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Peris Kibera


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2008 recipient of the Thomas Francis Jr. Fellowship.

Published in: Health & Medicine
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Peris Kibera

  1. 1. Impact of PMTCT service delivery on uptake and follow-through with care: A case study of two programs in Nairobi, Kenya Peris W. Kibera University of Washington School of Social Work & Department of Global Health Background: PMTCT expansion and service use In sub-Saharan Africa, the near decade-long expansion of highly subsidized services for prevention of mother-to-child transmission of HIV (PMTCT) continues to be faced with less than satisfactory uptake and utilization 1,2 . Although there exists a large corpus of literature that describes or maps out decline by type and service point in the cascade of PMTCT programming 2,3 – largely pointing to program ineffectiveness – much less is known about the service delivery dynamics that account for such trends and patterns. Conceived against this backdrop, the present study sought to examine the intersection of care, and service organization with uptake, use and follow-through with specific, as well as the entire package of PMTCT interventions. The study was conducted between September and December, 2008 at Pumwani Maternity Hospital, a referral hospital, and Mathare North Health Center, a community health facility – in Nairobi, Kenya. <ul><li>Selected references </li></ul><ul><li>Doherty, T., McCoy, D., & Donohue, S. (2005). Health systems constraints to optimal coverage of the prevention of mother-to-child HIV transmission programme in South Africa: Lessons form the implementation of the national pilot programme. African Health Sciences, 5 (3), 213-218. </li></ul><ul><li>UNICEF (2003). Evaluation of United Nations-Supported Pilot Projects for the Prevention of Mother-to-Child Transmission of HIV: Overview of Findings . New York, NY: UNICEF. </li></ul><ul><li>Moth, I. A., Ayayo, A. B., & Kaseje, D. O. (2005). Assessment of utilization of PMTCT services at Nyanza Provincial Hospital, Kenya. SAHARA-Journal of Social Aspects of HIV/AIDS, 2 (2), 244-250. </li></ul><ul><li>Acknowledgements </li></ul><ul><li>Thomas Francis, Jr. Global Health Fellowship </li></ul><ul><li>UW Health Sciences Magnuson Scholar Award </li></ul><ul><li>Population Reference Bureau PPC Fellowship </li></ul><ul><li>Pumwani Maternity Hospital and Mathari North Health Center </li></ul><ul><li>Research participants and staff at the two health facilities </li></ul><ul><li>Dr. James Kiarie, Dr. John Kinuthia, and Mr. Daniel Matemo </li></ul><ul><li>Drs. Diane Morrison, Taryn Lindhorst, Lynn Thomas, and Rachel Chapman </li></ul>Emerging Themes from Ongoing A nalysis … Completeness and quality of information given to patients : ARVs and infant feeding were the only interventions emphasized. However, timing of drug initiation, drug refilling and adherence were barely explained, often impacting whether patients returned to start or refill ARVs. Many patients were unaware about the full package of PMTCT services. Provider-patient interactions : Visits typically lasted no more than a few minutes. Patient engagement in discussion about care was limited, and generally appeared to be intimidated by providers. For some, this discomfort underlay their non-use of services in times when they deemed themselves to be most vulnerable, such as during labor. Continuity of care : Lack of patient panels per provider limited building of rapport between providers and patients, commonly resulting in patients being offered fragmented, incomplete information about ongoing care. Coordination of care : Provision of services by different categories of providers (nurse, doctor, nutritionist) in different stations within a facility, and also by different entities (e.g., a research project, university) lacked coordination, often leaving patients unclear about continued care. Profile of Pumwani Maternity Hospital and Mathare North Health Center Located in northern Nariobi, Pumwani Hospital and Mathari North Health Center primarily serve patients drawn from the low-income, and slum communities that surround the facilities. The demographic characteristics of the majority of patients seen at the facilities include: low education attainment, unemployed or employed in the informal section, and ranging in age between 14 and 23 years. Current estimates of HIV prevalence among women of child bearing age place Nairobi at close to 10%. Nairobi City Council (NCC) runs both facilities, with Pumwani serving as the referral hospital for the Council’s 52 health centers spread throughout the city The cost of services at both facilities is highly subsidized by the NCC. Both facilities are equipped to provide the full range of PMTCT services, from counseling and testing to delivery, antenatally, and family planning to infant HIV testing, postnatally. <ul><li>Research Design </li></ul><ul><li>A six-month ethnographic study of PMTCT implementation at the two health care facilities. </li></ul><ul><li>Study Objective : </li></ul><ul><li>Investigate : </li></ul><ul><li>The intersection of care , and service organization with uptake, use, and follow-through with PMTCT interventions </li></ul><ul><li>Main Questions </li></ul><ul><li>To what extent does : i) information given to patients , and ii) provider- patient interactions impact attendance at or follow-through with clinical visits related to ARV initiation and refill, and delivery at the facility? </li></ul><ul><li>How does the organization of services and/or the process of service delivery support or undermine uptake or follow-through with PMTCT interventions? </li></ul><ul><li>Methods : </li></ul>Pumwani Maternity Hospital Mathare North Health Center Review of institutional PMTCT guidelines Hospital has tailored guidelines on PMTCT implementation Guidelines used are those provided by the Kenyan Ministry of Health In-depth interviews with patients 15 HIV+ pregnant women receiving antenatal care 15 HIV+ pregnant women receiving antenatal care 15 recently delivered HIV+ women who missed some of their antenatal care appointments, and/or did not deliver at the facility. Participants in the foregoing group were identified when they returned to the facility for postpartum care/infant immunization Observation of service delivery Sit-in on visits with nurses, obstetrician, couples counselor, and nutritionist Sit-in on visits with nurses In-depth interviews with providers 2 nurses, 2 administrators, 1 obstetrician, and 1 nutritionist 1 nurse and 1 administrator