In total 15 interviews were conducted with Anova employed health care providers (9 lay health providers and 6 nurses). The health providers were interviewed based on availability and willingness to participate in the data collection. Interviews were conducted in 12 primary health facilities.
In order to provide context to the findings, respondents were asked to describe the duties which they conducted as part of their roles. The majority of the lay health providers described their role as that of a PNC facilitator, indicating that they are responsible for preparing and running club sessions. This included recruiting MIPs, preparing meeting and consultation rooms, ordering medication, psychosocial support, conducting peer support, recording club visits in the register, distribution of pre-packed medication, flagging high viral loads and positive HIV test results to the PNC nurse and tracing flagged high viral load and positive HIV test clients.
The nurses reported that they were responsible for clinical oversight of PNCs. Activities included provision of drug scripts for club members, provision of clinical care (HIV and non-HIV) for mothers and infants (general child health and PMTCT), blood tests (viral load, HIV tests), conducting pap smears and providing enhanced care for high-risk mothers.
Participants reported that they provided services and identified a range of benefits, challenges and suggestions; these are discussed below. The results are presented below within the dimensions of the RE-AIM framework.
Reach
The reach dimension included investigating participants’ perception of clients’ willingness to participate in PNC. Key topics included enablers and barriers related to the program, with a particular focus on enrolment strategies. A key facilitator to the reach of the program was the provision of integrated care through the “one-stop-shop” model. Health providers cited that the model was preferable to clients, as it offered convenient medication pick-up processes and reduced waiting times and clinic visits.
Furthermore, participants indicated that the model supports HIV status disclosure to families and provides clients with a space to form cohesive and positive group dynamics over time, thereby contributing to adherence to ART.
they do like the model because they have built relationships with everyone, so we engage together, they like the whole setting of sitting together and seeing each other on the same appointment day
PNC counsellors and nurses also cited that they were able to support clients beyond club days. Providers reported communicating through WhatsApp (either over groups or individually) which was also mentioned by providers as facilitating willingness of clients to participate in the model.
And also one other thing that they appreciate is this WhatsApp group that we have created because we can communicate with them to ask them to come to the clinic
In turn, participants noted that the main reason clients declined to use the program was fear of unintended disclosure. They described how some clients avoid going to clinics nearest to them or participating in HIV care because they did not want to be seen at the clinic collecting ART medication or participating in adherence clubs and, in doing so, being linked to having an HIV positive status. Another reported barrier to enrolment was mothers’ perceived lack of importance of continued care postpartum. This was particularly seen in multiparous women.
Effectiveness
Our assessment indicated that providers perceived PNC attendance to be associated with a considerable increase in retention in care. Participants further indicated that the model was effective in improving client adherence to medication.
Firstly, before we had the postnatal club, we used to have defaulters because they were waiting in the queue for a long time, waiting for medication and then the next day they have to come for family planning and then the following day they have to bring the child in for immunization and that takes a lot of time. After starting the Postnatal clubs, we see cooperation because the mother does not default anymore.
Additionally, providers pointed out that PNC contributed to decongestion of health facilities, with MIPs able to receive ART care and child health services in a single clinic visit, decreasing the number of clinic consultations and visits that take place overall. Furthermore, participants indicated that the model provided enhanced care for MIPs.
But now with the PNC, we dig deeper, we check the mother(‘s) viral load, we check if they are taking the medication, we engage with the mothers unlike when I used to do it before. PNC makes more sense than what I used to do before
Providers believed the model has a potential in improving MIPs outcomes, however, many participants recognized that availability of resources for proper implementation ultimately determines the effectiveness of the intervention.
Adoption
The South African National Department of Health recommends the use of differentiated modalities of care (DMoC) nationwide to encourage adherence and retention in care, with PNC being a form of DMoC for postnatal women and their infants. All participating providers expressed support for the PNC model and a belief that the program has potential to provide efficient, comprehensive and caring services. The assessment found consensus among participants that efforts towards scaling up PNC were perceived as worthwhile. Participants indicated the conventional PMTCT postnatal services, where mothers receive care independently from their infants, and HIV care may also be provided separately, do not cater to all maternal and infant needs. In their view, PNC was designed to address the specific needs and expectations of MIPs.
To ensure that the PNC model was implemented in a standardized format across the district, all Anova staff who were selected to work on PNC received standardized training on the model and were given manuals and job aids. A majority of the participants indicated that they had received this training and that it assisted them with implementing the model.
the workshop that I have mentioned, helped us a lot in a sense that by the time we got to the facility we were prepared with and we knew what is expected from us and what we are dealing with and how to implement it.
