PAPER: Determinants of HIV provider-initiated testing and counselling screening service used by pregnant women in primary health centres in Surabaya
Determinants of HIV provider-initiated testing and counseling screening service used by
pregnant women in primary health centers in Surabaya
Reference:
Handayani, S., Andajani, S., & Djuari, L. (2018). Determinants of HIV provider-initiated testing and counseling screening service used by pregnant women in primary health centers in Surabaya. Medical Journal of Indonesia, 26(4), 293-301.
Important words:
1. cross-sectional study in 9 Puskesmas with 150 participants with convenience sampling
2. The aim of the study is identifying determinants of HIV PITC service use in PHCs in Surabaya
3. The main result is Past use of midwife’s private service affected self-confidence of getting blood drawn for HIV test on HIV screening use, and self-confidence affected the use of HIV PITC.
4. This study results suggest that more midwives’ private practices are needed to increase the use of HIV PITC screening in PHC
5. Husband may not associate directly to increase wives's decision to do HIV test
6. The agreement was reached between the Surabayan chapter of the Midwife Professional Association (Ikatan Bidan Indonesia Surabaya). After the screening was done, women’s were referred back to the referring midwives.
7. Midwives’ service at these private practices and midwifery clinics usually are small and exclusively designed for maternal services, offering more intimate communication between midwives and patients, and among patients. These midwives are bounded to their professional organization’s commitment to send their patients to PHC.
8. Participants were also asked to self-report
ABSTRACT
Background: Offering free HIV screening service for pregnant women in primary health center in Surabaya has become obligatory since 2014, but only 70% used the service. Prior studies on HIV screening mostly focused on Voluntary Counseling and Testing. Methods: This was a cross-sectional study. Interviews were conducted with 150 pregnant women attending antenatal care in 1 of 9 public health centers (PHCs) in Surabaya and offered HIV screening within the same PHC. The eligibility criterium was pregnant women attending antenatal care in PHCs. The exclusion criteria were having been counseled for HIV prior to the interviews and/or experiencing an obstetric emergency. Using PRECEDE Framework with the concept of a comprehensive framework, this study focuses on identifying determinants of HIV PITC service use in PHCs in Surabaya. Binary logistic regressions and multiple binary logistic regressions were used in analyses. Results: The service use was associated with self-confidence of getting blood drawn for the test (p<0.001, adjusted OR=12.368, 95% CI=3.237–47.250) and past use of midwife private service for current pregnancy (p=0.029, adjusted OR=3.902, 95% CI=1.150–13.246). Self-confidence of getting blood drawn for HIV test mediated the effect of past use of midwife’s private service on HIV screening use. Conclusion: Past use of midwife’s private service affected self-confidence of getting blood drawn for HIV test on HIV screening use, and self-confidence affected the use of HIV PITC. This study results suggest that more midwives’ private practices are needed to increase the use of HIV PITC screening in PHC.
METHODOLOGY
This was a cross sectional study. Nine PHCs in 9 Surabaya areas where most pregnant women resided were chosen. Convenience sampling was applied for easiness, i.e. for convenience, a day per week was chosen for data collection time. That was the day pre-determined by PHCs as weekly elective antenatal visit day. All eligible pregnant women coming for antenatal care in a chosen day were recruited. New pregnant women came in any day outside the pre-determined day was served by PHCs but were not included in the study. Random sampling could not be applied because the antenatal care (ANC) clinics were walking-in sites. There was no need to make appointments prior to the visits, thus a list of patients where a random sampling would be based on could not be obtained. An interview using a structured questionnaire was conducted by a trained female interviewer in the PHC just after the participant used the routine antenatal care service. Participants were excluded from the study if they have been counseled in other health facilities prior to their visits to the participating PHCs and or were in obstetric emergency situations.
This study used Green’s and Kreuter’s definitions of predisposing, reinforcing and enabling factors of health service use. Predisposing factors refer to individual characteristics that motivate behavior.
Knowledge, attitude, belief, personal preferences, skills, and self-efficacy fall within this group. In this study, predisposing factors were explored by asking participants to self-report their perception on their knowledge on HIV and answer standard questions on HIV composed by the Joint United Nations Programme on HIV/AIDS UNAIDS13: “Can the risk of HIV transmission be reduced by having sex with only one uninfected partner who has no other partners?”, “Can a person reduce the risk of getting HIV by using a condom every time they have sex?”, “Can a healthy-looking person have HIV?”, “Can a person get HIV from mosquito bites?” and “Can a person get HIV by sharing food with someone who is infected?”
