ChildCount.org

By Chibulu Luo

PMTCT Module – What are the perceptions after one year in Kenya?

It has been precisely one year since the inception of the PMTCT Module in Sauri, Kenya.  Though, the MVP team has been unable to draw accurate conclusions on the end-user perception of the module. That is, how do CHWs feel about working with it? How can its functionality be improved? How acceptable has it been within communities?  On June 3^rd 2011, I travelled to Sauri with the aim to answer some of these questions.

“Nyamrerwa”

The pregnant woman in Sauri does not always visit the health facility for her scheduled clinic appointment. Poor accessibility or efficiency of health services, fear of realizing HIV status (it is required that pregnant women in Kenya test for HIV during the first antenatal appointment) or the lack of support from her husband or partner, might explain why she does not visit the health facility.  Though in some cases, the woman has simply forgotten; and it is the duty of her Community Health Worker (CHW) or “Nyamrerwa” (Healer) to remind her.

“Our job requires that we walk around the village, map each household and its members, identify pregnant women and from there we would follow up with them” says a CHW in Nyamninia sub-location.  

CHWs have become a great resource in their community that some women simply rely on their CHW to remind them of appointments.

“I often can’t remember my clinic appointments without the help of my CHW. She is the one who reminds me of my next appointment date” says a young mother in Ramula sub-location.

But the task to remind women of clinic appointments is only one item in the long list of activities that CHWs are performing every day; the demands of their job do not allow them to remind all women of clinic appointments.

“Say you have 8 mothers in your village you need to be able to track all of them. Each has a different clinic appointment, so planning out my schedule so that I am able to visit all of them in the month was very difficult,” recalls a female participant in Sauri.

Sadly, if some of these uncaptured women are HIV+, then every appointment missed increases the likelihood that their children will be born HIV+ also. In order to address this problem, the Millennium Villages Project (MVP) in Sauri Cluster implemented Prevention of Mother to Child Transmission (PMTCT) module in May 2010. The timing was perfect; in the previous year, MVP and UNAIDS had agreed the establishment of “MTCT-Free Zones” in all MVP sites (click here for more information).

The module worked by using SMS as the medium to remind CHWs to remind women to visit the health facility in their village. Quite simply, the module worked as a double-loop reminder system.  All of Sauri’s CHWs (approximately 109) were trained on how to use the module; and as of June 2011, 350 women were registered in the system. More continue to be added to the system every day.

PMTCT Module Follow-up

From the moment I arrived, I was both excited and anxious about my summer in Sauri. I spent my first few weeks familiarizing myself with the PMTCT module workflow and identifying the major stakeholders. I understood the module to work as follows –

1. The CHW registers the pregnant woman into the ChildCount+ system during his/her regular household visit and encourages her to visit the clinic  for her first antenatal appointment (for more information on how data is recorded see Casey’s blog)
2. A woman visits the clinic for her first antenatal appointment
3. The CHW at the clinicrecords her visit by sending an SMS to the CC+ system
4. The system adds the woman’s name to a schedule (i.e. records the date of her next appointment)
5. Three days prior to the woman’s next appointment, the CHW** receives an SMS giving details of the appointment
6. The CHW reminds the woman of her appointment
   1. The woman attends clinic on day of her appointment
   2. The cycle repeats

*Can be any CHW

**Same CHW as in 1 i.e. the CHW responsible for the woman’s village

I identified major stakeholders to be:  health facilitators, CHWs, nurses and mothers.  I spent some time acquainting myself with each of stakeholder, though the bulk of it was spent interviewing CHWs and mothers in the community. They had interesting things to say…

Interviews

I arranged interviews with over one hundred participants – about 30 CHWs and 70 mothers (both individually and in focus group settings). With CHWs, I tried to gauge their perceptions of the PMTCT module by asking them comparison-based questions i.e. how did they work before the PMCTC Module was implemented? Did they find those methods to be effective?

“In the past, we would visit each household within our catchment area and single out the women who were pregnant. We would then record details of their pregnancy using pregnancy tracking forms,” says a female interview participant at Bar Sauri clinic.

Some CHWs noted that they would use their own personal diary to record this data, and later refer to it whenever they made reminders.

“This method was not very effective because sometimes I would misplace my diary and forms” says a male participant in Gongo sub-location.

How is the PMTCT module better?

“The PMTCT module makes things easier because I will receive a reminder from the system about the woman’s appointment. So when I leave my home, I have it in my mind that I should visit a specific woman to remind her of her next appointment,” says another participant in Gongo sub-location.

The majority of mothers interviewed exhibited the same satisfaction with the PMTCT module and the work of CHWs in their villages.

“My CHW’s work has improved when compared to before. Previously I was not reminded of my next clinic appointment; though today, she reminds me often. She also encourages me to visit the clinic for ARVs” says a mother in Ramula.

“The job of CHWs has improved because they remind me of clinic appointments.  Previously, CHWs did not care much about the welfare of the community. I would just remind myself of my appointments by looking at my clinic book,” said another mother in Nyamninia.

PMTCT Module Improvements

While the module seems to be accepted by CHWs and mothers in the community, the following issues were raised (by CHWs) as barriers to performance:

-       Clinic level: CHWs working in clinics are extremely busy; as a result, they often forgot to fill out ChildCount+ forms and send text messages to the CC+ system.

-       Household level: the CC+ method of data collection takes up a lot of time – a single household visit might require 3 or more CC+ forms to be filled; as a result, one could easily spend up to 45 minutes in a single household.

-       Phone issues: CHWs noted that some phones did not have sufficient memory space to store messages. For example, if a CHW sent out a message to the CC+ system and received an error, he/she had no method of retrieving the same message to correct it; they would need to send an entirely new message.  Other phone issues were low battery life and poor network capture.

-       Communicating with mothers: CHWs said they had difficulties convincing some mothers of clinic appointments. “Some of these women are really hard to convince to visit the clinic; they can be ignorant and defiant,” says an interview participant in Nyamninia sub-location.

-       Training on PMTCT: CHWs stated that they would appreciate additional training on PMTCT as to enable them to better inform mothers on the benefits of visiting the clinic during pregnancy.

Whilst the PMTCT module as proven to be a useful tool for CHWs, only once these items are addressed can MVP realize the greater benefit of the PMTCT module.

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I had a wonderful summer in Kenya and I would like to say thank you to the following people – my supervisor Yanis Ben Amor, for linking me to this project, for being a great resource and colleague, and always ensuring that I was safe in the field. Dr Thomas Ouma and Jessica Masira for your guidance and support. Casey Iiams-Hauser, for providing me with ample information on the PMTCT module, helping me with the questionnaires, and always being available to give me advice. Oduor Paul Aginnah for being an amazing translator during the interview process. Samuel Omollo for your support and guidance whilst in Kenya. And lastly (but definitely not least!), the entire MVP team in Sauri – you made my summer in Kenya an experience that I will cherish for the rest of my life. Thank you.

Chibulu Luo