FACTORS AFFECTING UTILIZATION OF PREVENTION OF MOTHER TO

CHILD TRANSMISSION SERVICES AMONG HIV POSITIVE WOMEN

RECEIVING PMTCT SERVICES AT MLALEO CDF, MOMBASA, KENYA.

SSULEIMAN DARA MOHAMED

REG. NO: CHRIRT/J-0003/MOM/22

A RESEARCH PROPOSAL SUBMITTED TO THIKA SCHOOL OF MEDICAL AND

HEALTH SCIENCES IN PARTIAL FULLFILMENT OF THE REQUIREMENT FOR
THE AWARD OF CERTIFICATE IN HEALTH RECORDS AND INFORMATION
TECHNOLOGY.

AUGAST, 2023

1
DECLARATION
I hereby declare that this is my original research work and it has never been submitted to
Thika school of medical and health sciences and any other institution for academic purpose.
Signature...............................................date................
Suleiman Dara Mohamed

2
APPROVAL
The underlined certify that they have read and recommended to the department of Health
Records Information Technology for approval of the research entitled:
A RESEARCH PROPOSAL SUBMITTED TO KENYA MEDICAL TRAINING
COLLEGE IN PARTIAL FULLFILMENT OF THE REQUIREMENT FOR THE
AWARD OF IN HEALTH RECORDS AND INFORMATION TECHNOLOGY.

INTERNAL SUPERVISOR:
Madam Diana
Lecturer, Department of Health Records and Information Technology.
Thika school of Medical and Health Sciences.
Sign: ………………… Date: ……………………

3
ACKNOWLEDGMENT.
First and foremost, I want to thank almighty God for the gift of life and I wish to
acknowledge the support of all who contributed in various ways making this proposal
successful. Special thanks to my supervisor Madam Diana who guided me at each step of my
proposal development. Lastly, I wish to thank all my colleagues and friends who encouraged
me in my work of developing research proposal.

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Table of Contents
1. DECLARATION.............................................................................................................2
2. Table of Contents.............................................................................................................5
3. Abbreviations and Acronyms..........................................................................................7
4. CHAPTER ONE..............................................................................................................8
5. INTRODUCTION...........................................................................................................8
6. 1.1 Background of the study............................................................................................8
1.2 Problem of the Statement...................................................................................................9
1.4 Research questions........................................................................................................10
1.5.1 Broad Objective.........................................................................................................10
1.5.2 Specific Objectives....................................................................................................10
1.7 Scope and limitations.......................................................................................................11
7. CHAPTER TWO...........................................................................................................12
8. Literature review............................................................................................................12
2. 1 Introduction.....................................................................................................................12
2.1 Empirical review..............................................................................................................12
2.2 Antiretroviral drugs..........................................................................................................12
2.4 PMTCT service utilization in relation to socio-economic status.....................................13
2.5 Knowledge and PMTCT service utilization....................................................................14
2.6 Clinical resources.............................................................................................................14
2.7 The PMTCT Situation in Kenya......................................................................................16
2.8 Theoretical Framework....................................................................................................17
2.9 Conceptual framework.....................................................................................................19
9. CHAPTER THREE.......................................................................................................20
10. RESEARCH METHODOLOGY..................................................................................20
Introduction............................................................................................................................20
3.1 Study design.....................................................................................................................20
3.3 Target population.............................................................................................................20
3.3. 1 Inclusion criteria.......................................................................................................20
3.3.2 Exclusion criteria.......................................................................................................20
3 .4 Variables.........................................................................................................................21
3.4.1 Independent variables................................................................................................21
3.4.2 Dependent variable....................................................................................................21
3.6 The sample size and sampling procedures.......................................................................21
3.6.1 Sample size................................................................................................................21

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3.7 Development of data collection tool/ instruments...........................................................22
3.8 Data collection method....................................................................................................22
3.9 Pilot study.....................................................................................................................22
3.10 Validity of Research Instrument................................................................................23
3.11 Reliability...................................................................................................................23
3.12 Data Analysis and presentation Techniques..................................................................23
3.10 Ethical consideration......................................................................................................23
11. REFERENCES..............................................................................................................24
12. APPENDIX II: QUESTIONNAIRE FORM.................................................................27
13. APPENDIX III: BUDGET............................................................................................30
14. APPENDIX IV: WORKPLAN.....................................................................................31
15. APPENDIX V: CONSENT FORM...............................................................................32
16. APPENDIX VI: MAP FOR STUDY SITE...................................................................32