Participants were also asked to self-report their self-confidence to get their blood drawn and attend post-HIV-test counseling with this question: “Do you feel that you are confident to get blood drawn/take post-HIV-test counseling?” Participants were also asked to report their awareness of examinations or tests to detect HIV, HIV medication, and prophylaxis for HIV mother -to-child transmission and to rate their selfconfidence of using HCT service. These questions were pilot-tested and minor revisions were made. Reinforcing factors refer to “rewards or punishments following or anticipated as a consequence of a behavior.”
In this study, they were husband’s advice to participants to get tested and husband’s reminder to participant to get health checked in PHC, assuming that the women anticipated to gain at least verbal rewards after taking their advice. Past use of midwife service for current pregnancy was also a reinforcing factor, assuming that they would get better services when they were referred back to referring midwives. Midwives working in solo private and non-PHC facilities committed to send pregnant women to PHC for HIV checks. The agreement was reached between the Surabayan chapter of the Midwife Professional Association (Ikatan Bidan Indonesia Surabaya). After the screening was done, women’s were referred back to the referring midwives.
Enabling factors refer to “Environmental characteristics that facilitate action and skills or access to resources or services needed to adopt certain behavior”. These factors were explored by asking participants to self-report the order of their current pregnancy, the number of antenatal care they attended in the current PHC they were visiting, the distance between their residences and PHCs, the time needed to access the testing service, their preference on service hours, husbands’ advice to get tested for HIV, husbands’ reminder to get health checked in the PHC, and whether they used midwife services for the current pregnancy prior to their current visit to PHC. The study flow is presented in Figure 1.
pp 294-295
RESULT
Reference:
Handayani, S., Andajani, S., & Djuari, L. (2018). Determinants of HIV provider-initiated testing and counseling screening service used by pregnant women in primary health centers in Surabaya. Medical Journal of Indonesia, 26(4), 293-301.
Important words:
1. cross-sectional study in 9 Puskesmas with 150 participants with convenience sampling
2. The aim of the study is identifying determinants of HIV PITC service use in PHCs in Surabaya
3. The main result is Past use of midwife’s private service affected self-confidence of getting blood drawn for HIV test on HIV screening use, and self-confidence affected the use of HIV PITC.
4. This study results suggest that more midwives’ private practices are needed to increase the use of HIV PITC screening in PHC
5. Husband may not associate directly to increase wives's decision to do HIV test
6. The agreement was reached between the Surabayan chapter of the Midwife Professional Association (Ikatan Bidan Indonesia Surabaya). After the screening was done, women’s were referred back to the referring midwives.
7. Midwives’ service at these private practices and midwifery clinics usually are small and exclusively designed for maternal services, offering more intimate communication between midwives and patients, and among patients. These midwives are bounded to their professional organization’s commitment to send their patients to PHC.
8. Participants were also asked to self-report
ABSTRACT
Background: Offering free HIV screening service for pregnant women in primary health center in Surabaya has become obligatory since 2014, but only 70% used the service. Prior studies on HIV screening mostly focused on Voluntary Counseling and Testing. Methods: This was a cross-sectional study. Interviews were conducted with 150 pregnant women attending antenatal care in 1 of 9 public health centers (PHCs) in Surabaya and offered HIV screening within the same PHC. The eligibility criterium was pregnant women attending antenatal care in PHCs. The exclusion criteria were having been counseled for HIV prior to the interviews and/or experiencing an obstetric emergency. Using PRECEDE Framework with the concept of a comprehensive framework, this study focuses on identifying determinants of HIV PITC service use in PHCs in Surabaya. Binary logistic regressions and multiple binary logistic regressions were used in analyses. Results: The service use was associated with self-confidence of getting blood drawn for the test (p<0.001, adjusted OR=12.368, 95% CI=3.237–47.250) and past use of midwife private service for current pregnancy (p=0.029, adjusted OR=3.902, 95% CI=1.150–13.246). Self-confidence of getting blood drawn for HIV test mediated the effect of past use of midwife’s private service on HIV screening use. Conclusion: Past use of midwife’s private service affected self-confidence of getting blood drawn for HIV test on HIV screening use, and self-confidence affected the use of HIV PITC. This study results suggest that more midwives’ private practices are needed to increase the use of HIV PITC screening in PHC.
