Distribution and profile of antenatal clinics
Table 2 summarises the characteristics of the 12 ANCs. Clinics were owned by private (n=5) or government (n=7) entities. Privately-owned clinics were more likely to be semi-urban. The ANC's routinely collected data showed that in 2018, three of the clinics saw more than 2000, and these clinics were all government-owned and located in urban settings. Eight clinics, distributed equally among private and public hospitals, served 1000 to 2000 pregnant women annually. Public hospitals recorded a higher workload per week per clinical staff than their counterpart in private facilities.
Table 2: Profile of clinics included in this study
Clinic variable
|
Government
(n=7)
|
Private
(n=5)
|
Location
|
|
|
|
Urban, n (%)
|
5(71.4)
|
3(60)
|
|
Semi-urban, n (%)
|
2(28.6)
|
2(40)
|
Estimated clinic attendance
|
|
|
|
>2000/month, n (%)
|
3(42.9)
|
0(0.0)
|
|
1000-2000/month, n (%)
|
4(57.1)
|
4(80)
|
|
<1000/month, n (%)
|
0 (0.0)
|
1(20)
|
Antenatal clinic-related services
|
|
|
|
Focused ANC, n (%)
|
7(100)
|
4(80)
|
|
A group health talk, n (%)
|
7(100)
|
5(100)
|
|
History taking & physical examination, n (%)
|
7(100)
|
5(100)
|
|
Lab services (e.g. syphilis, malaria, G6PD), n (%)
|
3(42.9)
|
3(60)
|
|
Time spent in delivering health talk (mins), mean (SD)
|
19(3.7)
|
18(2.8)
|
|
Size of a group for a health talk, mean (SD)
|
41(18)
|
61(11)
|
HIV-related services
|
|
|
|
The opt-out offer of HIV test, n (%)
|
7(100)
|
5(100)
|
|
HIV service available 5 days/week, n (%)
|
6(85.7)
|
2(40)
|
|
Rapid HIV testing, n (%)
|
7(100)
|
5(100)
|
|
Information about HIV testing giving during health talk (Yes), n (%)
|
7(100)
|
5(100)
|
|
Positive test results confirmed at ANC, n (%)
|
4(57.1)
|
1(20)
|
|
Initiation of ART for pregnant women testing positive for HIV (Yes), n (%)
|
4(57.1)
|
1(20)
|
|
HIV testing performed by ANC staff, n (%)
|
6(85.7)
|
1(20)
|
|
HIV testing performed by dedicated staff outside the ANC, n (%)
|
2(28.6)
|
3(60)
|
Human resource capacity
|
|
|
|
Number clinicians (mean, range)
|
3(0-18)
|
2(0-4)
|
|
Number of nurses (mean, range)
|
10 (3-30)
|
9(3-20)
|
|
Number of HIV testing pregnant women/week (range)
|
426.3(260-1153)
|
392.3(175-459.3)
|
|
Number of weekly HIV testing clients/staff (range)
|
60.7 (32.8-103.3)
|
33(27-41)
|
SD=standard deviation; ANC=antenatal clinic; HIV=Human Immunodeficiency virus
Source: ANC register/field notes
Characteristics of pregnant women
Of the 448 pregnant women who answered the exit survey, 326 (71.8%) were from publicly funded hospitals. The entire sample's mean age was 28.3 years (SD=5.63; range 16 to 44 years), with the majority (80%) being between 27 and 30 years. Most women were urban dwellers (60%), married (73%), had some form of employment (75%), and had more than one pregnancy (75%). About 11% of pregnant women had no formal education, while 17% had high school education and above. Women attending public clinics differed significantly from private clinics regarding age, residence, and marital status but not in the number of pregnancies and occupation. Table 3 summarises the characteristics of pregnant women.
Table 3:Socio-demographic characteristics of pregnant women
|
Government clinic
n=326(71.8%)
|
Private clinic
n=122 (27.2%)
|
p-value
|
Mean age in years (SD)
|
28(6)
|
29(6)
|
0.0231
|
Place of residence, n (%)
|
|
|
0.0025
|
|
Urban
|
196(60)
|
77(63)
|
|
|
Peri-urban
|
83(26)
|
42(34)
|
|
|
Rural
|
41(13)
|
(2)
|
|
Marital status, n (%)
|
|
|
0.0035
|
|
Single
|
91(28)
|
16(13)
|
|
|
Divorced
|
4(1)
|
2(2)
|
|
|
Married
|
225(69)
|
104(85)
|
|
|
Missing
|
6(2)
|
0(0)
|
|
Number of pregnancies n(%)
|
|
0.2116
|
|
First pregnancy
|
80(25)
|
24(20)
|
|
|
> 1 pregnancy
|
240(74)
|
98(80)
|
|
|
Missing
|
6(2)
|
0(0)
|
|
Occupation, n (%)
|
|
|
0.3543
|
|
Unemployed
|
61(19)
|
19(2)
|
|
|
Student
|
19(6)
|
6(5)
|
|
|
Employed
|
249(76)
|
97(80)
|
|
|
Missing
|
6(2)
|
0(0)
|
|
Educational level, n(%)
|
|
|
0.1421
|
|
No formal education
|
40(12)
|
10(8)
|
|
|
Completed primary school
|
26(8)
|
7(6)
|
|
|
Completed junior high school
|
124(38)
|
40(33)
|
|
|
Completed senior high school
|
89(27)
|
35(29)
|
|
|
Some diploma
|
24(5)
|
16(13)
|
|
Characteristics of healthcare providers
Table 4 summarises the characteristics of healthcare providers. Most providers were from government-operated ANCs, compared to 34% in privately-run clinics. Providers were mostly females (89%) with a median age of 29 (20-59). A little over half (61%) reported having attained a diploma in nursing education, with more respondents from private-run hospitals acquiring some degree. More than half (68.9%) identified as midwives. The rest were nurses (17%), nursing assistants (5%), medical officers (2%) and HIV counsellors (5%). Private hospitals reported a higher proportion of midwives than government hospitals (76% versus 67%). Overall, respondents had provided HIV testing services for a median duration of 2 years (1-14). No statistically significant difference existed between providers in private and government hospitals regarding sex, age, years of working experience and professional background.
Table 4: Socio-demographic characteristics of providers
|
Government n=100 (66.2%)
|
Private n=51(33.8%)
|
p-value
|
Sex, 8 (%)
|
0.36112
|
|
Female
|
87(86.5)
|
47(91.7)
|
|
|
Male
|
13(13.5)
|
4(8.3)
|
|
Age (median, range)
|
28(20-48)
|
30(23-59)
|
|
Yrs. of HIV testing experience (median, range)
|
2(1-10)
|
2(1-14)
|
|
Educational background, n (%)
|
0.4759
|
|
Senior High School
|
2(2)
|
0(0.0)
|
|
|
Certificate
|
19(19)
|
9(18.0)
|
|
|
Diploma
|
61 (61)
|
28(56.0)
|
|
|
1st degree
|
17(17)
|
13(26)
|
|
Professional background, n (%)
|
0.5244
|
|
Registered Midwife
|
67(67)
|
37(75.5)
|
|
|
Registered Nurse
|
18(18)
|
8(16.3))
|
|
|
Medical Doctor
|
3(3.0)
|
0 (0.0)
|
|
|
Nursing Assistant
|
7(7.0)
|
1(2.0)
|
|
|
HIV counsellor
|
4(4.0)
|
3(6.1)
|
|
|
Other (field technician)
|
1(1.0)
|
0(0.0)
|
|
Adherence to coverage
Coverage was conceptualised in this study as the opportunity for pregnant women to know their HIV status while visiting the antenatal clinic [6]. Data on clinic attendance was available for 8 clinics, showing a total of 80933 clinic attendance. Seventeen per cent (13760) were first-time attendees and therefore offered an HIV test. A total of 13505 (98.1%) accepted the test offer. Table 5 summarises the coverage of HIV testing in the 8 clinics.
Table 5: Coverage and HIV prevalence of rapid HIV testing (2017) in 8 selected clinics
Facilities
|
Total Attendance for 2017
|
First attendance and offered HIV test
|
% accepting and testing for HIV
|
Facility 1
|
2000
|
1884
|
1884
|
Facility 2
|
27022
|
2652
|
2619
|
Facility 3
|
9426
|
1684
|
1684
|
Facility 4
|
20891
|
3307
|
3085
|
Facility 5
|
7234
|
984
|
984
|
Facility 6
|
4363
|
1453
|
1453
|
Facility 7
|
5596
|
1040
|
1040
|
Facility 8
|
4401
|
756
|
756
|
Totals (%)
|
80933(100%)
|
13760(17%)
|
13505(98.1% acceptance rate)
|
Adherence to the content of the opt-out test offer
The approach of the test offer did not always correspond with the guideline's recommendations (Table 5). Only 5 of the 12 clinics obtained informed consent through the opt-out approach, while 4 employed the opt-in approach. Three clinics employed a combination of opt-in and opt-out approaches. Despite the GAC and UNAIDS/WHO recommendations that removed the need for pre-test counselling, this study found that five ANCs employed some form of individual pre-test counselling. About half of the clinics adhered to this recommendation by delivering pre-test information in groups before an HIV test. No evidence of pre-test counselling or information delivery was observed in one clinic.
Table 6: Healthcare provider adherence to the opt-out approach to test offer
Approach of test offer
|
N (%)
|
Type of consent procedure
|
|
Opt-in approach only
|
4(33.3)
|
|
Opt-out approach only
|
5(41.7)
|
|
Both opt-in and opt-out
|
3(25.0)
|
Approach to informing women about the test
|
|
Pre-test counselling only
|
5(41.7)
|
|
Pre-test information only
|
6(50)
|
|
Both pre-test counselling and information
|
0(0)
|
|
Neither pre-test counselling nor information
|
1(8.3)
|
Adherence to the content of consent, confidentiality, counselling, and connection to services
Table 7 shows the frequency distribution of responses to each item on the adherence scale. There was significant bias (p-value <0.0001) observed for each response based on the type of ratter (direct observation and self-report). The 'Yes' response for each item was skewed towards self-reports (provider). A consistent response was observed for item 6 (agreed to test) between direct observation and self-report (provider) but not self-report (women). Also, consistency in adherence response between direct observation and self-report (women) was observed for item 12 (discussed partner testing) and item 14 (explained support services).
Adherence to the requirement of informed consent scored low for direct observation (M=54.71, SD=23.25), moderate for pregnant women's self-reports (M= 54.71 SD=13.45), and moderately high for healthcare providers' self-reports (M=85.06, SD= 12.60). However, most healthcare providers felt they instituted adequate measures to ensure a private testing process, as almost all (95.4%) affirmed the confidential nature of the process. More than half (69.8%) of the women corroborated this finding. Similarly, explaining to women that providers would not share test results without their permission received a moderately high (78.1%) adherence rating from providers, moderate (54.3%) from women and exceptionally low (19.7%) by direct observation.
Healthcare providers highly adhered to making women aware of what a negative test result meant. However, this was not the case in telling women about preventive strategies for HIV after testing negative, as just over half of the women (52.8%) reported receiving this information. Informing women of the need to bring a partner for testing was the least discussed post-test counselling by all the assessment methods, with only 31% of women saying that the healthcare provider offered this advice. The study saw a similar trend in non-adherence to the content of post-test counselling in explaining to women the possibility of a window period and retesting during the 34th week, and allowing women to ask questions. Explaining support services was least adhered to as assessed by direct observation (6.5%) and pregnant women's self-reports (5.9%). More than half of pregnant women (52.8%) mentioned that providers advised them on preventive measures, compared to the observations (36.8%).
Table 7:Frequency of response to each item on the adherence scale
Item
|
Variable
|
Direct Observation
N (%)
|
Self-report, woman
N (%)
|
Self-report Provider
N (%)
|
A
|
Consent
|
|
|
|
1
|
The HIV testing process explained
|
86 (54.8)
|
309 (70.1)
|
131 (89.1) *
|
2
|
Mother-to-child transmission explained.
|
58 (36.7)
|
297 (67.7)
|
129 (86.0) *
|
3
|
The meaning of positive & negative explained
|
73 (47.1)
|
274 (61.4)
|
132 (88.6) *
|
4
|
Women made aware of HIV preventive options
|
62 (39.2)
|
250 (56.9)
|
131 (90.3) *
|
5
|
The woman is allowed to ask questions
|
38 (24.1)
|
207 (47.2)
|
133 (90.5) *
|
6
|
A woman agreed to test
|
142 (91.0)
|
212 (48.0)
|
139 (93.9) *
|
7
|
Provider informed mother about her right to decline the test
|
36 (22.9)
|
141 (31.7)
|
81 (57.0) *
|
|
(Mean: SD)
|
(45.1,23.25)
|
(54.71,13.45)
|
(85.06,12.60)
|
B
|
Confidentiality
|
|
|
|
8
|
Explained that results would not be shared
|
31 (19.7)
|
238 (54.3)
|
114 (78.1) *
|
9
|
Provider & client believed results kept confidential
|
N/A
|
312 (69.8)
|
144 (95.4) *
|
C
|
Counselling
|
|
|
|
10
|
Meaning of results explained
|
146 (95.4)
|
389 (88.4)
|
122 (80.8) *
|
11
|
Advise on prevention
|
56 (36.8)
|
232 (52.8)
|
114 (76.0) *
|
12
|
Partner testing discussed
|
54 (34.4)
|
136 (31.0)
|
67 (46.2) *
|
13
|
Window period explained
|
36 (23.5)
|
232 (51.9)
|
115 (79.3) *
|
|
(Mean: SD)
|
(45.1,23.25)
|
(45.1,23.25)
|
(45.1,23.25)
|
D
|
Connection to care
|
|
|
|
14
|
Explain support services
|
10 (6.5)
|
26 (5.9)
|
107 (72.8) *
|
15
|
Allow time for questions
|
19 (12.4)
|
193 (43.9)
|
104 (69.8)
|
*Statistically significant
The mean percentage bias in adherence measure between direct observation and self-report (provider) was significantly higher compared with that observed between direct observation and self-report (women) (41.0 vs 16.8, p-value <0.0001). (See Figure 3)
Table 7 shows the level of agreement between adherence measured by direct observation and self-reported adherence. Agreement between direct observation and self-report (women) in measuring low, moderate, and high adherence was 16.3%, 35.5% and 18.8%, respectively. Also, an agreement between direct observation and self-report (provider) in measuring low, moderate, and high adherence was 10.6%, 16.1% and 43.8%, respectively. Overall, the level of agreement between direct observation and self-report (women) in measuring adherence was very poor (kappa= -0.082). Similarly, the level of agreement between direct observation and self-report (provider) in measuring adherence was very poor (kappa= -0.034).
Table 8: Measures of agreement between direct observations and self-reports
(N=151)
|
Direct observation
|
Kappa coefficient
|
Kendall's tau-b
|
Low adherence
|
Moderate adherence
|
High adherence
|
Self-report (women)
|
|
|
|
-0.082
|
-0.208
|
Low adherence
|
17 (16.3)
|
7 (22.6)
|
9 (56.3)
|
|
|
Moderate adherence
|
34 (32.7)
|
11 (35.5)
|
4 (25.0)
|
|
|
High adherence
|
53 (51.0)
|
13 (41.9)
|
3 (18.8)
|
|
|
Self-report (Provider)
|
|
|
|
-0.034
|
0.049
|
Low adherence
|
11 (10.6)
|
1 (3.2)
|
0
|
|
|
Moderate adherence
|
29 (27.9)
|
5 (16.1)
|
9 (56.3)
|
|
|
High adherence
|
64 (61.5)
|
25 (80.6)
|
7 (43.8)
|
|
|
Table 9 shows fidelity results calculated from percentage adherence totals. Fidelity was found to be low in direct observation and self-report (women) assessment methods, with a mean score of 38.8% (range of 61.1%–95.8%) for direct observation and 54.0% for the self-report (women). The fidelity results for each method with scores ≥80% (cut-off for 'high' fidelity) are in bold. Significant differences between governing authority, level of integration and sub-category' individual fidelity scores were found. Fidelity was found to be moderately high (78.9%) for self-report (provider)
Table 9: Adherence levels based on assessment methods used
|
Direct observation
% (SD)
|
Self-report (Women)
% (SD)
|
Self-report (Providers)
% (SD)
|
Total mean adherence score (SD)
|
38.8 (22.7)a
|
54.0 (25.2)b
|
78.9 (16.0)c
|
% mean adherence score per governing authority*
|
|
|
34.1 (19.7)a
|
49.7(23.2)b
|
78.7 (16.4)c
|
|
43.0 (24.4)a
|
55.6 (25.7)b
|
79.1 (15.8)c
|
% Mean adherence score per level of integration
|
|
|
46.8 (28.1)a
|
67.5 (24.2)b
|
81.3 (15.0)c
|
|
34.2 (18.7)a
|
51.0 (21.0)b
|
79.9 (15.4)c
|
|
33.7 (14.0)a
|
42.1 (22.9)a
|
76.0 (17.1)b
|
% mean adherence score by category^
|
|
|
|
|
40.1 (36.2)a
|
59.8 (34.5)b
|
87.0 (25.4)c
|
|
56.3 (25.7)a
|
39.5 (39.2%)b
|
72.9 (28.1)c
|
|
NA
|
61.5 (36.6)
|
85.4 (23.5)
|
|
35.5 (19.9)a
|
51.8 (23.1)b
|
73.1 (19.2)c
|
Superscript values denote significant differences between categories according to (a vs b, p-value <0.000), (a vs c, p-value <0.0001), (b vs c, p-value <0.0001).
*Significant differences between per governing authority according to DO (p-value <0.0001), Self-report (women, p-value <0.0001).
^ Values are compared using the Kruskal-Wallis test. N/A- not available (confidentiality had only one item).