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Abbreviations and Acronyms
WHO-World Health Organization
KDHS - Kenya Demographic and Health Survey
MOH – Ministry of Health.
HIV-Human Immunodeficiency Virus
AIDS-Acquired immune deficiency syndrome
TB- Tuberculosis
PMTCT- Prevention of mother to child transmission
ART- antiretroviral therapy
EBF-exclusive breastfeeding
MTCT-Mother to child transmission
HAART- Highly active antiretroviral therapy
ARV- antiretroviral
PLWHA- People living with HIV/Aids

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CHAPTER ONE
INTRODUCTION
1.1 Background of the study
Prevention of mother to child transmission are essentials for preventing HIV transmission
from mother to child during pregnancy, child birth and breastfeeding. PMTCT service include
HIV testing and counselling , Antiretroviral therapy for pregnant and breastfeeding women
and prevention of mother to child transmission drugs from infant.

Despite the availability of PMTCT services , there are still may HIV positive women who do
not utilize these services.a study conducted at Mlaleo CDF hospital, Mombasa, Kenya found
that only 60% of HIV positive pregnant women received PMTCT services.

Factors affecting include: lack of awareness ,lack of access ,negative attitude.

The high rates of PMTCT in developing countries, compared to much lower rates in richer
countries, illustrate growing inequalities in global health. In the wealthy countries, the rate of
PMTCT is less than 2% because of widespread access to anti-retro viral therapy (ART),
planned Caesarean sections (CS) where applicable, the means to safely formula feed, and
access to quality medical services. In countries like Kenya, there is a 30-40% chance that an
HIV-positive breastfeeding mother will pass HIV to her child in the absence of these services.
ARV prophylaxis pregnancy, labor and delivery and during breastfeeding period can
substantially reduce MTCT. In resource poor settings, it is critical that prevention procedures
be integrated into existing sexual and reproductive health (SRH) and maternal and child health
(MCH) services, reaching as many women as possible and lowering transmission rates.
Concerted efforts between governments, pharmaceutical companies, donor and implementing
partners have helped expand access to HIV testing for pregnant women and use of
Antiretroviral drugs. For instance, in 2003 only 10% of pregnant women globally had access
to ARVs compared to 54% in 2009 (NATIONAL AIDS & STI CONTROL PROGRAMME
2012)

Kenya National AIDS/STI Control Program (NASCOP) estimates that there were 1.55 million
babies born in 2011 in Kenya and that as many as 6.3% of pregnant women in Kenya were
living with HIV/ AIDS. With an estimated population of 38.6 million in the year 2010, the
number of HIV - exposed babies is estimated to be 97,272, and at least 38,900 HIV-positive
babies are born, assuming a 40 % transmission without any interventions (PMCTC guideline
2012)

8
In Kenya, PMTCT has not attained 100% due to certain barriers such as education, social-
economic status, government policy, and availability of services. Among the HIV positive
women, 70-80% of them were receiving anti retro viral drugs treatments to prevent mother to
child transmission.
Therefore, a gap exists in Kenya when trying to have PMTCT adherence due to several factors
that make it difficult for women to attend to clinics that offer such services. Women have not
been empowered enough in terms of knowledge and resources in fight against the HIV/AIDS
transmission.
(Bott, S., Neuman, 2015)

1.2 Problem of the Statement

The knowledge gap among the pregnant mothers has been one of the factors associated with
poor utilization of the PMTCT services at Mlaleo CDF Health Centre, Mombasa. Majority of
the women don’t visit health facilities to get the services because they lack knowledge on how
the program will help prevent MTCT. Some of the women don’t not know their HIV status
and even if they are expectant, they won’t utilize PMTCT programs in order to ensure that
their children remain healthy. Those who have knowledge on the existence of the program and
its benefits tend to utilize it and HIV prevalence rate among their newborns is low.
Prevention of mother to child transmission of HIV is an important global public health issue.
The HIV infection has emerged to be one of the health risks both to the mother and the
newborn. In Kenya, only 10% of the 13% HIV positive pregnant women receive the PMTCT
services. The low level of utilization of the PMTCT service utilization in Mombasa County is
due to socioeconomic factors that make it difficult for the pregnant mothers to access the
program.
Those mothers that are socioeconomically well off tend to utilize the PMTCT services because
they can afford travel expenses and any other expenses linked to the program. The mothers
from poor background are likely not able to utilize the program even after testing as they
cannot be able to afford small expenses associated with access to the program even though it
is offered at no cost.