METHODOLOGY
This was a cross sectional study. Nine PHCs in 9 Surabaya areas where most pregnant women resided were chosen. Convenience sampling was applied for easiness, i.e. for convenience, a day per week was chosen for data collection time. That was the day pre-determined by PHCs as weekly elective antenatal visit day. All eligible pregnant women coming for antenatal care in a chosen day were recruited. New pregnant women came in any day outside the pre-determined day was served by PHCs but were not included in the study. Random sampling could not be applied because the antenatal care (ANC) clinics were walking-in sites. There was no need to make appointments prior to the visits, thus a list of patients where a random sampling would be based on could not be obtained. An interview using a structured questionnaire was conducted by a trained female interviewer in the PHC just after the participant used the routine antenatal care service. Participants were excluded from the study if they have been counseled in other health facilities prior to their visits to the participating PHCs and or were in obstetric emergency situations.
This study used Green’s and Kreuter’s definitions of predisposing, reinforcing and enabling factors of health service use. Predisposing factors refer to individual characteristics that motivate behavior.
Knowledge, attitude, belief, personal preferences, skills, and self-efficacy fall within this group. In this study, predisposing factors were explored by asking participants to self-report their perception on their knowledge on HIV and answer standard questions on HIV composed by the Joint United Nations Programme on HIV/AIDS UNAIDS13: “Can the risk of HIV transmission be reduced by having sex with only one uninfected partner who has no other partners?”, “Can a person reduce the risk of getting HIV by using a condom every time they have sex?”, “Can a healthy-looking person have HIV?”, “Can a person get HIV from mosquito bites?” and “Can a person get HIV by sharing food with someone who is infected?”
Participants were also asked to self-report their self-confidence to get their blood drawn and attend post-HIV-test counseling with this question: “Do you feel that you are confident to get blood drawn/take post-HIV-test counseling?” Participants were also asked to report their awareness of examinations or tests to detect HIV, HIV medication, and prophylaxis for HIV mother -to-child transmission and to rate their selfconfidence of using HCT service. These questions were pilot-tested and minor revisions were made. Reinforcing factors refer to “rewards or punishments following or anticipated as a consequence of a behavior.”
In this study, they were husband’s advice to participants to get tested and husband’s reminder to participant to get health checked in PHC, assuming that the women anticipated to gain at least verbal rewards after taking their advice. Past use of midwife service for current pregnancy was also a reinforcing factor, assuming that they would get better services when they were referred back to referring midwives. Midwives working in solo private and non-PHC facilities committed to send pregnant women to PHC for HIV checks. The agreement was reached between the Surabayan chapter of the Midwife Professional Association (Ikatan Bidan Indonesia Surabaya). After the screening was done, women’s were referred back to the referring midwives.
Enabling factors refer to “Environmental characteristics that facilitate action and skills or access to resources or services needed to adopt certain behavior”. These factors were explored by asking participants to self-report the order of their current pregnancy, the number of antenatal care they attended in the current PHC they were visiting, the distance between their residences and PHCs, the time needed to access the testing service, their preference on service hours, husbands’ advice to get tested for HIV, husbands’ reminder to get health checked in the PHC, and whether they used midwife services for the current pregnancy prior to their current visit to PHC. The study flow is presented in Figure 1.
pp 294-295
Data were collected in 2014 from 150 participants
in 9 participating PHCs. Twenty one (14%)
participants declined and 129, pp 296
More frequent antenatal visits at PHC are also expected to build more pregnant women’s trust towards health workers in PHCs, but this was not the case in this study. There was no association between antenatal visit frequency and HIV PITC test uptake found in this study. Interestingly, the test uptake significantly associated with prior antenatal visits to midwives at private practice sites as well as midwifery clinics outside PHCs, general clinics and general hospitals. Midwives’ service at these private practices and midwifery clinics usually are small and exclusively designed for maternal services, offering more intimate communication between midwives and patients, and among patients. These midwives are bounded to their professional organization’s commitment to send their patients to PHC. Visits to physicians’ solo private practices did not relate to test uptakes although it offers more private doctor- patient communication, most likely because the physicians are not interested in sending pregnant women to PHCs for HIV tests, as private physicians know that they are perceived more valuable by the Indonesian community than the more affordable public services at PHCs. In addition, the medical doctor professional organization does not have commitments to send pregnant women to PHCs in support of government’s free HIV test policy. These findings are different from the Ethiopian study’s19 where antenatal visit frequency significantly associated with the test uptake in clinics and hospital. The difference might be due to the higher HIV prevalence in Ethiopia that leads to more rigorous testing policy, including patient-health worker communication in the pre-HIV counselling. pp 299
