A hierarchical modelling approach to identify factors associated with the uptake of HIV counselling and testing, maternal health services, and prevention of mother to child HIV transmission programme services among post-partum women in Ethiopia
Lerebo, Wondwossen Terefe
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The HIV/AIDS epidemic remains an unbeaten challenge that affects all parts of the global population. Since the identification of the epidemic in the early 1980s, nearly 58 million people have become infected with the virus and 25 million people have died of HIV-related complications. This study aimed to elucidate individual and community level factors associated with the uptake of antenatal care (ANC), health facility delivery, HIV Counselling and Testing (HCT), and Prevention of Mother-to-Child Transmission of HIV (PMTCT) services by implementing a hierarchical (multilevel) methodological approach. This study used a cross-sectional, multistage sampling design in which health facilities were first selected (stage 1), followed by recruitment of post-partum women who came for child immunization from each health facility (stage 2), in Tigray region. Structured interview guides were developed for interviews. Four-fifths (80.0%) of mothers used antenatal services at least once during their most recent pregnancy and of these 74.6% of women accessed HCT. Sixty nine percent of women had delivered at a health facility, 79% of mothers and 55.7% of their children had received PMTCT services. Place of residence was significantly associated with ANC attendance and place of delivery, with women living in urban areas almost 2 times (OR=1.75, 95% CI 1.06, 2.92) more likely to deliver at a health facility. With the addition of one health facility per 25000 people, the likelihood of delivering at a health facility increased by 2.45 fold (OR=2.45, 95% CI 1.04, 5.78). Attending ANC (OR=4.54; 95%CI 2.82,7.33) and getting support from husband (OR=1.97; 95%CI 1.25,3.10) were significantly associated with HCT, at the individual level. At the community-level, for the addition iii of one health facility and HCT site for every 25000 people increase the likelihood of HCT utilization by 2.1 and 2.4 fold respectively. Mothers who delivered at a health facility were 18 times (OR=18.21; 95%CI 4.37,75.91) and children born at a health facility were 5 times (OR=4.77; 95%CI 1.21,18.83) more likely to receive PMTCT services, compared to mothers delivering at home. With the addition of one nurse per 1500 people, the likelihood of getting PMTCT services for a mother increases by 7.22 fold (OR=7.22; 95% CI 1.02,51.26). Community-level random-effects were also significant and there was confirmation of nesting at the community-level even after controlling for individual and communitylevel variables. Findings also showed that HCT utilization was nested according to district of residence, contributing 11.3% of the variance. In addition, the variation of mothers getting PMTCT services between districts was only 0.6%, but was 27.2% for children. Conclusion: Factors influencing utilization of maternal health services work at different levels, individual and community. Hierarchical models reveal these differences in ways that single-level (individual or community) models do not. Interventions are needed to increase spouse involvement in ANC utilization, and explore effective ways of increasing health facility delivery among poor women with little formal education in rural areas and increasing the number of health facility per people are important. The government should focus on increasing ANC access, educating couples on the importance of health services utilization, increasing the number of health facilities and HCT sites per population to improve HCT utilization. In addition to these, programmes should focus on increasing health facility delivery, training traditional birth attendants to understand the need for PMTCT and increasing iv HCT coverage to advance getting PMTCT services for mothers at the individual level and for children at both individual and community level. Permission to conduct the study was granted from the Ethics Committee of the University of the Western Cape and from Tigray Region Health Bureau. Verbal informed consent was obtained from each participant in the health facility based interview.