9
1.3 Justification
The study will identify challenges and opportunities in attempt to utilize PMTCT services
among HIV positive women. The identification of the challenges that hinder women from
adhering to such programs from the study will be helpful for the country to come with
strategies at national or county level to ensure that mother to child HIV transmission is
eliminated. The study will also help the ministry of health plan on how to ensure that
resources needed to support PMTCT program is available if HIV infection in new-born is to
be reduced.

1.4 Research questions.

1.Do socio-economic factors have negative/positive effect on utilization of PMTCT among
HIV positive women attending Mlaleo CDF Health Centre, Mombasa?
2.Is there a relationship between the level of knowledge and utilization of PMTCT HIV
programs among women attending Mlaleo CDF Health Centre, Mombasa?

1.5 OBJECTIVES
1.5.1 Broad Objective
To determine factors influencing utilization of PMTCT services aiming at the reduction of
HIV infections in children among women of reproductive age at Mlaleo CDF Health Centre,
Mombasa.
1.5.2 Specific Objectives
1. To identify social economic factors affecting utilization of PMTCT programs among HIV
positive women attending Mlaleo CDF Health Centre, Mombasa.
2. To assess the level of knowledge on PMTCT among HIV positive women attending the
services at Mlaleo CDF Health Centre, Mombasa.
3. To determine the availability of resources in utilization of PMTCT services among women
attending Mlaleo CDF Health Centre, Mombasa.

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1.6 Significance of the study
The study will identify challenges and opportunities in attempt to utilize PMTCT services
among HIV positive women. The identification of the challenges that hinder women from
adhering to such programs from the study will be helpful for the country to come with
strategies at national or county level to ensure that mother to child HIV transmission is
eliminated. The study will also help the ministry of health plan on how to ensure that
resources needed to support PMTCT program is available if HIV infection in new-born is to
be reduced.
1.7 Scope and limitations
Scope of this study will be focused on Mlaleo CDF Health Centre, Mombasa and PMTCT
program adherence among women seeking health services at the facility to ensure that time is
enough for the study, human labor and cost to conduct the research is enough. It will also
focus on finding the factors associated and utilization level of PMTCT program in conjunction
with the research questions, and other variables of interest in order to eliminate issues of
information bias.
The possible limitations will include time, information bias, human resource, and funds to
acquire facility needs during the study.

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CHAPTER TWO
Literature review
2. 1 Introduction
This section of chapter two will discuss about; theoretical literature where it will demonstrate
different theories regarding PMTCT, empirical literature, critical review and research gaps
identification then the conceptual framework.
2.1 Empirical review
The primary mode of HIV acquisition in children worldwide is through mother-to child
transmission (MTCT) during pregnancy, childbirth, or breastfeeding. Before the development
of effective interventions to reduce PMTCT of HIV infection, estimated transmission rates
were 15%–25% among non-breast-feeding populations In 2010, around 390,000 children
under 15 became infected with HIV, mainly through mother-to-child transmission (Goga, et
al., 2019). About 90% of children living with HIV reside in sub-Saharan Africa where, in the
context of a high child mortality rate, AIDS accounts for 8 percent of all under-five deaths in
the region (Pickbourn, and Ndikumana, 2019). In high income countries MTCT has been
virtually eliminated in regards to effective voluntary testing and counseling, access to
antiretroviral therapy, safe delivery practices, and the widespread availability and safe use of
breast-milk substitutes (ROGERS, 2018). If these interventions were used worldwide, they
could save the lives of thousands of children each year. Effective PMTCT requires a three-fold
strategy; (1) preventing HIV infection among prospective parents by making HIV testing and
other prevention interventions available in the populace (2) avoiding unwanted pregnancies
among HIV positive women by providing appropriate counseling on contraception and (3) the
use of prophylactic antiretroviral during pregnancy as well as other interventions aimed at
reducing the risk of vertical transmission (Bwana, 2019)

