost (patient tracing attempted but patient could not be found); (6) despite counselling, patient refused to return for clinical care; (7) infant infected and successfully enrolled into care and started on ART; and (8) infant definitively not infected (weaned and repeat PCR negative). Data from pregnant women and exposed infants enrolled in the Tingathe-PMTCT programme between March 2009 and March 2011 were analysed. The closing date for follow-up was October 31, 2011. Data were de-identified prior to analysis. Aggregate data were reported as mean with standard deviation or median with interquartile range (IQR) based on normality. For the multivariate logistic regression, all outcomes preventing completion of the PMTCT cascade were grouped together including miscarriage/foetal demise, maternal/infant death, transferred/moved, lost and refused ongoing care. To identify factors that predicted non-completion, unadjusted and adjusted odds ratios and 95% confidence intervals were obtained using binary and multivariate logistic regression, respectively. All covariates, irrespective of the significance of the binary model, were entered into the multivariate model by forward stepwise selection, with entry testing based on the significance of the score statistic and removal testing based on the likelihood-ratio statistic with conditional parameter estimates. Only covariates with a significant score statistic (p<0.05) were retained in the final model. Analyses were performed using IBM SPSS Statistics (version 19; SPSS, Inc., Chicago, IL, USA). The Malawi National Health Sciences Research Committee and the Baylor College of Medicine institutional review board granted ethics approval.

I-AI Digest

Study Justification:

The Tingathe programme was implemented to address the challenge of high loss to follow-up in the prevention of mother to child transmission of HIV (PMTCT) programme in Malawi. The study aimed to evaluate the impact of the Tingathe-PMTCT intervention, which utilized community health workers (CHWs) to provide comprehensive care within the PMTCT cascade. The goal was to improve service utilization and retention of mothers and infants in the PMTCT programme.

Highlights:

– The Tingathe-PMTCT programme enrolled 1688 pregnant women living with HIV over a period of 24 months.
– The intervention resulted in high rates of CD4 testing and initiation of antiretroviral therapy (ART) for eligible women.
– Maternal and infant outcomes were positive, with high rates of ARV prophylaxis, HIV testing, and initiation of cotrimoxazole for infants.
– The overall transmission rate at the first PCR test was 4.1%, indicating successful prevention of mother to child transmission in the majority of cases.
– CHWs played a crucial role in providing case management and support to ensure continuity of care throughout the PMTCT cascade.

Recommendations:

– Expand the Tingathe-PMTCT programme to other communities in Malawi to reach a larger population of pregnant women living with HIV.
– Strengthen the training and supervision of CHWs to ensure high-quality care and adherence to guidelines.
– Improve data collection and monitoring systems to track outcomes and identify areas for improvement.
– Collaborate with community leaders and stakeholders to increase community awareness and support for PMTCT services.
– Consider integrating the Tingathe-PMTCT model into the national healthcare system to sustain and scale up the intervention.

Key Role Players:

– Community health workers (CHWs): Dedicated CHWs are essential for providing case management and support to pregnant women living with HIV.
– Healthcare providers: Medical professionals, including doctors, nurses, and midwives, play a crucial role in providing clinical care and guidance.
– Community leaders: Engaging community leaders is important for promoting awareness and support for PMTCT services.
– Policy makers: Government officials and policymakers are needed to support and implement the recommendations of the study.

Cost Items for Planning Recommendations:

– Training and supervision of CHWs: Budget for developing and conducting training programs for CHWs, as well as ongoing supervision and support.
– Medications and supplies: Allocate funds for antiretroviral drugs, HIV testing kits, cotrimoxazole, and other necessary medications and supplies.
– Data collection and monitoring systems: Invest in the development and maintenance of systems to collect and analyze data on PMTCT outcomes.
– Community engagement and awareness campaigns: Allocate resources for community sensitization meetings, educational materials, and outreach activities.
– Integration into the national healthcare system: Consider the cost implications of integrating the Tingathe-PMTCT model into existing healthcare infrastructure and services.

Amandla Obufakazi

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study provides detailed information on the implementation of the Tingathe-PMTCT pilot program and its impact on PMTCT service utilization and outcomes. The study includes a large sample size and uses multivariate logistic regression to evaluate factors associated with failure to complete the PMTCT cascade. However, the abstract could be improved by providing more specific information on the results of the logistic regression analysis, such as the odds ratios and confidence intervals for the factors associated with non-completion. Additionally, the abstract could benefit from a clearer description of the study design and methods, including the inclusion and exclusion criteria for the study population. To improve the abstract, the authors could consider providing more specific information on the intervention itself, such as the training and responsibilities of the community health workers, and the specific components of the PMTCT cascade that were targeted by the intervention. Overall, the evidence in the abstract is strong, but providing more specific information and clarifying the study design and methods would further strengthen the evidence.

