CHAPTER community-based public health interventions and chart ways for


0 Discussion Many women in need of PMTCTare not being reached by current programmes and this can be attributed tosocio-cultural, economic, systemic and programmatic factors. Domiciliarydeliveries conducted by traditional birth attendants are commonplace in ruralZimbabwe and are on the rise (Macro International , 2007). Moreover; PMTCTprogrammes insist on corresponding methodologies to avoid missed opportunitiesin this evolving context. This report is among the several attempts that havebeen made towards evaluating the practicability as well as the appropriatenessof the involvement of TBAs in PMTCT initiatives.Some of the attributes of the TBAs in thisrural perspective included being elderly, married or widowed, with the lowestlevel of education. Such socio-demographic qualities are comparable to those ofTBAs in other locations (Itina, 1997.). Untrained TBAs whowere not trained in most cases were younger, possessed less experience than TBAswho had been trained.

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These TBAs had learned to assist on their own or by assistinganother TBA. The reduction in training programmes targeted for TBAs in Zimbabwecould provide an explanation as to why younger cadres fall within the untrainedTBAs group.None of the traditional birth attendantskept records of their clients, and none enquired if their clients knew theirHIV status.In order to realize valuable gains tocommunity-based public health interventions and chart ways for a number ofactivities connected to prevention and care there is need for there to beexisting links between community health workers such as TBAs and the formalhealth services. Corresponding approaches, through which community-based mediationsare paired with the reinforcement and/or spreading out of services at the healthfacility level, also possess the ability to tackle a variety of other healthchallenges, such as the limited acceptance to HIV testing and compliance to PMTCTregimens.

Studies that have been carried out in therecent past have suggested some problems associated with home deliveries withreference to uptake of PMTCT interventions (Albrecht, et al., 2006). Studies havedemonstrated that outside the TBAs’ current activities which include but arenot limited to assisting women during delivery and in the post-delivery stage,they are also willing to broaden the range of their work in mother-and-childactivities to encompass PMTCT with some restrictions identified such as escortingthe child to the health centre to be given medication as well as assisting staffat the health centre to document ANC services rendered to the women. This data hintson the need to reinforce the health care network system between the recognizedhealth services and the rural populations including TBAs. For this, incorporatingthe services of TBAs into the conventional health care delivery system is thereforeof utmost importance and should be implemented. The health care system that isin existence has to build-up collaboration with TBAs who provide services inthe informal sector and assist in expanding communication skills in thereferral process. Moreover, authorities mandated to provide health care andhealth personnel need to identify the cultural and practical involvement ofTBAs to the health system.The role played by andstatus accorded to TBAs in any given community determine the achievementrealised from community-based interventions that underscore the contribution ofTBAs.

In India, a reduction of more than 60% in neonatal deaths was realised asa result of community-targeted approach that encompassed training of TBAs aswell as women in the communities to recognize and treat sick new-born babies inthe community (Bang, et al., 1999). Additionally, significantgains in the decrease of peri-natal deaths and maternal deaths were documented ina pilot training of and incorporating TBAs in the conventional health-care systemin Pakistan (Jokhio, et al., 2005 ).The results of oursurvey reveal that TBAs interviewed in this location have inadequate informationwith regards to issues pertaining to HIV/AIDS overall, also PMTCT to bespecific. However this situation can be enhanced through prioritizing educatingthese cadres that are at present available and operating in these communities.Selected trainings have to be specifically designed to match the duties thatthe TBAs are expected to carry out, the education and proficiencies that are essentialas well as modifying the training syllabuses to the TBAs’ level of education.

The current study reinforcesthe need to strengthen TBA’s level of appreciation on MTCT reduction interventionsbefore they could play a part in the delivery of PMTCT packages. Currently, ina rural district setting as this one, TBA cadres’ guidance provided to womenwith regards to issues of HIV/AIDS (not excluding PMTCT) is somehow not apriority for them. It is therefore of utmost importance to, at national level,review the TBA training manual and include sections which look at simple, easyto understand concepts of HIV infection (Choguya, 2015). Studies that were carried out  in Tanzania came up with results thatindicated that if TBAs are motivated enough and supported with necessary skills,they can sufficiently perform their roles in the implementation of the saidprogrammes, contributing to accessing women who do not give birth at health-carefacilities where PMTCT interventions are made available (such as counselling,as well as administering single-dose nevirapine sdNVP) (Busza, et al., 2012). It was alsoconcluded in studies carried out in Uganda that when selection is conducted carefully,complemented by proper training and regular and uninterrupted follow-upsupport, TBAs provided an integral part in championing and referring expectingwomen for health centre-based PMTCT services (Barigye, et al., 2010).Conducting blood test forHIV was one activity that TBAs were reluctant to perform in the study.