However, most participants noted a lack of appreciation of facility staff in the model, with them not directly implementing postnatal clubs and questioning participants about the value of the PNC model. They reported that facility staff perceive that the intervention was developed for and implemented by an external entity;
Because when you come in they would say “no this is an Anova thing
Despite facility staff’s lack of involvement, some participants reported pockets of support.
Firstly the management gave us all the support that we needed in terms of using their staff to attend to our patients on Fridays and again when we got here the two mentor mother's walked us through what happens on Fridays to conduct the club's because they had their experience …. on how to run the club's so they took us to step by step from getting files and preparing
Another participant reported collaboration with other non-PNC implementing staff:
Because we understand each other, if she sees someone even on her side (work station) who is not the part of the club but needs the intervention, she knows where to direct that person and she knows how to assist that person and she knows what I am here for.
Participants cited that involvement of government department stakeholders was necessary to promote their buy-in and support the integration of the intervention within established workflows of the clinics.
Participants suggested that demonstrating the competitive advantages of PNC with improved communication and dissemination would be beneficial, i.e., showcasing that the model was designed to make a difference. Participants emphasized the need to support other facility staff not directly involved in implementing the clubs to understand what role or gap PNC is designed to fill.
Implementation
While the PNC model has proven to be acceptable to our study participants, the implementation of the model is not without challenges. As described above (Figure 1), PNCs have four core components which encourage the provision of structured, standardized care. However, participants reported variations in implementation that they attributed largely to a lack of resources. One major challenge cited by many providers was unavailability of space to conduct group sessions. The concern about space was repeated by several participants, this challenge was linked to deviation from the group model.
……. if we can have space where we will do the sessions. Because now we call this PNC but we see mothers one by one and they do not know that they need to be in a group with all the other mothers.
Inadequate human resource was also identified as a constraint to effective delivery of PNC in the facilities. Health providers reported that PNC are inadequately staffed, emphasizing the shortage of professional nurses, which resulted in nurses rotating among different facilities rather than being able to focus on PNC implementation at a single site. This had led to some facilities deviating from the model by conducting groups with different infant age categories in a single group. In the original PNC model, MIPs are grouped according to the age of the baby.
Other providers felt that appropriate planning prior to implementation should have taken place to ensure the necessary resources (e.g., space, staffing and equipment) were in place prior to the start of the project.
I think before the Postnatal club was implemented in September, it would have worked if we identified the space where the session will take place. Because what happened is that we went to the facility, we told them about the PNC and we started and no resources were identified for us so, we had to arrange for ourselves to see how we go about.
Other factors that constrained the implementation of PNC included insufficient medical equipment and lack of communication gadgets like phones Participants reported that access to a “one-stop-shop” model was not possible in some facilities because of a lack of essential equipment, which meant clients had to move around the facility to access other services that cannot be provided in the same room.
The baby scale [is a challenge] and I also struggle with the BP scale [blood pressure monitor] to check the blood pressure for the mothers. I do not have a weight scale. Sometimes it gets confusing for them because I tell them that we will do everything in one room, now I don’t do that. so, they need to go on the other side to do their weight and come back to me, so, those are my challenges.
There were concerns around suboptimal implementation of clubs with some PNC components missing. Specifically, participants reported that there were no health talks, very few group meetings and clients were not accessing care in one room. This was cited by some providers to have contributed to a lack of adoption, likely because the model appears more cumbersome and less efficient than it was originally designed to be. Participants pointed out that the current state of implementation in some facilities was perceived by other staff as a duplication of existing immunization and PMTCT programs.
So, there is no space to sit together and have a session so we both do it individually, so that is why I am saying it is a duplicate [of] what is being done on the other side of the clinic…… if I invite the sister to come and join us for the session, she would ask me what are you doing there that is different from what I do? and I would not be able to answer her because there is nothing that is different, so I do not see that there is a gap that is being filled.
Even though participants reported challenges in the implementation of the PNC, all participants indicated that they had to adapt the model to ensure the intervention was delivered. This flexibility is necessary as PNCs need to integrate with the health facility’s processes in order to be successful. This emphasizes the importance of maintaining agility when implementing PNC at health facilities.
Sustainability
Sustainability includes both integration of an intervention into routine practice and integration of a limited number of program components that may improve patient care (19). The integration of an intervention into routine practice has been linked with prospects for maintaining the intervention. A key driver of successful institutionalization at the facility level was having the necessary resources readily stocked and available, which requires support from and coordination with facility management. Participants believed that the project would likely not be sustainable in the future due to the lack of support and adoption of the model by the non-PNC focused facility staff.
That is why there is no support at all because they feel that its …… not a national mandate.
When asked what would facilitate continuing the project, participants felt that this will require increased advocacy support from facility management.