In line with our study findings, husbands may be targeted by the PHC to increase their wives’ antenatal HIV screening at PHCs as husbands’ reminder is important to the wives to get to the PHCs. Efforts to generate more knowledgeable husbands needs to be carefully designed in order to support pregnant women’s decision in such ways that will not result in women's dis-encouragement on using HIV screening service pp 300
This study revealed that test uptakes significantly related to self-confidence to get blood drawn for HIV test. With an adjusted OR of 12.368, self- confidence to get blood drawn was the most important factor for the test uptake. Again, trust might have a role in that self-confidence development gained from more intimate communications between midwives and patients in for women only facilities. From the trust gained, midwife might encourage patients to take an HIV test that cannot be more painful than to get blood drawn like in other existing antenatal laboratory tests. While mother-to-child HIV transmission may be halted through increased HIV PITC testing and medication, incomplete-consintent patient for this testing can be ethical. pp 299
Considered both husband’s and midwife’s roles. However, this study did not find the role of husbands on the women’s decision to take HIV screening. In Indonesia, detailed domestic health businesses within the households have traditionally belonged to female’s domain. pp 299
The implementation of HIV screening policy could be improved if midwife service is expanded to HIV education for women so that their self- confidence to take HIV test will also be developed based on increased knowledge in addition to trust or other non-rational processes. Inside the PHCs, an already missed opportunity of educating pregnant women about HIV before HIV test should be recaptured by providing an information session or distributing printed materials pp 300 In conclusion, HIV PITC screening use was affected by a predisposing factor, i.e self-confidence of getting blood drawn for HIV test. The self- confidence was affected by past use of midwife’s service affected on HIV screening use. The use of HIV screening service at PHCs may be indirectly improved by increasing husbands’ involvement in reminding their wives to get their health checked pp 300
More frequent antenatal visits at PHC are also expected to build more pregnant women’s trust towards health workers in PHCs, but this was not the case in this study. There was no association between antenatal visit frequency and HIV PITC test uptake found in this study. Interestingly, the test uptake significantly associated with prior antenatal visits to midwives at private practice sites as well as midwifery clinics outside PHCs, general clinics and general hospitals. Midwives’ service at these private practices and midwifery clinics usually are small and exclusively designed for maternal services, offering more intimate communication between midwives and patients, and among patients. These midwives are bounded to their professional organization’s commitment to send their patients to PHC. Visits to physicians’ solo private practices did not relate to test uptakes although it offers more private doctor- patient communication, most likely because the physicians are not interested in sending pregnant women to PHCs for HIV tests, as private physicians know that they are perceived more valuable by the Indonesian community than the more affordable public services at PHCs. In addition, the medical doctor professional organization does not have commitments to send pregnant women to PHCs in support of government’s free HIV test policy. These findings are different from the Ethiopian study’s19 where antenatal visit frequency significantly associated with the test uptake in clinics and hospital. The difference might be due to the higher HIV prevalence in Ethiopia that leads to more rigorous testing policy, including patient-health worker communication in the pre-HIV counselling. pp 299
In line with our study findings, husbands may be targeted by the PHC to increase their wives’ antenatal HIV screening at PHCs as husbands’ reminder is important to the wives to get to the PHCs. Efforts to generate more knowledgeable husbands needs to be carefully designed in order to support pregnant women’s decision in such ways that will not result in women's dis-encouragement on using HIV screening service pp 300
This study revealed that test uptakes significantly related to self-confidence to get blood drawn for HIV test. With an adjusted OR of 12.368, self- confidence to get blood drawn was the most important factor for the test uptake. Again, trust might have a role in that self-confidence development gained from more intimate communications between midwives and patients in for women only facilities. From the trust gained, midwife might encourage patients to take an HIV test that cannot be more painful than to get blood drawn like in other existing antenatal laboratory tests. While mother-to-child HIV transmission may be halted through increased HIV PITC testing and medication, incomplete-consintent patient for this testing can be ethical. pp 299
Considered both husband’s and midwife’s roles. However, this study did not find the role of husbands on the women’s decision to take HIV screening. In Indonesia, detailed domestic health businesses within the households have traditionally belonged to female’s domain. pp 299
The implementation of HIV screening policy could be improved if midwife service is expanded to HIV education for women so that their self- confidence to take HIV test will also be developed based on increased knowledge in addition to trust or other non-rational processes. Inside the PHCs, an already missed opportunity of educating pregnant women about HIV before HIV test should be recaptured by providing an information session or distributing printed materials pp 300 In conclusion, HIV PITC screening use was affected by a predisposing factor, i.e self-confidence of getting blood drawn for HIV test. The self- confidence was affected by past use of midwife’s service affected on HIV screening use. The use of HIV screening service at PHCs may be indirectly improved by increasing husbands’ involvement in reminding their wives to get their health checked pp 300
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