Applyingthis intervention using community health cadres such as TBAs is directly linkedto the national policy framework of each particular country and if it were evergoing to be adopted it would require uninterrupted and vigilant observation andfollow-up. The first known PMTCT programme to utilize TBAs in the provisionof  private  and confidential counselling and testing for HIVusing a fluid rapid test applied orally was in Cameroon (Nkenfou, et al., 2013 Aug 9). This method was implementedby way of community involvement, training and accompanied with assistance from nurseswho provide supervisory visits to the rural communities on monthly schedules.Engaging TBAs in PMTCT issues is backed by anumber of exclusive reports that have shown enhancement of TBAs’ efficiency inthe delivery of public health services. In one systematic review that wasproduced it was revealed that training TBAs seems to enhance attendance of antenatalcare by women by rates exceeding 38% (Sibley, et al.

, 2004).In this particular district of Zimbabwe, achievementsderived from  MTCT prevention programmesmay be enhanced by intensifying community-based interventions, as well as involveTBAs who then could: bring about linkages between communities and healthservice providers and, make available health education to promote improvedutilization of ANC services, consequently access to PMTCT; sensitizecommunities targeting a family-aligned PMTCT approach (Abrams, et al., September 2007).

 Thisalso encompasses informing and communicating the basic knowledge piecesconcerning  PMTCT as well as the significanceof  being tested for HIV to the expectingmothers  and their spouses; delivercommunity-aligned HIV counselling and testing (Shetty, et al., 2005).One more significantconclusion was the unquestionable relationship between women who gave birth athome and the chance they had to pick their desired location for delivery. Thepower to make decisions, gender imbalances as well as collective  insistence from the society particularly fromspouses including other kinfolks has been reported to considerably affectutilization of maternal and child health care (Beckera, et al., 2014).

It is well acknowledgedthat in Africa women do not possess the authority to make decisions on theirown, decisions pertaining to their own and their children’s health care (Acharya, et al., 2010).As this study reveals,most of the women who were assisted to deliver by a TBA, as well as the TBAsthemselves mentioned that cost fees were a chief determining factor whenchoosing a place to deliver, a point that is coherent with other conclusionsderived in similar settings (Tebekaw, et al., 2015). Such an element, coupledwith the standard of care articulated in this research as unfavourableexperiences women meet when they interact with health personnel in earlierpregnancies, have been recognized as imperative justifications for the womennot to utilize maternal services as well as PMTCT services and choosing otherplaces for them to deliver, other than the conventional health service (Belay & EndalewGemechu, 2016). With regards tocircumstances like this one encountered here in which women mix TBAs and specializedcare and where TBAs urge women to make use of ANC service, reinforcement of establishedbasic antenatal service delivery overall and prior introduction of extrainterventions which also include PMTCT packages in particular is of paramountimportance (Sarker, et al., January 5, 2016).Fear of being judgedand branded, and even or violation of privacy was at the forefront as theleading causes for women to shun HIV testing and knowing their status.

 Being terrified of knowing one’s HIV statushas been elucidated before as a very significant reason why women may drop outof taking PMTCT services and low levels of HIV status revelation (Both & van Roosmalen, 2010). Receiving reproductivehealth care at healthcare centres in the presence ofTBAs dissuaded women from taking the medication for fear of having their HIVstatus known. It is therefore imperative to extend and strengthen collaborationsbetween various stakeholders at health centre and community level to reinforceeducation and health information access for each and every woman specificallyand the public in general so that stigma and discrimination may then beprevented. Furthermore, teaching, placement and regulation of community healthcadres TBAs included, must highlight the importance of keeping client healthinformation confidential, also the need to encourage women when they disclosetheir HIV sero-status (Kadowa & Nuwaha, 2009 Mar).Increase in access to HIV and treatment programmes can be attributed to HIVstatus disclosure, a rise in prospects for risk decline and consciousness ofHIV risk to partners that have not been tested for HIV, which can in turn resultin much improved uptake of voluntary HIV counselling and testing, and devotionto the guidance provided to prevent postnatal and sexual HIV transmission (Hart, 2010). TBAs expressedwillingness to be involved in PMTCT work, as confirmed by the qualitativeresults shown in the focus group discussions. However, as was found out in thecommunity study, women who gave birth at a health centre or assisted by a TBA concurredthat for TBAs to be taken aboard in PMTCT programmes they have to undergotraining first. There exist numerous possible shortcomingsthat have to be attended combined to the results of this study.