Abstract

The Tingathe-PMTCT pilot programme took place in Area 25 and Kawale, two large peri-urban communities in Lilongwe. The estimated population is 310,000 people, with 15,000 deliveries/year, 2000 HIV-exposed infants delivered/year and 12% adult HIV prevalence [16]. Over 96% of pregnant women attend at least one antenatal visit [17] and 99% of ANC attendees are tested for HIV [18,19]. All PMTCT clinical care was provided in accordance with MOH and WHO guidelines [20,21]. Figure 2a details all components of the PMTCT cascade available at the intervention sites. HIV testing, counselling and consent were conducted via opt-out testing per MOH guidelines. (a) Components of the PMTCT cascade available at programme intervention sites. (b) Curriculum of community health worker training. At the start of our programme, ART eligibility was defined as WHO Stage 3 or 4 or CD4≤250 cells/mm3 [21]. ART eligibility changed in August 2010 to CD4≤350 cells/mm3 for pregnant or lactating women living with HIV. For women who did not qualify for ART, single dose nevirapine for the mother and infant and a bottle of zidovudine (AZT) syrup for the infant was dispensed at the first ANC visit. AZT was dispensed beginning at 28 weeks, and mothers returned for monthly refills. A 1-week supply of AZT/lamivudine (3TC) tail was distributed during labour and delivery [21]. During the intervention period, the national infant feeding guidelines recommended exclusive breastfeeding until 6 months of age followed by gradual weaning [22,23]. Universal ART initiation for HIV-infected infants younger than 1 year of age was the standard of care. We used three sources for preintervention data. The first was a published report of maternal and infant utilization of PMTCT, EID and paediatric HIV services at five sites (including our two intervention sites) within Lilongwe between 2004 and 2008 [19]. This source contained preintervention comparison data for PMTCT prophylaxis, infant PCRs and ART initiation for HIV-infected infants. For information not included in this report, we used the 2004 Malawi Demographic and Health Survey, which provided national statistics for numbers of women accessing ANC, location of delivery and infant feeding choice after birth [17]. Finally, ANC CD4 log records documented CD4 test dates and whether or not results were returned to pregnant women. Consistent records were not kept at A25. At Kawale, records were available from March to October 2008. The main focus of this programme was CHW-based patient case management in both the health facility and community (Figure 1). The intervention began at ANC when pregnant women identified as living with HIV were assigned a dedicated CHW and voluntarily enrolled into the programme. CHWs ensured that mother-infant pairs received all necessary PMTCT services. They followed their clients at their homes and at health centres, from initial diagnosis up until confirmation of definitive HIV-uninfected status after cessation of breastfeeding or successful ART initiation for HIV-infected infants. Receipt of PMTCT was recorded only upon confirmation with the mother after delivery to verify that medication had actually been ingested, not just dispensed [7]. Women living with HIV who were identified at labour and delivery or after the birth of the infant were also followed up and provided services but were not included in this cohort. Criterion for CHW selection included living within the community, completion of primary schooling and ability to read and write in English and Chichewa, ability to ride a bicycle and HIV-infected or affected. Both men and women were recruited. Due to the large volume of applicants, we first conducted group interviews, inviting those who performed well in these for individual interviews. Once selected, CHWs earned a stipend for work-related transportation and food (2.50 USD/day). A specialized 2-week training, followed by a 2-week on-site orientation, was developed (Figure 2b). Trainees were monitored closely by supervisors and were only allowed to conduct unsupervised patient visits after competency had been verified. CHWs also received half-day quarterly refresher trainings by Baylor paediatricians. To help free up clinical staff for essential clinical care, specific tasks were shifted to CHWs, including patient registration, nutritional assessments, infant feeding counselling, pill counting and distribution of nutritional supplements. All CHWs were responsible for both health centre-based tasks (40% time) and community work (60% time). CHWs generally followed up to a maximum of 50 mother-infant pairs at one time. Prior to the programme intervention, consultative meetings were conducted with community leaders. CHWs conducted daily education sessions in the health centres and held ongoing sensitization meetings in the community. The main focus of education was promoting the utilization of PMTCT, EID and paediatric HIV treatment services. An individual patient mastercard was used to facilitate patient case management, and a patient register was used to monitor CHW activities. The mother-infant mastercard was opened on programme entry, updated after every visit and key data entered into registers weekly. Information from registers was entered into a Microsoft Access database bimonthly. CHWs were supervised weekly by site supervisors and monthly by the programme coordinator. Supervisors also conducted unscheduled visits with patients to ensure that they were satisfied with the services being provided. CHWs received bi-annual performance evaluations. Mother-infant pairs exited the programme if they reached one of the following outcomes: (1) maternal death; (2) miscarriage, stillbirth; (3) infant death; (4) transferred/moved outside the catchment area; (5) lost (patient tracing attempted but patient could not be found); (6) despite counselling, patient refused to return for clinical care; (7) infant infected and successfully enrolled into care and started on ART; and (8) infant definitively not infected (weaned and repeat PCR negative). Data from pregnant women and exposed infants enrolled in the Tingathe-PMTCT programme between March 2009 and March 2011 were analysed. The closing date for follow-up was October 31, 2011. Data were de-identified prior to analysis. Aggregate data were reported as mean with standard deviation or median with interquartile range (IQR) based on normality. For the multivariate logistic regression, all outcomes preventing completion of the PMTCT cascade were grouped together including miscarriage/foetal demise, maternal/infant death, transferred/moved, lost and refused ongoing care. To identify factors that predicted non-completion, unadjusted and adjusted odds ratios and 95% confidence intervals were obtained using binary and multivariate logistic regression, respectively. All covariates, irrespective of the significance of the binary model, were entered into the multivariate model by forward stepwise selection, with entry testing based on the significance of the score statistic and removal testing based on the likelihood-ratio statistic with conditional parameter estimates. Only covariates with a significant score statistic (p<0.05) were retained in the final model. Analyses were performed using IBM SPSS Statistics (version 19; SPSS, Inc., Chicago, IL, USA). The Malawi National Health Sciences Research Committee and the Baylor College of Medicine institutional review board granted ethics approval.

