1. Introduction 1
2. Context 1
2.1. Objectives of the MNCH/PMTCT Communication Strategy 2
2.1.1. Sociopolitical and Environmental Objectives 2
2.1.2. Service Delivery Objectives 2
2.1.3. Community Level Objectives 2
2.1.4. Individual Level Objectives 3
3. Guiding Principles 3
4. Levels of Strategy 4
4.1. Barriers to PMTCT 5
5. Creative Brief by Audience 6
5.1. Individual Domain 6
5.1.1. Pregnant Women 6
5.1.2. HIV Positive Pregnant Women 9
5.1.3. Male Partners 11
5.2. Community Domain 14
5.2.1. Men and Women of Reproductive Age 14
5.2.2. Influential Leaders 16
5.3. Service Delivery Domain 17
5.3.1. Health Service Providers at Facilities 17
5.3.2. Support Staff at Health Facilities 20
5.3.3. Community Based Service Providers (Health Extension Workers) 22
1. Introduction
The PMTCT communication strategy is developed through a collaborative effort of the Ministry of Health, the HIV/AIDS Prevention and Control Office (HAPCO), Johns Hopkins University Bloomberg School of Public Health Center for Communication Programs (CCP), and different partners.
CCP conducted a literature review to assess the current situation in the country regarding Maternal, Newborn, and Child Health (MNCH)/ Prevention of Mother-to-Child Transmission of HIV (PMTCT) services and materials. Furthermore, in order to better understand the barriers and facilitators impacting pregnant women in general and HIV positive pregnant women in particular from accessing services, focused group discussions with HIV positive mothers was conducted.
In addition, CCP, in collaboration with the Federal Ministry of Health, HAPCO and other partners, conducted a workshop from 14 to 17 December, 2010. The workshop allowed stakeholders to come to a shared consensus on major themes linked with PMTCT, which prolongs to be an essential constituent of the larger MNCH communication.
Health professionals and representatives from various organizations intervening on PMTCT, HIV positive pregnant women, the Federal Ministry of Health, and HAPCO participated in the workshop. The workshop included a review of the literature review conducted by CCP, a review of existing materials on PMTCT services, and presentations on national and community level responses to PMTCT, the process of behavior change, and steps to design behavior change communication materials, audience segmentation and branding. This MNCH/PMTCT communication strategy directly reflects the outputs of the strategy development workshop.
2. Context
According to the 2010 FMOH/HAPCO Single Point Estimate, the number of pregnant mothers who were living with HIV reaches 90,311. At the same time 14,276 HIV-positive children were expected to be born. Little accessibility and uptake of prevention of MTCT (PMTCT) services were believed to be the major causes to the prevalence. Only 38% of health centers and hospitals in the country supplied PMTCT services and 68% of women got ANC services from health sects, health centres or hospitals that did not grant PMTCT services in 2009. Among the pregnant women who attended ANC in the 1,103 health facilities offering PMTCT, 84% were tested and received their results. Thus, the overall percentage of pregnant women who got tested remains low. The proportion of those antenatal clients who tested positive was 2.1% and only 58% of the HIV positive mothers received ARV prophylaxis. (FMOH Service Delivery Data 2009/2010).
PMTCT is a first-rate means to guard children from HIV, and to recognize those children who entail treatment in the early hours. Prior to the age of 2, 50% of HIV-positive children die. In general these deaths could be barred with premature diagnosis and commencement of treatment. Nevertheless, a small number of women obtain HIV testing in the period of pregnancy and, amongst those who are reactive; hardly any of the infant gets tested.
Mothers, or parents as a whole, are required to get sufficient and integrated care, information from family planning to avoiding unintended pregnancies, receiving ANC services including HIV testing and counselling, and availing ARVs for HIV reactive pregnant mothers and their newborn, and early diagnosis of infants (National Health Sector Development Plan – IV).
2.1. Objectives of the MNCH/PMTCT Communication Strategy
This MNCH/PMTCT communication strategy addresses issues surrounding little accessibility and minimized uptake of Mother-to-Child Transmission (MTCT) services. Specifically, the strategy addresses:
· Lack of consumption of health services, specially ANC/PNC/PMTCT services
· Deprived ease of use and fragile link of ANC/PNC/PMTCT services within other health services
· Scarce resources for MNCH services
· Reduced accessibility of user-friendly healthcare services, and
· Shortage of PMTCT focused media messages
Therefore, the interventions outlined under this strategy will contribute to the following goal and objectives:
GOAL: All expecting mothers will benefit from health services that ensure the health of the mother and the baby, and prevent the transmission of HIV from an HIV positive mother to the newborn.