The first thingbeing that the study was conducted in just one district in the whole ofZimbabwe, therefore the results may not may not show the true picture of thesituation of the whole of the country. However, the socio-economic traits of ladiesof child bearing age who were selected in this survey are similar to those ofZimbabwe as well as several other African locations (Solanke, 2017). Furthermore, interviewees’versions of independent events around gestation and giving birth could havebeen liable to recollection bias. Another issue that could be up for considerationwas the possibility that there could have been inconsistences with regards towhere interviewees did not possess understanding of the approved Shona expressionsbecause this could have had a bearing on the perception of some queries by the interviewees.

This was somehowaverted from the training that data enumerators received with regards to termsto be utilized for the Shona languages interpretations to reduce mistakes andby way of piloting of the tools.        CHAPTER SIX – CONCLUSION AND RECOMMENDATIONS                                      6.1 Conclusion The researchertherefore would like conclude that when doctors and nurses are not available,TBAs play a very huge role in providing an option in reproductive health in sub-Saharancountries like Zimbabwe which suffer high burden of HIV. These research findingsgive an idea that Zimbabwe, even though in the long run making available ANCservices should remain the responsibility adequately trained personnel, emboldeningthe involvement of TBAs in community health interventions will go a long way inelevating and widening the coverage of reproductive health care covering PMTCTas well. Such a way of doing things possesses a capability to avoid missed chancesin situations where a significant caseload of expecting mothers see homedeliveries as an alternative. One fundamental role that traditional birthattendants can play is their involvement in the devolved programmatic effects ofincluding more composite regimens in the ongoing PMTCT services especiallyfocussing on support and drug adherence follow-up. In developing countries,utilizing, to the maximum, the human resources that are available, includingthe TBAs has remained a huge challenge for policy makers, and this includesplanning as well as implementation of a definite, well thought public healthstrategy with roots in the fundamental reproductive care made available bytrained health workers.                                                         Both ANC and PMTCTservices are under-utilized.

Poor knowledge of HIV and cultural factors whichinfluence their attitude and practices are major barriers that prevent ruralwomen of Chegutu District from accessing PMTCT services because they do notattend ANC which serves as an important entry point and so the opportunity toutilize the prevention of mother-to-child transmission services is missed.Secondly, geographic accessibility is not a barrier to access of ANC. However,some health facility related factors may also contribute to theunder-utilization of ANC and PMTCT services as there seems to be a disconnectbetween the study population and the health facilities in the sense that eventhose who were found to have adequate antenatal attendance were lacking basicHIV and HIV prevention knowledge. This raises the question of the quality ofthe ANC services and whether or not HIV education is effectively deliveredduring the antennal clinics in the health facilities. It will be worthwhile tohave a closer look at what actually goes on during antenatal visits and PMTCT sessionsin these facilities, to give a better picture of the facility related barriers.

Availability of PMTCT services is a good start and in line with the nationalPMTCT policy to scale up as more facilities within the district are at presentbeing equipped to carry out these services. 6.2 RecommendationsBased on the findings documented in this study,the following specific recommendations are proffered to the various bodies: 1. Rural Community:There is a need to changetheir orientation to encourage women to utilize ANC and delivery services. Thiscan be achieved by sensitizing the men and educating them on how important itis for pregnant women to utilize healthcare services.2.

Chegutu DistrictMedical Office, there is a need to: a. Organize campaigns tosensitize the rural community on the type of services available in the healthfacilities and re-orient them on the importance of utilizing health services,especially with regards HIV prevention. This can be achieved by involving theircommunity heads in the process. b. Enlighten the ruralcommunity by organizing frequent HIV education outreach sessions, highlightingthe benefits of ANC and PMTCT services and the benefits of utilizing theservices.c. Regularly train healthworkers on quality service delivery laying emphasis on important messages onANC and PMTCT, to be conveyed to all women visiting the facilities regardlessof their purpose of visit.

 3. Zimbabwe Ministry ofHealth and Child Care needs to: Strengthen HIV education,focusing on prevention especially regarding PMTCT through the media especiallythe radio, which almost all rural folk own and listen to regularly.