Izinto zokwakha

N/A

Emisha

The Tingathe-PMTCT pilot programme in Malawi utilized several innovations to improve access to maternal health. These innovations include:

1. Utilizing community health workers (CHWs): The programme assigned dedicated CHWs to pregnant women living with HIV, who provided case management and support both in health facilities and in the community. CHWs ensured that mother-infant pairs received all necessary PMTCT services and followed up with them at their homes and health centers.

2. Continuum of care: The programme aimed to create a complete continuum of care within the PMTCT cascade, starting from the diagnosis of the mother at antenatal care (ANC) through the final diagnosis of the infant. This approach improved service utilization and retention of mothers and infants.

3. Opt-out HIV testing: HIV testing, counseling, and consent were conducted via opt-out testing, following Ministry of Health (MOH) guidelines. This approach increased the number of pregnant women tested for HIV and identified those who needed PMTCT services.

4. Shifting tasks to CHWs: To free up clinical staff for essential clinical care, specific tasks such as patient registration, nutritional assessments, infant feeding counseling, pill counting, and distribution of nutritional supplements were shifted to CHWs. This allowed clinical staff to focus on providing medical care while CHWs handled other aspects of patient support.

5. Patient case management: CHWs used individual patient mastercards and patient registers to facilitate patient case management. These tools helped track the progress of mother-infant pairs, record key data, and ensure that necessary PMTCT services were provided.

These innovations in the Tingathe-PMTCT programme improved access to maternal health by addressing challenges such as loss to follow-up and ensuring that pregnant women living with HIV received comprehensive care throughout the PMTCT cascade.

AI Innovations Description

The Tingathe programme is a pilot intervention in Malawi that aims to improve access to maternal health services, specifically in the prevention of mother-to-child transmission of HIV (PMTCT) cascade. The programme utilizes dedicated community health workers (CHWs) to provide a continuum of care for pregnant women living with HIV and their exposed infants.

The key components of the Tingathe-PMTCT programme include:

1. Identification and enrollment of pregnant women living with HIV into the programme at antenatal care (ANC) clinics.
2. Assigning a dedicated CHW to each enrolled mother-infant pair to provide case management and support.
3. Ensuring that all necessary PMTCT services are received, including HIV testing, counseling, and consent; CD4 testing; initiation of antiretroviral therapy (ART) if eligible; provision of prophylactic medication for mother and infant; and regular follow-up visits.
4. Conducting home visits and accompanying mothers to health centers to ensure continuity of care.
5. Providing education and sensitization sessions in both health centers and the community to promote the utilization of PMTCT, early infant diagnosis (EID), and pediatric HIV treatment services.
6. Monitoring and supervision of CHWs by site supervisors and program coordinators.
7. Regular training and refresher courses for CHWs to enhance their skills and knowledge.
8. Use of patient mastercards and registers to facilitate patient case management and monitoring of CHW activities.
9. Exit from the program occurs when mothers and infants reach specific outcomes, such as maternal or infant death, transfer/move outside the catchment area, loss to follow-up, refusal of ongoing care, or successful enrollment into HIV care and treatment for infected infants.