2.1.1. Sociopolitical and Environmental Objectives
· For policymakers to be committed to allocate adequate resources to expand and integrate MNCH/PMTCT services,
· For heads of regional and woreda health offices to prioritize and integrate MNCH/PMTCT services within health facilities,
· To improve the quality of MNCH/PMTCT services provided in catchment areas.
2.1.2. Service Delivery Objectives
· For MNCH/PMTCT services to be user-friendly and easily accessible, accommodating for male partners,
· To increase the knowledge and skills of Health Extension Workers (HEWs) on MNCH/PMTCT, and enable them to properly communicate with clients,
· To increase the percentage of HEWs that provide appropriate ANC/PMTCT services at the kebele level
2.1.3. Community Level Objectives
· To increase awareness and eliminate misconceptions about MNCH/PMTCT and harmful traditional practices regarding MNCH/PMTCT, encourage discussions at the household and community levels, and foster positive attitude towards health services
2.1.4. Individual Level Objectives
· To encourage service seeking behavior among pregnant women and their partners regarding MNCH/PMTCT and other HIV services such as HIV Testing and Counseling;
· To raise awareness and understanding of the benefits of partner involvement, and increase the number of male partners who support their significant other during and after pregnancy, by encouraging them to get MNCH/PMTCT services, planning and preparing for birth, and being actively involved in all aspects of MNCH;
· To increase the number of partners who remain faithful to their significant other;
· To increase the number of HIV positive pregnant women who disclose their status to their partners; and
· To increase the number of HIV positive women who discuss family planning needs with their partners and health service provider.
3. Guiding Principles
This MNCH/PMTCT communication strategy and its implementation will be guided by the following principles:
· Behavior change oriented: For maximum impact, communication interventions should have specific and measurable behavioural objectives, address factors that influence behaviour, and reflect a multi-channelled approach. Channels and interventions should be complementary and mutually reinforcing.
· Audience-centered: Design of messages, materials, and communication interventions will rely on a thorough understanding of the audiences for which they are intended. This includes pretesting messages and materials, as well as involving audience members in the development of approaches and materials.
· Evidence-based: Communication interventions and strategies will be based on research and lessons learned through prior and ongoing programs.
· Culturally appropriate: Communication will take into account cultural norms, beliefs, and practices that influence the uptake of MNCH/PMTCT services, and will be delivered in a culturally sensitive manner.
· Community participation: The engagement of communities is essential in formulating a strong response that is locally appropriate and draws on available resources.
· Services-linked: All communication will refer MNCH/PMTCT clients and caregivers to service providers and/or will be implemented at the service delivery sites.
· Human rights: The framework reinforces equity of access, confidentiality of services and information, and gender-sensitivity.
· Commitment and Coordination: Commitment to building local capacity and coordinating partner efforts in MNCH/PMTCT communication is essential.
· Partner involvement: The effectiveness of MNCH/PMTCT services highly demands the involvement of male partners in supporting their partners to get the services.
4. Levels of Strategy
Communication does not occur in a vacuum. Numerous factors at different levels play various roles in shaping human behavior and societal values and attitudes. Effective communication is grounded in a particular socio-ecological context, including enabling environments, service delivery systems, communities, households, and individuals.
Therefore, the MNCH/PMTCT communication strategy is modeled after the ecological model, identifying and understanding pathways to change within the complexity of the system to address these behavioral pathways. The following diagram illustrates the pathways to healthy behaviors regarding MNCH/PMTCT.
4.1. Barriers to PMTCT
Using the above pathways framework, potential barriers to PMTCT and different audiences are identified at the three levels. The following matrix summarize the barriers at the three levels.
Domain / BarrierIndividual / Low level of ANC/PMTCT/PNC awareness
Lack of economic empowerment for women
Traditional gender norms
Negative perception of ANC/PMTCT service delivery
Conservative religious beliefs that impact ANC/PMTCT uptake
Heavy reliance on traditional birth attendants
Lack of self-efficacy
Poor health seeking behavior
Community / Male dominance
Lack of information on MNCH
Negative perception towards health services
Use of traditional birth attendants and traditional healers
Conservative cultural and religious beliefs and attitudes
Service Delivery / Lack of same sex health service providers
Poor referral linkages
Lack of user-friendly services
Limitations in supplies and equipment
Lack of guidelines and job aids for service providers
Poor interpersonal communication between clients and service providers
Lack of continuing education, supervision, guidance on client handling for health service providers
Environmental/Policy / Problems relating to human resources such as lack of motivation, and lack of training and support on client handling
High transportation costs and poor road systems in many areas
High cost of services
5. Creative Brief by Audience
5.1. Individual Domain
Three key audience groups are identified under the individual domain, namely: pregnant women, HIV positive pregnant women, and male partners. Outlined below is the strategy for these three groups.
5.1.1. Pregnant Women
Audience Profile
Shewaamene is 18 years old with elementary level education. Currently she lives in Desse, and is married and pregnant with her first child. She is a house wife, and does every chore in the house. As a hobby she enjoys weaving and threading cotton. Shewaamene dreams of a prosperous life with three healthy children. One of her greatest fears is that drought will leave her family without any means to survive. Her loving husband Taye is older than her, and controls the family’s money that he brings from his farming. He spends much of his time farming or at the market selling their crops. She is not economically empowered and relies solely on her husband. Her grandmother is a role model to her, because she was a strong woman that raised a large family and maintained a peaceful home without any complaints. With regards to ANC, Shewaamene does not have much exposure to the media outside of a small radio that she listens to when her husband is home. Her understanding of ANC/HIV/PMTCT is very low, and she does not know both her and her husband’s status. She is aware of the health facility in her area, but believes that women only access health services when there are complications with their pregnancies. Thus far, she feels healthy, and does not intend to visit a health facility. She and her husband have never discussed visiting the clinic, and she plans to deliver at home with the local traditional birth attendant.
Pregnant women that are aware of ANC/PMTCT services are often afraid to seek services for fear of getting tested and learning their status. There is also a stigma associated with being seen accessing services or getting tested. Male dominance often makes it challenging to discuss testing with their partners. Increasing awareness and open communication about the importance of knowing your status in order to prevent MTCT is key. Pregnant women along with their families often don’t unaware of the importance of ANC. Pregnant women often visit health center only when there is a complication with the pregnancy. For those that do seek ANC, there is a drop in follow-up after the first visit. Pregnant women are unaware of ANC/PMTCT services. There is a need to increase the awareness level and self-efficacy of pregnant women.
Communication Objectives
· Increase the percentage of pregnant women who discuss HIV testing with their partners and get tested;
· Increase the percentage of pregnant women who are aware of MNCH/PMTCT services, contextualize risk of not utilizing ANC services, and complete the recommended 4 ANC visits during pregnancy;
· Increase the number of women who give birth at health facilities or with a skilled birth attendant;
· Increase the percentage of mothers who follow through PNC and exclusive infant feeding for the first six months after delivery.
Key Issues
· Male dominance acts as a barrier to accessing ANC/PMTCT services.
· Lack of knowledge about discordant result in regards to testing.
· Overall there is a lack of follow up after the 1st visit for many pregnant women.
· There is a lack of support of family members and partner to access ANC/PMTCT.
Key Promise and Supporting Statements
Key Promise / Supporting Statement· Attending ANC/PMTCT can provide a safe delivery for mothers and improve the chances of having a healthy baby.
· Institutional delivery or by a skilled birth attendant helps keep the mother and the baby safe and healthy.
· Attending ANC/PMTCT can impact the health of both parents. / · If you are positive there is care for you. (Not to worry!)
· If you attend an ANC clinic a trained health provider will assist you.
· The birth of a a healthy child is important for everyone.
Call to Action
· Be informed! Your baby’s health depends on it.
· Come and visit the nearest health facility and see what services are available.
· Communicate with your partner about your ANC needs for your family’s health.
· Attend at least 4 ANC visits so you have higher chances of getting a healthy baby.
Activities for Pregnant Women
Activity / Detail / LinkagesPopular entertainment: music, drum and lyrics / Make sure the lyrics of the songs are specific to the topic.
Use participatory theater to show the benefits of attending ANC.
Use drums to call the attention of the community members.
Focus on market days or churches.
Identify setting early, and communicate with well known women in the community to guide the events.
Work closely with health posts and clinics so to make sure they are prepared for more clients.
Work with the MOH and city admin.
(Once a month for 6 months)
Participatory theatre
Local horns with testimonials
Audio drama (Iddir) / Develop an audio drama and discussion guide that addresses specific needs of pregnant women.
Drama/Soap Opera / Develop a drama that can be viewed in waiting rooms in health facilities or TV that focuses on the benefits of accessing ANC
Put the topic a discussion in community capacity enhancement / Community discussions hosted by extension workers to address/answer any questions/comments/concerns from pregnant women and further encourage them to access services.
Magazine / Magazines that are available at the hair dressers
5.1.2. HIV Positive Pregnant Women
Audience Profile