2.2 Antiretroviral drugs

Antiretroviral drugs are used in PMTCT for both the HIV positive mother and her baby.
Women who have reached the advanced stages of HIV disease require a combination of
antiretroviral drugs for their own health. This treatment, which must be taken every day for the
rest of a woman's life, is also highly effective at preventing mother-to-child transmission
(PMTCT). Women who require treatment will usually be advised to take it, beginning either
immediately or after the first trimester. Their newborn babies will usually be given a course of
treatment for the first few days or weeks of life, to lower the risk even further ( Rawlinsonet
al.,2017). The simplest of all PMTCT drug regimens was tested in the HIVNET 012 trial,
which took place in Uganda between 1997 and 1999. This study found that a single dose of

12
Nevirapine given to the mother at the onset of labor and to the baby after delivery roughly
halved the rate of HIV transmission (Sirirungsi et al., 2016). As it is given only once to the
mother and baby, single dose Nevirapine is relatively cheap and easy to administer. Since
2000, many thousands of babies in resource-poor countries have benefited from this simple
intervention, which has been the mainstay of many PMTCT programs. So as to address the
challenge of resource limitation, WHO drafted guidelines on PMTCT drug regimens that
highlight the importance of administering HIV drugs and the various stages of administration.
This incorporates the initiative of providing free drugs in resource-limited settings. These
guidelines provide various options for consideration as per the 2010 recommendations. This
however was after a review of the previous 2006 recommendations, which addressed the issue
of drug resistance.

2.4 PMTCT service utilization in relation to socioeconomic status

In resource-poor settings due to poor social economic status leads to shortages of PMTCT
staff, interruptions in treatment and supplies of medical equipment, as well as a shortfall in
counseling services, which in turn act as barriers to PMTCT services. These factors often
mean long waiting times for post test counseling and many leave without getting their HIV
test results (Maes, K. 2016). One study from Mlaleo reported that 92 percent of respondents
lacked privacy in their counseling rooms (Mugo, 2017). A critical step to an effective PMTCT
service is voluntary counseling and testing, enabling all pregnant women to be aware of their
HIV status. Uptake of antenatal services in low and middle-income countries is high, with
nearly 80% of women being seen at least once during pregnancy (Darnton-Hill, and Mkparu,
2015), representing a valuable opportunity for the implementation of PMTCT. It is
recommended that women receive HIV counseling and testing at their antenatal booking visit,
with an assessment of CD4 count and clinical staging to determine eligibility for ART for
their own health, or ARV prophylaxis for PMTCT; post-delivery infants should be tested for
HIV at approximately 6 weeks, and mothers and infants followed for 2 years (WHO, 2010).
The WHO recommends various initiatives to improve initial testing of pregnant women with,
at minimum, a rapid HIV test at approximately 20 weeks gestation (WHO, 2010). Poor
monitoring of PMTCT services by healthcare workers also leads to poor retention in care. One
study from Ethiopia reported poor follow-up rates in the PMTCT program because healthcare
facilities did not have registered information on HIV-positive mothers (Merdekios, &
Adedimeji, 2011). For the prevention of mother-to-child transmission (PMTCT) of HIV-1 in
resource limited settings, the World Health Organization (WHO) recommends that HIV
infected mothers receive antiretroviral therapy (ARV) and practice exclusive breastfeeding
(EBF) for the first 6 months post-partum followed by complementary feeding unless

13
environmental and social circumstances are safe for and supportive of replacement feeding
(WHO, 2010) Finally, follow-up of PMTCT participants after delivery is generally poor in
operational programs, but essential to support infant feeding practices from birth to 24 months,
ensure testing of all HIV-exposed children with appropriate referral of those found to be
positive and follow-up of HIV-infected mothers, both those already on HAART for treatment,
and those with higher CD4 counts for pre-ART care (Ginsburg et al., 2007) (Manzi et al.,
2007). Maternal mortality is increased in HIV-prevalent areas, with an excess of 1300
maternal deaths per 100,000 live births attributed to HIV (Ronsmans & Graham, 2008). HIV-
infected mothers are also reported to suffer from increased morbidity, including respiratory
infections, diarrhea, anemia and tuberculosis, all treatable conditions if identified and
managed appropriately (Collin et al., 2007).

2.5 Knowledge and PMTCT service utilization

The study finding suggest that increasing utilzation of PMTCT services at Mlaleo CDF
hospital would have postive inpact on the PMTCT situatuon at the hospital. By the increasing
the number of women who utilizes PMTCT services, the hospital would be achieve higher
rates of HIV testing and counselling and ART linkageand profilaxis.
Studies done in Uganda and Tanzania on awareness and knowledge about HIV and PMTCT in
pregnant women, in southwestern Tanzania shows a low level of knowledge on MTCT during
pregnancy and moderate knowledge on the risk of breastfeeding and MTCT (Ebuy, Yebyo,
and Alemayehu, 2015). The risk of MTCT can be reduced up to 2% if comprehensive
approach of PMTCT will be put in place. Treating mothers with ARV in late pregnancy and
breastfeeding period has shown to result in low postnatal HIV transmission. However little
information is available on pregnant women are knowledge and attitude towards PMTCT
intervention, and whether there are educational and behavioral change impacts from antenatal
HIV counseling (Peltzer et al., 2017).

2.6 Clinical resources

In resource-poor settings, shortages of PMTCT staff, interruptions in treatment and supplies
of medical equipment, as well as a shortfall in counseling services, all act as barriers to
PMTCT services. These factors often mean long waiting times for post test counseling and
many leave without getting their HIV test results.).. Understanding context-specific barriers is
the first step to addressing them, followed by design of interventions that are informed by the
evidence base yet tailored to each. Several evaluations have been undertaken to analyze the
real-world effectiveness of PMTCT programs in resource-limited settings. These have
revealed substantial challenges to providing optimal PMTCT services. Staffing issues include

14
a shortage of health care providers, particularly those with sufficient training, and poor
behavior among staff, including scolding or discriminating against HIV-positive. Poor referral
links and tracking systems hamper linkage between antenatal and ART services. The potential
of PMTCT program to virtually eliminate vertical transmission of HIV will remain elusive
unless these barriers are tackled. In sub-Saharan Africa models of care need to adapt to
support continued scale up of Antiretroviral therapy (ART) and retain millions in care. Task
shifting, coupled with community participation has the potential to address the workforce gap,
decongestant health services, improve ART coverage, and to sustain retention of patients on
ART over the long-term.). In Uganda and Kenya community, health workers or volunteers
delivered ART at home. In Mozambique people living with HIV/AIDS (PLWHA) self-
formed community-based ART groups to deliver ART in the community. These examples of
community ART programs made treatment more accessible and affordable. However, to
achieve success some major challenges need to overcome: first, community programs need to
be driven, owned by and embedded in the communities. Second, an enabling and supportive
environment is needed to ensure that task shifting to lay staff and People Living with
HIV/AIDS is effective and quality services are provided. Finally, a long-term vision and
commitment from national governments and international donors is required

2.7 The PMTCT Situation in Mlaleo hospital

The utilization of PMTCT services at Mlaleo hospital has a direct impact on the PMTCT
situation at the hospital. When more women utilize PMTCT services ,the hospital is able to
achieve higher rate of HIV testing and counselling, ART linkage and infant prophylaxis. This
lead to lower rate of HIV transmission from mother to child.

Kenya has the fourth-largest HIV epidemic in the world. In 2012, an estimated 1.6 million
people were living with HIV, and roughly, 57,000 people died from AIDS related illnesses.
(Menon, Rossi, Harmon, Mabeya, and Callens, 2017). Moreover, there are now 1.1 million
orphans to the epidemic. (USAID, 2013) Although HIV prevalence among the general
population has fallen in Kenya, women continue to disproportionately get affected by the
epidemic. In 2012, 6.9 percent of women were living with HIV compared with 4.2 percent of
men. Young women (aged 15-24) are almost three times likely to be living with HIV than men
of the same age (3 percent and 1.1 percent respectively). . The National HIV and AIDS
Estimates Working group estimated HIV prevalence rate among people aged 15-49 to be 6.0%
in 2013. Although the Spectrum results show a continued decline of HIV prevalence among
adult population from late 1990s to 2008 the prevalence has since stabilized. Kenya’s HIV
epidemic is geographically diverse, ranging from a prevalence of 25.7 percent in Homa Bay

15
County in Nyanza region to approximately 0.2 per cent in Wajir County in North Eastern
region. These new estimates confirm a decline in HIV prevalence among both men and
women at National level. Prevalence remains higher among women at 7.6% compared to men
at 5.6%. (Zuma et al., 2016). Levels of infection among individuals in Marriage unions are
high. Based on the four-pronged approach promoted by the WHO, it focuses on primary
prevention of HIV infection in women, prevention of unintended pregnancies, reducing
transmission during pregnancy, labour and breastfeeding, and providing support to HIV-
positive women and their families. As such, the Kenyan guidelines encourage four or more
antenatal care (ANC) visits with an essential package of services that includes (but is not
limited to) counseling, medical history and examination, nutritional assessment, testing for
opportunistic infections including tuberculosis (TB), positive prevention counselling
(including disclosure, condom use, psycho-social support for families), and an effective
contraception plan (WHO, 2017). The revised guidelines have a much greater focus on
pharmaceutical prophylaxis than previous guidelines and promote earlier initiation of therapy
for all pregnant women. Women who are eligible to receive ART (CD4 cell count of 350 or
below with WHO clinical stage of I or II, or WHO clinical stage III or IV, regardless of CD4
cell count) should be started on highly active Antiretroviral therapy (HAART) regardless of
gestational age. Women not eligible for HAART should be started on combination
Antiretroviral (ARV) prophylaxis at 14 weeks, or shortly thereafter and receive a combination
of AZT, 3TC, and NVP at the onset of labour Linguissi et al., 2019)

2.8 Theoretical Framework

This will apply to the research stemmed from the troubling situation of low PMTCT service
utilization in Mlaleo hospital, Mombasa County. The need to know the factor influencing the
use of these services in the health centers is necessary as well as where interventions should be
focused on with respect to knowing the causes of the low utilization and the effect it is having
on the PMTCT Program are in line with the positivist tradition (Nashandi, 2016). Also, the
principle of determinism which believes that once the causative factor is identified and
manipulated then future similar events will be eliminated. This is in line with the target of
eliminating MTCT. With a reductionism perspective, the different causes of this low
utilization will be identified and solutions to getting them solved. This study is a quantitative
study and hence not based on any assumption but rather applied quantitative, empiricism and
objectivity are applied in carrying out the research. Since the research is center on utilization
of PMTCT services, the researcher provides a conceptual framework of how PMTCT services
are accessed in Nigeria using FCT as case study. This is re-enforced using Anderson
behavioral model (ABM) for health service utilization. This model was developed to assist the

16
understanding of why families use health services. It suggests that people’s use of health
services is a function of their predisposition to use the services, factor which enables or
impedes use and their need for care. This ABM is a multilevel model that incorporates both
individual and contextual determinants of health services use (Andersen 1995: 1-3).
Determinants of health services utilization are grouped into four namely: Environment: Health
care system (policy, resources and organization) and external environment. Population
characteristics – Predisposing factors, enabling factors and needs factor. Health behavior –
Personal health practices and use of health care services. Outcomes – Perceived health status,
evaluated health status and customer satisfaction. Behaviorism theory asserts that knowledge
independently exists outside people and learners must get experience for them to be able to
utilize such knowledge. The women need to be equipped with knowledge to help them
respond to stimuli which is PMTCT programs in this case so that they can be able to reduce
transmission of the virus to the children.

17
 2.9 Conceptual framework
The framework graphically represents how the variables influence each other when the
women are seeking the PMTCT services.

Independent variables intervening variable dependent

variable

Level of
knowledge

Availability of
clinical resources

Utilization of PMTCT
Healthcare policies services

Socio-
economic
resources

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CHAPTER THREE
RESEARCH METHODOLOGY
Introduction
This chapter entails at explaining techniques applied to answer the research questions. It
provides a clear view of the research design to use, the target population by the researcher,
sampling techniques to use, data collection instruments and methods, reliability and validity
testing, how data will be analyzed and presented, inclusion criteria as ethical considerations to
observe when conduction researcher will be carrying the study.
3.1 Study design
The study will adopt cross-sectional study design as the data collected will involve
comparison of level of utilization of PMTCT services among women from different age
groups and socioeconomic settings. The reason for adopting the study is that the study will
entail both qualitative and quantitative data. Additionally, the design will ensure reduced
biasness, hence leading to reliability of the findings from conducted research, which can be
used to make inference concerning the study topic
3.2 Study area
The research will be conducted in Mlaleo CDF Health Center in Nyali subcounty. The sub-
County comprises of Mijikenda community as the dominant and its bordering sub-counties
including Mvita, ziwa la ngombe, and Kisauni

3.3 Target population

The target population for the study are women of reproductive age that reside within Nyali
Sub- County receiving antenatal care services at Mlaleo CDF Health Center.
3.3. 1 Inclusion criteria
In order to participate in the study, the participants must possess certain characteristics. The
participants must be female of reproductive age regardless of their HIV status.
3.3.2 Exclusion criteria
The characteristics that possessed by the participants which researcher feel could affect the
accuracy of the findings will be excluded. In this study, the participants who have at one point
not conceived or are not expecting to conceive will be excluded because they might provide
false information thus leading to wrong conclusion and recommendations.
3 .4 Variables
3.4.1 Independent variables
The independent variables of the study with their associated indicators will include knowledge
level, clinical resources, and socio-economic indicators comprising of income.

19
3.4.2 Dependent variable
Utilization of PMTCT services

3.5 Sampling techniques

The study will utilize simple random sampling technique which will be used. whereby women
at the reproductive age will be selected randomly and given questionnaire forms to fill. Each
woman attending ANC and PNC clinic will have equal chance of participate in the research
process.

3.6 The sample size and sampling procedures

A sample is a subject selected from a population to be representative of the whole population
from where is drawn. The sample size will be determined using the Fishers formula and
sampling
3.6.1 Sample size
The sample size will be determined using Fisher’s et al, 2003 Formula. The formula will be
used to estimate the smallest possible categorical sample size.
n = z2pq
d2
Where: n = the desired sample size (N>10000)
z = the standard normal deviate, usually set at 1.96 which corresponds to 95% confidence
level
p = the proportion of target population estimated to have a particular characteristics and
behavior attending Mlaleo CDF Health Center is not known therefore 50% (0.5) will be used.
d = Permitted error (5%, if the confidence level is 95%); 0.05
q = 1 – p; (1-0.5=0.5)
Therefore n=1.96*1.96*0.5*0.5
0.05*0.05
=384.16

Since the study population was less than 10000 1 adjusted it by the following
formulae;
n
nf =
n
1+ ¿
n
¿

20
 Nf =desired sample when population is less than 100000

n
nf =
Therefore, n
1+ ¿
n
¿
384
nf =
384
1+
101 ¿
¿
=80 respondents

3.7 Development of data collection tool/ instruments

All women at the reproductive age will be issued with self-administered questionnaire and the
key informant guide given to health workers from the health facilities. The questionnaire will
have two parts which will ask respondents about their background information and factors
influence them when seeking to utilize health services.
3.8 Data collection method
The data will be collected using closed-structured questionnaire that will be administered to
the participants. The questionnaire will comprise questions with options where the
respondents will need to select among the options given. The questionnaire forms will be
issued to the participants to fill and the researcher collect them at the end of the interview for
analysis.

3.9 Pilot study

The questionnaire will be subjected to pre-test for modifications before the actual study. The
pilot test will be carried out a week before the main study. The testing process will comprise 5
respondents and administering the questionnaire to them to help find out if there is any
problem with test instructions. When questionnaire form is not clear, the questionnaire will be
formatted and typographical errors or inconsistencies rectified to ensure that there is no
confusion during the actual study.
3.10 Validity of Research Instrument
Validity is defined as the accuracy and meaning of inferences which are based on study
findings. It is important to conduct validity on research instrument before using the

21
instruments in research. The research instruments validity will be obtained through content
and construct validity. Content ensure that the objectives are in line with the topic of the study.
3.11 Reliability
It is vital to have reliable testing so as to ensure accuracy and precision of the instrument. It
will be achieved through accurate and careful phrasing of each question to avoid ambiguity in
the research instruments. The research instrument will also undergo retesting prior to the study
to ensure that the questions lead to an answer for reliability purposes and enhance ruefulness
among the responds when responding to questions.
.
3.12 Data Analysis and presentation Techniques
Data analysis will entail data clean up, reduction, differentiation and explanation. Data clean
up involve editing, coding and tabulation in order to detect anomalies. Data will be then
analyzed using computer program known as Microsoft excel. The analyzed data will be
presented in forms of tables, charts and graphs.
3.10 Ethical consideration
Researcher will be trained on data collection techniques and meanings for each technical term
clarified for them for uniformity. The permission to conduct the study will be sought from
Mlaleo Health Center Medical superintendent. The Study participants will fill consent form to
grant permission to collect data from them.
Participants will be free withdraw from the study at level of the study. The researcher will
guarantee confidentiality and anonymity to the participants. Finally, since the respondents will
be aware of the cultural norms of the study arena, the study will sure that words and language
that is sensitive to religion, disability, marriage status or tribe will be omitted.

22
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ROGERS, T. (2018). FACTORS INFLUENCING UTILIZATION OF ELIMINATION OF
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APPENDIX II: QUESTIONNAIRE FORM.
Date…………………... Study Site……………. Code of the interview………
PARTICIPANTS’ INSTRUCTIONS
Do not write your name, tick √ only one correct response and multiple responses where
applicable. Only women attending antenatal services at Mlaleo CDF Health Center are eligible
for the participation. The acronym PMTCT stands for Prevention of Mother to Child
Transmission.

Part One: Socio-demographic and economic questions

1. Sex/Gender?
Male [ ] Female [ ]
2. What is your age in years? 18-28[ ] 29-39 [ ] Above 39 [ ]
3. What is your current level of education?
a. Primary school [ ]
b. Secondary school [ ]
c. College/Tertiary institution [ ]
5. What is your religious status?
a. Christian (catholic protestant) [ ]
b. Muslim [ ]
c. Other [ ]
6. Does your religion restrict you from accepting use PMTCT services?
Yes [ ] No [ ]
7. What is your ethnicity?
a. Luo [ ]
b. Mijikenda [ ]
c. Other [ ]
8. Are you married? Yes [ ] No [ ]
9. Do you have any other source of income? Yes [ ] No [ ]

Part Two: Knowledge and awareness of PMTCT services

26
10. Have you ever heard of HIV Counseling and Testing services? Yes [ ] No [ ]
11 Are you aware of availability of PMTCT services? Yes [ ] No [ ]
12. If yes do you use the services? Yes [ ] No. [ ]
13. Do you know the importance of PMTCT services?
a. Yes [ ]
b. No [ ]
14. If yes in 12 above, what were they? (Tick all applicable)
A. Prevent transmission of HIV to the child[ ]
B. Reduces spread of HIV/AIDS[ ]
C. I don’t know [ ]
15. Have you ever attended any training on PTMTCT services?
Yes [ ]
No. [ ]
16. If yes in 15 above, did it have influence on the use of PMTCT services?
A. Yes[ ]
B. No. [ ]
17. Do you think there are enough clinical resources?
A. Yes[ ]
B. No. [ ]
18. If yes in 17 above, does it influence PMTCT service utilization?
A Yes [ ]
B No. [ ]

Part Three: Antiretroviral drugs and Clinical resources in relation to PMTCT service
utilization
16. Do you have access to drugs?
Yes [ ] No [ ]
17. If no in 16 above, give reason.
A. they are far [ ]
B. they are expensive to get [ ]
C. They are not available [ ]

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 18. How frequent do you visit health facility to seek information concerning Antiretroviral
drugs, availability and benefits?
A. Once a week [ ]
B. Once a month [ ]
C. Once a year [ ]
D. Not at all [ ]

Part Four: Government policies

Tick √ on against the statement according to your view.
Statement Strongly agree Agree Strongly disagree Disagree

The government has

good policy to
support PMTCT
programs
There are poor policy
regarding PMTCT
programs
The government has
put enough budget on
PMTCT programs

Government needs to
make PMTCT
services free of
charge for all women

THANK YOU FOR PARTICIPATING

APPENDIX III: BUDGET
ITEM ESTIMATED PRICE (KSH)
Stationary expenses 6,000

28
Travelling and upkeep expenses 2,500
Photocopying and Binding 7,000
Personnel 3,000
Miscellaneous 400
TOTAL 18900

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APPENDIX IV: WORKPLAN
Activities Timeline

Proposal writing SEPTEMBER

2023

Present the SEPTEMBER

proposal and 2023
make corrections

Data collection, SEPTEMBER

Data entry, 2023
cleaning and
analysis

Writing, OCTOBER
Submission and 2023
defending of
project

Corrections and OCTOBER

final submission 2023

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APPENDIX V: CONSENT FORM
Dear sir/madam, my name Suleiman Mohamed, a student from Thika School of Medical and
Health Sciences, Mombasa campus. I would like you to participate in a study on utilization of
PMTCT services among women attending Mlaleo CDF Health Center. We will ask you
questions about utilization of PMTCT services at the facility. All information shared with us will
be kept confidential and we will not reveal your identity to any other person apart from us. Do
you consent to participate in the study?
Kindly sign below to indicate your consent to participate in the study
Name: ……………………………………………………………….
Signature: …………………………………………….
Date: ………………………………………………………………...

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APPENDIX VI: MAP FOR STUDY SITE

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