The Tingathe-PMTCT programme has shown promising results in improving service utilization and retention of mothers and infants in the PMTCT cascade. Over a 24-month period, 1688 pregnant women living with HIV were enrolled in the program. The majority of women received CD4 testing and ART initiation if eligible. Prophylactic medication was provided to the mothers and infants, and a high percentage of infants were tested for HIV and started on cotrimoxazole. The overall transmission rate at the first PCR test was low.

The success of the Tingathe-PMTCT programme can be attributed to the dedicated CHWs who provide personalized care and support to the enrolled mothers and infants. The CHWs play a crucial role in ensuring that all necessary services are received and in addressing barriers to accessing care, such as transportation and stigma. The program also emphasizes community engagement and education to increase awareness and utilization of PMTCT services.

Based on the positive outcomes of the Tingathe-PMTCT programme, it can be recommended to scale up and replicate this model in other settings to improve access to maternal health services, particularly in the context of HIV. The use of dedicated CHWs, comprehensive case management, and community engagement can contribute to better retention and outcomes in the PMTCT cascade.

AI Innovations Methodology

Based on the information provided, the Tingathe-PMTCT pilot program in Malawi utilized community health workers (CHWs) to improve access to maternal health services and retention of mothers and infants in the prevention of mother to child transmission of HIV (PMTCT) cascade. The program showed positive outcomes in terms of PMTCT service utilization and retention.

To further improve access to maternal health, here are some potential recommendations:

1. Strengthening community-based interventions: Expand the role of CHWs in providing comprehensive maternal health services, including antenatal care, postnatal care, and family planning. This can be done by providing additional training and resources to CHWs, and integrating them into the formal healthcare system.

2. Mobile health (mHealth) interventions: Utilize mobile technology to improve access to maternal health information and services. This can include sending SMS reminders for antenatal care visits, providing access to educational resources through mobile apps, and enabling teleconsultations with healthcare providers.

3. Task-shifting and task-sharing: Train and empower a wider range of healthcare providers, such as nurses and midwives, to deliver maternal health services. This can help alleviate the burden on doctors and increase access to care, especially in remote or underserved areas.

4. Community engagement and awareness campaigns: Conduct community-based awareness campaigns to educate and empower women and their families about the importance of maternal health. This can include promoting early antenatal care, encouraging facility-based deliveries, and addressing cultural and social barriers to accessing care.

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

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as antenatal care coverage, facility-based deliveries, postnatal care utilization, and contraceptive uptake.

2. Collect baseline data: Gather data on the current status of these indicators in the target population or area. This can be done through surveys, interviews, or existing health records.

3. Develop a simulation model: Create a mathematical or statistical model that simulates the impact of the recommendations on the selected indicators. This model should take into account factors such as population size, healthcare infrastructure, and resource availability.

4. Input data and parameters: Input the baseline data and parameters into the simulation model. This includes information on the current utilization of maternal health services, the potential impact of the recommendations, and any assumptions or constraints.

5. Run simulations: Run multiple simulations using different scenarios and assumptions to assess the potential impact of the recommendations on the selected indicators. This can help identify the most effective strategies and estimate the magnitude of the improvements.

6. Analyze and interpret results: Analyze the simulation results to understand the potential impact of the recommendations on improving access to maternal health. This can include comparing different scenarios, identifying key drivers of change, and assessing the feasibility and cost-effectiveness of the interventions.

7. Refine and validate the model: Refine the simulation model based on feedback and validation from experts and stakeholders. This can involve adjusting parameters, incorporating additional data, or improving the model’s accuracy.

8. Communicate findings and recommendations: Present the simulation results in a clear and concise manner, highlighting the potential benefits of the recommendations and their implications for policy and practice. This can help guide decision-making and resource allocation for improving access to maternal health.

It’s important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data. It’s recommended to involve relevant stakeholders and experts in the design and implementation of the simulation study to ensure its validity and relevance.

Umbhali

Dima Health

Statistics:

Citations: 80

Identifiers:

DOI: 10.7448/IAS.15.4.17389

Research Areas:

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

Study Countries:

Malawi

Study Design:

Cohort Study, Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Male & Female

Yabelana ngalokhu: