DETERMINANTS OF LOSS TO FOLLOW UP HIV EXPOSED INFANTS IN LUSAKA, ZAMBIA BY RUTH CHEMBA- RN/RM/ BSc A dissertation submitted in partial fulfilment of the requirements for the Degree of Master of Science in Midwifery, and Women Health at the University of Zambia MARCH 2022 NOTICE OF COPYRIGHT “© 2022 by Ruth Chemba. All rights reserved.” i DECLARATION I, Ruth Chemba, declare that the work presented in this dissertation for the award of a Degree of Master of Science in Midwifery, and Women Health to the University of Zambia is entirely my work and has not been presented wholly or partially for any other qualification at any other Institution or University. Signature………………………………………… Date…………………………… (Candidate) ii Certificate of Completion I, Dr Concepta Kwaleyela, having supervised and read through this dissertation, am satisfied that this is the original work of the author under whose name it is presented. I confirm that the work has been completed satisfactorily and approve it for final submission. Signed..................................................................... Date.................................................. (Supervisor) Signed..................................................................... Date.................................................. (Candidate) iii Certificate of Approval The University of Zambia approves the dissertation on “Determinants of loss to follow up HIV exposed infants in Lusaka, Zambia” in partial fulfilment for the requirements for the award of Master of Science in Midwifery and Women Health Degree Examiner’s Name...................................................................................................... Signature ............................................................................Date............................ Examiner’s Name...................................................................................................... Signature ............................................................................Date............................ Examiner’s Name...................................................................................................... Signature ............................................................................Date............................ iv DEDICATION This dissertation is dedicated to my beloved husband Elisha Chipandwe for always supporting and encouraging me during the course of my study. To our beloved children Kaluba, Chishimba, Manyowa and Konjela for the love and understanding. To the entire family members for the love, support and encouragement rendered to me. v ACKNOWLEDGEMENTS I am grateful to the following for their contributions: Firstly, my utmost gratitude goes to my Supervisors, Dr. Concepta Kwaleyela and Ms. Mutinke Zulu for their mentorship, advice and great assistance to produce this dissertation I also thank Lusaka District Health Office for allowing me to conduct this study from the health centres in the district. I thank the health centre in-charges for their support. Many thanks go to the caretakers and health care providers who participated in the study. vi TABLE OF CONTENT DECLARATION .................................................................................. Error! Bookmark not defined. CERTIFICATE OF COMPLETION .................................................... Error! Bookmark not defined. CERTIFICATE OF APPROVAL ......................................................... Error! Bookmark not defined. DEDICATION ...................................................................................... Error! Bookmark not defined. ACKNOWLEDGEMENTS .................................................................. Error! Bookmark not defined. TABLE OF CONTENT ....................................................................... .Error! Bookmark not defined. APPENDICES .................................................................................... Error! Bookmark not defined.I LIST OF FIGURES ............................................................................ Error! Bookmark not defined.I LIST OF TABLES .............................................................................. Error! Bookmark not defined.I ABSTRACT ....................................................................................... Error! Bookmark not defined.V ABBREVIATIONS ................................................... ERROR! BOOKMARK NOT DEFINED. CHAPTER ONE: INTRODUCTION 1.0 INTRODUCTION ................................................... ERROR! BOOKMARK NOT DEFINED. 1.1 BACKGROUND ..................................................... ERROR! BOOKMARK NOT DEFINED. 1.2 STATEMENT OF THE PROBLEM ....................... ERROR! BOOKMARK NOT DEFINED. 1.3 CONCEPTUAL FRAMEWORK ............................ ERROR! BOOKMARK NOT DEFINED. 1.3.1 APPLICATION OF THE FRAMEWORK TO THE STUDY ....... ERROR! BOOKMARK NOT DEFINED. 1.4 JUSTIFICATION OF THE STUDY ....................... ERROR! 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RESEARCH QUESTION ....................................... ERROR! BOOKMARK NOT DEFINED. 1.6. RESEARCH OBJECTIVES ................................... ERROR! BOOKMARK NOT DEFINED. 1.6.1 GENERAL OBJECTIVE ...................................................... ERROR! BOOKMARK NOT DEFINED. 1.6.2 SPECIFIC OBJECTIVES ...................................................... ERROR! BOOKMARK NOT DEFINED. 1.7 CONCEPTUAL DEFINITION OF TERMS ........... ERROR! BOOKMARK NOT DEFINED. 1.8 OPERATIONAL DEFINITION OF TERMS ......... ERROR! BOOKMARK NOT DEFINED. 1.9 VARIABLES ........................................................... ERROR! BOOKMARK NOT DEFINED. 1.9.1 DEPENDENT VARIABLE ........................................... ERROR! BOOKMARK NOT DEFINED. 1.9.2 INDEPENDENT VARIABLES ..................................... ERROR! BOOKMARK NOT DEFINED. 1.9.3 VARIABLES CUT OF POINT…. ...................................................................................... 11 CHAPTER TWO: LITERATURE REVIEW 2.0 INTRODUCTION ................................................... ERROR! BOOKMARK NOT DEFINED. 2.1 OVERVIEW OF LTFU ....................................... ERROR! BOOKMARK NOT DEFINED. 2.2 KNOWLEDGE OF CARETAKERS AND HEALTH CARE PROVIDERS ABOUT EMTCT .................................................................................... ERROR! BOOKMARK NOT DEFINED. 2.3 DISTANCE TO HEALTH FACILITY AND TRANSPORT AFFORDABILITY .... ERROR! BOOKMARK NOT DEFINED. 2.4 PLACE OF DELIVERY ...................................... ERROR! BOOKMARK NOT DEFINED. 2.5 PROPHYLAXIS GIVEN .................................... ERROR! BOOKMARK NOT DEFINED. 2.6 ATTITUDE OF HEALTHCARE PROVIDERS . ERROR! BOOKMARK NOT DEFINED. 2.7 WAITING TIME ................................................. ERROR! BOOKMARK NOT DEFINED. CONCLUSION .......................................................... ERROR! 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file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc161757969 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163200503 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163200503 viii CHAPTER THREE: METHODOLOGY 3.0 INTRODUCTION ............................................... ERROR! BOOKMARK NOT DEFINED. 3.1 STUDY DESIGN................................................. ERROR! BOOKMARK NOT DEFINED. 3.2 STUDY SETTING............................................... ERROR! BOOKMARK NOT DEFINED. 3.3 STUDY POPULATION ...................................... ERROR! BOOKMARK NOT DEFINED. 3.4 ELIGIBILITY CRITERIA................................... ERROR! BOOKMARK NOT DEFINED. 3.4.1 INCLUSION CRITERIA.................................. ERROR! BOOKMARK NOT DEFINED. 3.4.2 EXCLUSION CRITERIA ................................ ERROR! BOOKMARK NOT DEFINED. 3.5 SAMPLING TECHNIQUE ................................. ERROR! BOOKMARK NOT DEFINED. 3.6 SAMPLE SIZE .................................................... ERROR! BOOKMARK NOT DEFINED. 3.6.1 SAMPLE SIZE FOR CARETAKERS ............. ERROR! BOOKMARK NOT DEFINED. 3.7 DATA COLLECTION ........................................ ERROR! BOOKMARK NOT DEFINED. 3.7.1 DATA COLLECTION TOOL .......................... ERROR! BOOKMARK NOT DEFINED. 3.7.2 DATA COLLECTION TECHNIQUE ............. ERROR! BOOKMARK NOT DEFINED. 3.8 DATA MANAGEMENT AND STORAGE ....... ERROR! BOOKMARK NOT DEFINED. 3.9 VALIDITY .......................................................... ERROR! BOOKMARK NOT DEFINED. 3.10 RELIABILITY ................................................... ERROR! BOOKMARK NOT DEFINED. 3.10 ETHICAL CONSIDERATION ......................... ERROR! 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ERROR! BOOKMARK NOT DEFINED. 4.1 DATA PROCESSING AND ANALYSIS........... ERROR! BOOKMARK NOT DEFINED. 4.2 DATA PRESENTATION .................................. ERROR! BOOKMARK NOT DEFINED.4 4.2.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF CARETAKERS ................. ERROR! BOOKMARK NOT DEFINED.4 4.2.2 CARETAKERS’ KNOWLEDGE ABOUT EMTCT ........... ERROR! BOOKMARK NOT DEFINED.7 4.2.3 ENVIRONMENTAL AND SERVICE RELATED FACTORS .... ERROR! BOOKMARK NOT DEFINED.8 4.2.4 SERVICE RELATED FACTORS FROM CARETAKERS’ PERSPECTIVE ................... 29 4.3 ASSOCIATIONS BETWEEN VARIABLES ..... ERROR! BOOKMARK NOT DEFINED. 4.14 BINARY LOGISTIC REGRESSION OF FACTORS ASSOSSCITED WITH LTFU .................................................................................... ERROR! BOOKMARK NOT DEFINED. CHAPTER FIVE: DISCUSSION OF FINDINGS 5.0 INTRODUCTION ............................................... ERROR! BOOKMARK NOT DEFINED. 5.1 SOCIO DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS .................. ERROR! BOOKMARK NOT DEFINED. 5.2 CARETAKERS KNOWLEDGE ABOUT EMTCT ............... ERROR! BOOKMARK NOT DEFINED. 5.3 PLACE OF BIRTH .............................................. ERROR! BOOKMARK NOT DEFINED. 5.4 PROPHYLAXIS GIVEN AT BIRTH ................. ERROR! 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ERROR! BOOKMARK NOT DEFINED. 5.6 TRANSPORT AFFORDABILITY ..................... ERROR! BOOKMARK NOT DEFINED. 5.7 ATTITUDES OF HEALTH CARE PROVIDERS.................. ERROR! BOOKMARK NOT DEFINED. 5.8 WAITING TIME ................................................. ERROR! BOOKMARK NOT DEFINED. 5.9 LIMITATIONS OF THE STUDY....................... ERROR! BOOKMARK NOT DEFINED. 5.10 IMPLICATIONS TO NURSING .................... ERROR! BOOKMARK NOT DEFINED.4 5.10.1 Implication to Nursing Administration ................................ Error! Bookmark not defined.4 5.10.2 Implication to Nursing Practice............................................ Error! Bookmark not defined.4 5.10.3 Implication to Nursing Research .......................................... Error! Bookmark not defined.4 5.11 CONCLUSION .................................................. ERROR! BOOKMARK NOT DEFINED. 5.12 RECOMMENDATIONS ................................... ERROR! BOOKMARK NOT DEFINED. 5.12.1 Recommendation to the Health Care Providers ..................... Error! Bookmark not defined. 5.12.2 Recommendations to the DHOs ........................................... Error! Bookmark not defined.5 5.12.3 Recommendations to the MoH ............................................... Error! Bookmark not defined. 5.13 PLAN FOR DISSEMINATION OF DATA ...... ERROR! BOOKMARK NOT DEFINED. 6.0 REFERENCES .................................................... ERROR! BOOKMARK NOT DEFINED. file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202163 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202164 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202165 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202166 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202167 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202168 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202169 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202170 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202171 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202172 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202173 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202174 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202175 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202176 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202177 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202178 xi APPENDICES APPENDIX 1: PARTICIPANT INFORMATION SHEET .......... ERROR! BOOKMARK NOT DEFINED. APPENDIX 2: INFORMED CONSENT FORM ...... ERROR! BOOKMARK NOT DEFINED. APPENDIX 3: QUESTIONNAIRE FOR CARETAKERS .......... ERROR! BOOKMARK NOT DEFINED. APPENDIX 4: SELF ADMINISTERED QUESTIONNAIRE FOR HEALTH WORKERS .................................................................................... ERROR! BOOKMARK NOT DEFINED. APPENDIX 5: NYANJA PARTICIPANT INFORMATION SHEET ... ERROR! BOOKMARK NOT DEFINED. APPENDIX 6: NYANJA CONSENT FORM ........... ERROR! BOOKMARK NOT DEFINED. APPENDIX 7: NYANJA QUESTIONNARE ........... ERROR! BOOKMARK NOT DEFINED. APPENDIX 8: BUDGET .......................................... ERROR! BOOKMARK NOT DEFINED. APPENDIX 9: GHANT CHART .............................. ERROR! BOOKMARK NOT DEFINED. APPENDIX 10: AUTHORIZATION LETTER FROM NATIONAL HEALTH RESEARCH AUTHORITY…………………………………………………………………………………... ERROR! BOOKMARK NOT DEFINED.6 APPENDIX 11: ETHICS CLEARANCE ..................................................................................... 87 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202180 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202180 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202180 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202181 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202181 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202182 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202182 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202182 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202183 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202183 _Toc163202183 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202184 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202184 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202184 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202185 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202185 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202186 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202186 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202187 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202187 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202188 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202188 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202189 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163202189 _Toc163202189 xii LIST OF FIGURES Figure 1.1: Conceptual Framework .............................................. Error! Bookmark not defined. file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203329 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203329 xiii LIST OF TABLES Table 1.1: Infants LTFU at 18 Months in Lusaka district .............................................................. 6 Table 1.2: Variables, Indicators and Cut off Points ....................... Error! Bookmark not defined. Table 4.1: Socio-demographic characteristics of caretakers .......... Error! Bookmark not defined. Table 4.2: Socio-demographic characteristics of health care providers ...... Error! Bookmark not defined. Table 4.3: Caretakers’ knowledge about eMTCT) ........................ Error! Bookmark not defined. Table 4.4: Environmental related factors ....................................... Error! Bookmark not defined. Table 4.5: Service related factors ................................................... Error! Bookmark not defined. Table 4.6: Waiting Time ............................................................................................................... 31 Table 4.7: Reasons caretakers gave for discontinuing follow up care .......................................... 31 Table 4.8: Association between respondents’ demographical characteristics and LTFU ............ 32 Table 4.9: Association between knowledge of caretakers and LTFU ......... Error! Bookmark not defined. Table 4.10: Association between environmental factors and LTFU .......... Error! Bookmark not defined. Table 4.11: Association between service related factors and LTFU .... Error! Bookmark not defined. Table 4.12: Binary Logistic Regression Analysis .......................... Error! Bookmark not defined. file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203330 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203330 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203331 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203332 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203333 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203334 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203335 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203338 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203339 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203340 file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203341 xiv Table 4.13: Factors likely to influence LTFU HIV exposed infant ............. Error! Bookmark not defined. ABSTRACT Introduction - Prevention of Mother-To-Child-Transmission (PMTCT) programmes aimed at preventing vertical transmission have been widely implemented in Zambia by the Ministry of Health (MoH). However, many infants are not benefitting from the programmes due to loss to follow up (LTFU) at different points of the PMTCT cascade, with the highest loss occurring at 18 months. This compromises the effectiveness of PMTCT services. The aim of this study was to establish determinants of LTFU infants born to HIV positive women in Lusaka district. Methodology - A descriptive cross sectional study design using a quantitative approach was conducted in three Lusaka Urban District Clinics. The sample size comprised of 160 caretakers of LTFU infants and 25 health care providers. Data from caretakers were collected using a semi- structured questionnaire while that from healthcare workers were through a self-administered semi-structured questionnaire. Data were analysed using the Statistical Package for Social Sciences (SPSS) version 22.0 and presented using frequency tables, bar charts, and cross tabulations. Logistic regression was used to test associations between the dependent and independent variables. The cut off point for statistical significance was set at 5%. P-values of 0.05 or less were considered statistically significant. Results - The finding showed that 42.4% caretakers were not aware that they needed to continue with follow up care, while 28.0% stated forgetting taking their infants for follow up care. The results further showed that the association between gender of caretaker [OR 0.252 (1.101-0.633) p-value 0.003], relationship between caretaker and infant [OR 0.592 (0.699-0.189) p-value 0.003], staff attitude [OR 10.012 (4.194-23.947) p-value 0.003], prophylaxis given at birth [OR 0.299 (0.131-0.684) p-value 0.004], and place of birth [OR 2.324 (1.050-5.143) p-value 0.037] file:///C:/Users/LIAS%20RN/Documents/FUNDAMENTALS%20OF%20NURSING/FN%20%20SECOND%20SEMESTER/TABLE%20OF%20CONTENT.docx%23_Toc163203342 xv and LTFU were statistically significant. Binary logistic regression indicated that association between gender of caretaker [OR 0.4 (CI, 0.287-0.966) p-value-0.040], negative staff attitude [OR-2.7 (1.050-5.114) p-valu-0.047] and waiting time [OR 0.7 (CI-0.314-5.665) p-value-0.003] and LTFU were also statistically significant. Conclusion - The results suggest that change in staff attitude and improvement in waiting time can reduce chances of loss to follow up care. Therefore, the study recommends that clinics should come up with an easy appointment scheduling process to help reduce waiting time for follow up care clients; such as providing a specific appointment time. Key Words: HIV-exposed infants, Lost to follow up, Prevention of mother to child transmission. ABBREVIATIONS AHRQ - Agency for Healthcare Research and Quality ANC – Antenatal care ART- Antiretroviral Therapy CD4 - Cluster Differential Cells CSO – Central Statistical Office eMTCT - Elimination of Mother to Child Transmission EID - Early Infant Diagnosis HAART- Highly Active Antiretroviral Therapy HIV- Human Immunodeficiency Virus IOM - Institute of Medicine ICRW - International Center for Research on Women LTFU- Lost to follow up xvi MoH- Ministry of Health MTCT- Mother-to-Child-Transmission NAC - National AIDS Council PMTCT- Prevention of Mother to Child Transmission UNAIDS- Joint United Nations Program on HIV/AIDS USAID - United States Agency for International Development UNZA - University of Zambia WHO- World Health Organisation ZDHS - Zambia Demographic and Health Survey 1 CHAPTER ONE: INTRODUCTION 1.0 INTRODUCTION An infant born from a Human Immune Virus (HIV) infected mother is referred to as an HIV exposed infant. Majority of HIV exposed infants acquire HIV infection through vertical transmission from their infected mothers (World Health Organisation [WHO], 2016). The WHO (2013) has, therefore, devised measures to prevent mother-to-child-transmission (MTCT) of HIV infection, and such measures include; initiating lifelong antiretroviral therapy (ART) to all HIV positive pregnant women and breastfeeding mothers and administering prophylactic ART to HIV exposed infants from birth to 6 weeks old. According to the Joint United Nations programme on HIV and acquired immunodeficiency syndrome (AIDS) (UNAIDS, 2014), an HIV exposed infant is less likely of dying from an AIDS related illness if given ART within the first 12 weeks of life. It is therefore, important that all infants born to mothers living with HIV get tested between four to six weeks of age and initiated on ART if HIV positive (UNAIDS, 2016). However, majority of these infants end up being LTFU at different points of the PMTCT cascade, with the highest loss occurring at age of 18 months (MoH, 2017). 1.1 BACKGROUND HIV infection remains a challenge to the world and continues to be a major global public health problem, with increase in the number of HIV infections in children (UNAIDS 2014). The increase can be attributed to the rising number of HIV infected women of childbearing age, majority of which live in low- and middle-income countries (WHO, 2014). According to global HIV and AIDS statistics of 2014, an estimated 36.9 million people are living with HIV out of which 2.6 million are children (UNAIDS, 2018). About 90% of the infected infants acquired the virus through MTCT during pregnancy, delivery, or breast-feeding (United Nations International Children's Emergency Fund ([UNICEF], 2012). In the presence of effective interventions, the risk of MTCT is less than 2% (Bucagu, 2014). However, the uptake of PMTCT programmes is affected by various barriers that hinder pregnant women with HIV from accessing and engaging in the HIV care continuum (UNAIDS, 2017). 2 In Zambia, 1.2 million people are living with HIV; of which 94,000 are children under the age of 15 years (UNAIDS, 2016). In 2017, around 41,000 adults and 7,300 children became newly infected with HIV (UNAIDS, 2018). Since the start of the HIV pandemic, children have been severely affected, with an estimated 72,000 living with HIV as a result of vertical transmission, arising from a high antenatal HIV prevalence (UNAIDS, 2018). As a response to this burden, Zambia initiated the PMTCT within HIV programme in 1999 with support from various donors, including the United States Agency for international Development (USAID) and Zambia Prevention, Care and Treatment Partnership (ZPCT) (MoH, 2010). Integration of PMTCT into all Maternal, New-born and Child Health Services throughout the country was done with the goal of preventing new HIV infections in children, early diagnosis of infection in pregnant women, and commencement of ART (UNAIDS, 2016) to reduce morbidity and mortality rates (MoH, 2010). In 2013, the WHO released a new set of guidelines directed towards eMTCT of HIV (WHO, 2013). Many countries worldwide, including Zambia, adopted the guidelines. The guidelines recommend that all pregnant women diagnosed with HIV infection should be commenced on life-long ART regardless of their cluster differential cells (CD4) count, while HIV exposed infants receive daily Nevirapine or Azidothymidine from birth up to six weeks, regardless of infant feeding method (WHO, 2013). In the past, there was poor health outcomes associated with early cessation of breastfeeding (Cournil et al., 2015). Women are therefore, currently advised to continue breastfeeding up to two years or more, as evidence proved that commencing ARV drugs to either an HIV-infected mother or HIV exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding to less than 5% (WHO, 2018). The guidelines, further, recommend a scheduled series of HIV virologic tests for exposed infants to be done between four to six weeks, at nine months, and at eighteen months, to confirm or exclude perinatal HIV infection (WHO, 2013). Continued follow-up of exposed infants is hence, required to ensure success of these strategies. HIV-related follow-up care for infants have benefits that include continued counselling to the mother regarding eMTCT, administering neonatal ARV prophylaxis, early infant diagnosis (EID) to determine HIV status, and timely initiation of ART for positive results (WHO, 2013). However, many infants miss out on these benefits due to high rates of LTFU 3 (Lain et al., 2020). In Zambia the situation is not different. Despite effective eMTCT programmes, with about 92% of pregnant women living with HIV receiving ART yearly (UNAIDS 2014), retaining HIV exposed infants in the eMTCT programme is a problem. According to the Zambia National AIDS Council (NAC, 2013), around 70% of HIV exposed infants were tested in 2013, while in 2017, only 47% of exposed infants were retained in the care, and 53% were LTFU (MoH, 2018). Thus, non-retention of infants under HIV care is a problem in Zambia. There are several factors that may contribute to LTFU of HIV exposed infants. The factors can be categorised into two; namely, socio-behavioural factors and service related factors. Disclosure of HIV status is an important factor in promoting ART adherence and patient retention in care (Umeokonkwo et al., 2019), and it is a crucial goal in HIV testing and counselling, as well as PMTCT (Alemayehu et al., 2015). This is because patients receive social support from family members, which is a key factor in fostering and maintaining adherence to ART. However, with all the benefits of status disclosure, the disclosure rates in developing countries are still low; they range between about 16.7% - 86% (Stockton et al., 2018). There is strong evidence indicating that women’s fears of stigma and involuntary HIV status disclosure to family members are barriers to EID and the continuation of HIV care for mothers and their children (Hampanda et al., 2017). Even though women do enrol in PMTCT programmes or HIV care; fears of accidental disclosure, stigma, and discrimination may make it difficult for them to adhere to ART prophylaxis or highly active antiretroviral therapy (HAART) if they need to hide HIV clinic visits and medications from others, or if permission has to be obtained from their partners to travel to access services (Colombini et al., 2018). In many settings around the world, traditional gender roles and cultural beliefs give power to the males in decision making, which include women’s use of HIV-related services, such as; follow up appointments, and uptake and adherence to ARV regimens (Central Statistical Office [CSO], 2017). It is therefore, important that men are fully incorporated in health issues of women and children for positive outcomes. Male involvement could enhance partner support for follow-up care for HIV-positive women and HIV exposed infants, including ARV adherence, improved 4 adherence to infant feeding methods, and early management of HIV exposed infant. The low proportions of HIV disclosure to the male partners by the HIV-positive female partners' highlights reported low male partner involvement (Kigen et al., 2018). Adane et al. (2018) in a study to explore Male involvement in prevention of mother to child transmission of human immunodeficiency virus and associated factors in Enebsiesarmider District, North West Ethiopia, highlighted the beneficial impact of male involvement in programmes to prevent MTCT of HIV to tackle new infections among infants. The practice could also eliminate harmful consequences faced by women who seek PMTCT services, such as, stigmatisation and gender-based violence (GBV). Moreover, male involvement in PMTCT services could address the healthcare needs and responsibilities of men, providing them with positive male norms, and linking them to other healthcare services. In a multitude of settings, HIV positive people experience HIV-related stigma and discrimination in their daily lives (Dong et al., 2018). Stigma affects quality of life, healthcare service utilisation, and mental health (UNAIDS, 2017). In addition to the stigma of being HIV-positive, stigma associated with having a child while being HIV positive is also encountered (People Living with HIV [PLHIV], 2015). This causes women to struggle disclosing their HIV status to their partners for fear of negative consequences (Prudden et al., 2017). Stigma and discrimination negatively affect the PMTCT cascade at any stage, as well as the uptake and retention of PMTCT services, which may significantly impact rates of infant HIV infection (Prudden et al., 2017). According to the International Center for Research on Women (ICRW, 2014) over 50% of vertical HIV transmissions globally can be attributed to the cumulative effect of stigma. Similarly, Prudden et al (2017) state that while the effect of stigma on retention of women at any given stage along the PMTCT cascade can be relatively small; the cumulative effect can be large. Stigma influences a pregnant woman’s decision to enrol in PMTCT programmes and adherence to treatment and retention in care for themselves and their infants (Nepua, 2016). Access to health care is defined as having timely use of personal health services to achieve the best possible health outcome (Institute of Medicine [IOM], 1993). Access requires gaining entry into the health-care system, getting access to sites of care where patients can receive needed services, and finding providers who meet the needs of patients and with whom patients can 5 develop a relationship based on mutual communication and trust (Agency for Healthcare Research and Quality [AHRQ], 2017). Patients fail to access care if it does not exist in their geographic area. Such care includes PMTCT and other HIV related services. Even though patients are not charged for services, barriers such as walking long distances or unaffordable transportation costs incurred when travelling to ART centres, and sometimes in difficult terrain may contribute to non-retention in the care of patients on ART programmes (Mpinganjira et al., 2020) Staff shortage influences retention in care of patients on ART as it leads to long queues at the clinic, resulting in long waiting times (Mukumbang et al., 2017). Because of this, patients get frustrated and tired of waiting to be seen. Long waiting times is perceived as a predictor of LTFU (Kweyamba, et al., 2018). Patient clinic waiting time is therefore, an important indicator of quality of services offered (Pandit et al., 2018). The amount of time a patient waits to be seen is one factor which affects utilisation of healthcare services and leads to LTFU (Opio et al., 2019). The attitudes of health workers can affect health care utilisation in a positive or negative way. Evidence suggests that poor provider attitudes have a variety of adverse impacts on patient care and health outcomes (Dapaah, 2016). Just like a friendly, informative and reassuring manner can help to reduce the existing fears of a patient, an uncaring, judgmental or hostile attitude can exacerbate fears, and inhibit people from seeking reproductive and maternal health care services including PMTCT services (Kawale et al., 2015). 1.2 STATEMENT OF THE PROBLEM PMTCT programmes provide many benefits such as providing virological testing to infants after birth and during the breastfeeding period, administering ART prophylaxis for prevention and effective treatment to HIV exposed infants. The programmes are widely implemented at various sites in Zambia. The Government and various stakeholders have made this possible by ensuring that all HIV services are free and accessible by increasing EID through health education. However, despite the efforts and interventions put in place, many infants do not benefit from the programmes mainly due to the LTFU problem, which compromises their effectiveness. MoH (2017) estimated that out of 38,128 HIV exposed children; only 43% (16,431) got tested at 18 6 months’ country wide, indicating that 56% (21,697) were LTFU. The figures for Lusaka district are not different from the national ones. Table 1.1 shows levels of about 50% of infants in Lusaka being LTFU. The causes of LTFU are unclear, and hence, this was the motivation for conducting this study. Table 1.1: Infants LTFU at 18 Months in Lusaka district DURATION INFANTS ENROLLED INFANTS RETURNED AT 18 MONTHS % INFANTS LTFU AT 18 MONTHS% 2016 9,681 40% (3,872) 60% (5,809) 2017 10,204 44% (4,490) 56% (5,714) 2018 9,088 39% (3,544) 61% (5,544) Source: Lusaka DHO, HMIS (2016-2018). 1.3 CONCEPTUAL FRAMEWORK This study was guided by Andersen’s Health Care Utilisation Model, which was developed by Ronald M. Andersen in 1968. The model aims at demonstrating factors that lead to utilisation of health services (Andersen, 1968). According to the model, usage of health services is determined by three factors: predisposing factors, enabling factors, and need factors (Andersen, 1968). Some of the probable factors could be accessibility to health facilities, shortage of staff, stigma and, discrimination. These factors can influence utilisation of follow up care services independently or as a group, hence, affecting the outcome of the dependent variable, which in this study is LFTU. To suit the focus of the study the model was modified to enable answer the research question and address the research objectives. 7 Figure 1.1: Modified Andersen’s Health Care Model 1.3.1 APPLICATION OF THE FRAMEWORK TO THE STUDY Predisposing factors include biological factors that may influence the likelihood of an individual needing a health service, social structure that may influence how an individual can cope with health problems and health beliefs that may influence an individual's perceptions of their need for health. In this study the factors comprised of knowledge levels and demographic characteristics because, these factors encouraged caretakers to adhere to the prescribed follow up visits. An individual who believes that follow up visits are beneficial will most likely utilise health services. Enabling factors are factors that make it possible for individuals to change their behaviour or their environment, and they include resources, conditions of living, societal supports and skills (Andersen, 1968). In this study they comprised of place of birth, distance to health facility and transport affordability. Need factors represent both perceived and actual needs for health care services, and in this study they comprised of ARV prophylaxis given at birth, health status of 8 infant/caretaker and staff attitudes. According to Andersen (1968) an individual will feel the need for health services based on their experiences and current health status. 1.4 JUSTIFICATION OF THE STUDY According to UNAIDS (2017) an estimated 180,000 children became newly infected with HIV and AIDS worldwide. Most of the cases live in sub-Saharan Africa (UNAIDS, 2017). Based on this information, many studies have been conducted in low to middle income countries, including Zambia. Despite the plethora of studies on HIV and AIDS, LTFU has remained a challenge in the implementation of programmes aimed at preventing vertical transmission. Most studies conducted on LTFU focused mainly on mother-infant pairs, such as; a cohort study by Obai et al. (2017) entitled rate and associated factors of non-retention of mother-baby pairs in HIV care in the elimination of mother-to-child transmission programme, Gulu-Uganda, and the other by Chipukuma et al. (2013) on factors contributing to low turn up of HIV exposed children for follow up care between 12 to 18 months in Chongwe, Livingstone and Ndola districts. Information obtained from only HIV positive mothers may miss out on other associated factors influencing LTFU, as other caretakers were not part of the study. In Zambia there is inadequate information and follow up studies to determine why infants in the country exposed to HIV still discontinue follow up care, hence this study was conducted. The results of this study have provided information on the factors in association with the LTFU and what factors influence LTFU. Consequently, the results can help in the implementation of strategies that will target the barriers to utilisation of eMTCT programmes, increase PMTCT service uptake and retention of HIV exposed infants in the PMTCT cascade. 1.5. RESEARCH QUESTION What are the determinants of LTFU HIV exposed infants in Lusaka district? 1.6. RESEARCH OBJECTIVES 1.6.1 General Objective The general objective of this study was to establish determinants of LTFU in infants born to HIV positive women in Lusaka District. 9 1.6.2 Specific Objectives The specific objectives were to: 1. Determine the knowledge levels of caretakers of LTFU HIV exposed infants about the eMTCT programmes. 2. State environmental factors associated with LTFU of HIV exposed infants. 3. Identify health system factors that influence LTFU of HIV exposed infants. 1.7 CONCEPTUAL DEFINITION OF TERMS eMTCT refers to interventions aimed at eliminating transmission of HIV from an HIV positive mother to her infant during pregnancy, labour, delivery, or breastfeeding (United States Agency for International Development [USAID], 2015). Knowledge refers to understanding of information about a subject which has been obtained by experience of study and which is either in a person’s mind or possessed by people generally (Burn and Groove, 2005) PMTCT refers to interventions to prevent transmission of HIV from an HIV-positive mother to her infant during pregnancy, labour, delivery, or breastfeeding (USAID, 2015). 1.8 OPERATIONAL DEFINITION OF TERMS LTFU refers to an infant that has failed to attend an HIV clinic 30 days after the date of their last appointment, and has not been documented as having been transferred to another clinic or died. Determinant is a circumstance or fact that actively influences caretakers of HIV exposed infants from taking them for follow up care. Follow up care refers to interventions put in place for HIV exposed infants to prevent vertical transmission, early detection of infection and commencement of ARVs upon identification at 6 weeks, 9 months and 18 months of age. Caretakers refers to either a male or female family member aged 18 years and above, looking after an HIV exposed infant. 10 1.9 VARIABLES 1.9.1 DEPENDENT VARIABLE The dependent variable of the study is Loss to Follow Up. 1.9.2 INDEPENDENT VARIABLES The independent variables are:  Caretakers’ knowledge  Place of delivery  Prophylaxis given  Distance to health facility  Transport affordability  Healthcare providers’ attitudes  Waiting time 11 1.9.3 VARIABLES, INDICATORS AND CUT-OFF POINTS Table 1.2: Variables, Indicators and Cut off Points VARIABLE INDICATOR CUT OFF POINT QUESTION NO. DEPENDENT VARIABLE Loss to follow up Yes Missed scheduled appointment for 30 days 22 No Up to date with scheduled appointment INDEPENDENT VARIABLES VARIABLE INDICATORS CUT OFF POINTS QUESTION NO. Knowledge High A score of 11-15 on knowledge questions 10-21 Moderate A score of 6-10 on knowledge questions Low A score below 0-5 on knowledge questions Place of delivery Yes If Place of delivery had influence on LTFU 29 No If Place of delivery had no influence on LTFU Prophylaxis given at birth Yes If prophylaxis given at birth had influence on LTFU 30 No If the prophylaxis given at birth did not have an influence on LTFU Distance to health facility Yes If distance to health facility had influence on LTFU 40-42 No If distance to health facility had no influence on LTFU Transport Yes If transport to health facility had an influence on LTFU 43-45 No If transport to health facility had no influence on LTFU Attitude of Health care Providers Negative If attitude of healthcare providers had an influence on LTFU 24-28 Positive If attitude of healthcare providers had no influence on LTFU Waiting time Yes If waiting time had an influence on LTFU 22 No If waiting time had an influence on LTFU 12 CHAPTER TWO: LITERATURE REVIEW 2.0 INTRODUCTION Chapter two provides information on the literature that was reviewed. The aim of the review was to establish what has been researched about the topic and to identify gaps in the existing literature. The literature review is presented according to the study variables which include; Overview of LTFU, Knowledge of caretakers and Health care providers about eMTCT, Distance to health facility, Place of Birth, Prophylaxis given, Attitude of health care providers, and Waiting time. The sources of this literature include electronic search from PubMed, Science Direct, Directory of Open Access Journals (DOAJs), WHO, UNAIDS, Google, and Google Scholar websites. 2.1 OVERVIEW OF LTFU PMTCT has undergone considerable evolution based on scientific evidence, resulting in vertical transmission rates of 1% or less in the developed countries; which demonstrates that eMTCT is possible (Phanuphak, 2016). Success in eMTCT can be achieved through effective strategies such as identifying women with HIV and initiating them on ARVs, providing ARV prophylaxis for the exposed infant and continuous post-test counselling (WHO, 2018). As a result, the 2013 WHO treatment guidelines recommend that infants exposed to HIV should be tested at the first postnatal visit, and that infants who test positive for HIV should start treatment immediately (WHO, 2013). However, even where treatment is available and accessed, retention in care is a problem in many countries (Ahoua et al., 2020). Chances of children becoming LTFU is higher than any age stage (Kranzer et al., 2017), this is because decisions to gain access to healthcare services is made by their caretakers. EID coverage globally still remains low; with only 43% of infants exposed to HIV in 2016 receiving an HIV test within the first recommended two months of life (UNAIDS, 2017). LTFU care has a negative influence on the effectiveness of strategies put in place as seen by continued occurrence of new HIV infections in children globally, and a challenge in timely diagnosis and treatment of infants and children living with HIV (WHO, 2018). A Cohort study by Kyaw et al. https://www.ncbi.nlm.nih.gov/pubmed/?term=Phanuphak%20P%5BAuthor%5D&cauthor=true&cauthor_uid=27482444 13 (2017) on Low mother-to-child HIV transmission rate but high loss-to-follow-up among mothers and babies in Mandalay revealed that there is an unacceptable high rate of LTFU mothers and HIV exposed infants at several points in the PMTCT care cascade. The proportion of mothers who were LTFU after delivery was found to be five times higher than LTFU before delivery. HIV positive pregnant women in sub-Saharan Africa are lost between ANC registration and delivery, whereas about 24% of infants are LTFU by three months. More infants are lost after HIV testing (Ankunda et al., 2020). The results are concurrent with those of Kalembo and Zgambo (2012), with rates of LTFU mother-child pairs ranging from 19% to 89.4%. These percentages show that there is a great loss of mother-child pairs to follow-up in PMTCT in sub- Saharan Africa. 2.2 KNOWLEDGE OF CARETAKERS AND HEALTH CARE PROVIDERS ABOUT eMTCT Lack of awareness and knowledge about HIV/AIDS, MTCT and PMTCT follow-up services have a negative impact on postnatal follow-up services. A number of studies have identified a connection between these factors with uptake of PMTCT services. Haile et al., (2016) concluded that adequate knowledge levels are associated with various factors such as experiencing at least one pregnancy, higher education levels, higher household wealth, living in an urban area, being exposed to HIV education, having taken an HIV test or knowing where to get tested for HIV. This information was from a study involving more than 10,000 women of which women living with HIV were more likely to have adequate knowledge of MTCT (56%) than women who were HIV negative (46%). Coulibaly et al. (2016) investigated Prevention and care of paediatric HIV infection in Ouagadougou, Burkina Faso: knowledge, attitudes and practices of the caregivers. The results of the study revealed that, Overall, 97 % of caregivers knew that the main transmission route for HIV-infected infants was through their mothers. Fourteen (38 %) specified that mother-to-child transmission occurred during pregnancy or delivery. 87 % of the caregivers responded that testing mothers and providing ARVs to the HIV-infected ones can help prevent children’s HIV infection. despite an overall knowledge of MTCT modes, a few misconceptions still existed 14 (Coulibaly et al., 2011). Knowledge levels therefore resulted in a 92% HIV testing uptake among participants (Tatagan et al., 2011). However, other studies have associated high levels of HIV, MTCT and PMTCT knowledge with lower acceptability and utilisation of PMTCT services. According to CSO (2015) majority of respondents had high levels of knowledge about eMTCT. Results from the survey further revealed that around 89% of women and 82% of men knew that HIV can be transmitted through breastfeeding (CSO, 2015). Around 82% of women and 66% of men were aware that the risk of MTCT can be reduced during pregnancy by taking ART (CSO, 2015). Contrary to the results of the survey, a study done by Ramoshaba and Sithole (2017) discovered that majority of the participants lacked knowledge on how a mother can transmit HIV to her child after birth. Participants failed to mention breastfeeding as a mode of transmission (Ramoshaba and Sithole, 2017). Mothers who lack knowledge about MTCT may ignore follow- up care, and miss out on HIV treatment for both their health and that of their babies. It is important therefore to increase knowledge levels about HIV, MTCT and importance of ART, which is critical in reducing MTCT of HIV (CSO, 2015). Kiyaga et al. (2018) who investigated the Retention outcomes and drivers of loss among HIV- exposed infected infants in Uganda concluded that frequent late entry and high drop out among infants enrolling for care and EID were due to lack of knowledge and understanding of EID by service providers and consequently, caregivers. Other studies are in agreement that mother infant pairs who have good knowledge about HIV and ARVs being able to reduce MTCT are more likely to have successful follow up outcomes (Bwana et al., 2018). However Kigen et al. (2018) concluded that parents’ lack of knowledge that HIV exposed infants should receive follow-up care for 18 months despite initial HIV-negative PCR results could influence a caregiver's decisions on continuing appointments for HIV exposed infants who appear healthy. Another study by Kweyamba et al. (2018) concluded that mothers’ knowledge about the possibility of infecting their babies is a predictor for LTFU. This indicates that mothers are knowledgeable about the transmission of HIV to their babies. But, upon defaulting from the PMTCT care, mothers may perceive that their breastfed child is HIV positive and hence, fear returning to the clinic to avoid being blamed by the health workers if the child turns out to be 15 HIV positive on testing (Kweyamba et al., 2018). It is therefore important to improve health provider attitudes and provide training to help change the way patients perceive care and their choice on whether to continue receiving care or not. 2.3 DISTANCE TO HEALTH FACILITY AND TRANSPORT AFFORDABILITY Geographical distance to health facilities influences utilisation of health services greatly, despite ART services being free. Travel distance and additional costs incurred on travelling to ART centres contribute to non-retention in the care of patients on ART programme (Mukumbang, 2017). A number of authors have documented the association between distance and health care utilisation; indicating patients who live closer to healthcare facilities having higher rates of utilisation of services than those who live far away. Escamilla et al. (2015) in a study to determine association between distance from household to a clinic and its association with the uptake of PMTCT regimens in rural Zambia concluded that uptake of any PMTCT regimen and ART for PMTCT decreased as the per kilometre (km) distance to the clinic increased. Results of the study revealed that distance between a woman’s home and clinic affects the uptake of ART during pregnancy and breastfeeding. Adelekan et al. (2019) concluded that the high cost of transport is a major barrier in preventing access to HIV treatment. Inability to afford transport costs related to the long distances to hospitals has been cited as strongly associated with mother infant pairs being LTFU (Mpinganjira ·et al. 2020). Results from a study done by Akullian et al., (2016) also concluded that patients on ART encountered financial difficulties in attending follow-up visits. 2.4 PLACE OF DELIVERY HIV positive women’s choice of delivery location is influenced by various factors which include; cultural influences, poor socio-economic status, and fear of the stigma associated with an HIV positive status (Kifle et al. 2018). It is the care that women receive during labour and delivery that can facilitate successful PMTCT programmes. A study by Kebede et al. (2014) on delay in EID and high LTFU among infants born to HIV infected women in Ethiopia found that the dynamics between place of delivery and PMTCT interventions were major challenges to EID. Mothers who delivered at government health institutions had the highest rate of early HIV 16 DNA-PCR testing compared to deliveries which took place in homes. Most mothers who gave birth in homes did not receive ARV prophylaxis during labour and the infants were not given ARV prophylaxis immediately on delivery (Kebede et al., 2014). In addition, mothers who delivered at private health facilities were less likely to bring their infants for EID. Elang (2015) is in agreement with the results in a study on factors associated with LTFU of infant-caretaker pairs enrolled in the early EID clinic. The study concluded that mothers that delivered from the hospital were less likely to become LTFU (Elang, 2015). This is an indicator that accessing delivery services and care can facilitate successful PMTCT programme and retention in care. This may probably be due to timely counselling offered to the mother/caretaker on how to keep their HIV exposed infants negative and also ARVs given during postnatal periods which motivate caretakers to return for follow up care. 2.5 PROPHYLAXIS GIVEN Initiation of ART to HIV positive pregnant women is important not only for maternal health and in reducing MTCT; but also improves follow-up of HIV exposed infants (Muyunda et al., 2019). A study by Feinstein et al. (2015) revealed that having a mother on ART was associated with a significant reduction in LTFU compared to not having a mother on ART; and thus efforts to ensure linkage of testing with treatment in the Option B+ programme are likely to reduce LTFU amongst HIV exposed infants. The findings of the study are in line with Lain et al. (2020), who concluded that mothers who take ARVS during labour and delivery with their infants given cotrimoxazole prophylaxis is a strong protective effect in preventing the infant from being LTFU, as mothers are more likely to remain in contact with the health facility. However, the results are different from those of Tukei et al. (2020) in a cohort study on 24-Month HIV-free survival among HIV-exposed Infants in Lesotho: the PEAWIL. Results from the study indicated that there was a high proportion of ARV prophylaxis uptake among HIV exposed infants, yet a great number of infants were found to be LTFU (Tukei et al., 2020). It is likely that perceptions of mothers regarding the advantages of continuing follow-up care after 6 weeks decrease when pharmacological intervention is terminated. 17 2.6 ATTITUDE OF HEALTHCARE PROVIDERS The attitudes of health care providers can affect utilisation of health services positively or negatively. This is because it influences satisfaction of health services by patients and their families. Interactions between health care providers and their patients therefore, play an important role in improving the uptake of health services (Yelin, 2015). Effective interaction between care provider and patients brings about satisfaction with health services, acquisition of knowledge and adherence to care (Molina-Mula & Gallo-Estrada, 2020). Provider-patient interaction that consists of negative provider attitude is among the cited barriers to retention of patients on ART in sub-Saharan Africa (Layer et al., 2014). Stigma and discrimination in the community, self-stigma and stigma by care providers also contribute to discontinuation of treatment by patients (Helms et al., 2018). After an HIV positive pregnant woman gives birth, fears of stigma and discrimination again become a barrier to adherence to follow up care for the infant or the mother due to the need to hide visits and medications from others (Suryavanshi, et al. 2018). 2.7 WAITING TIME Waiting time is very important in health care because it has an impact on patient satisfaction. Long waiting time has been considered frustrating to patients and thus appears to be a potential cause of patient dissatisfaction (Sun et al, 2017). It is therefore important that patients are seen within a reasonable time frame, for a better experience. Kweyamba et al. (2018) indicated that waiting at the health facility for more than an hour before being attended to by a health worker was a predictor of LTFU. Long waiting time could be as a result of low staffing levels compared to the volumes of patients. In another study by Ankunda et al. (2020) a health worker pointed out that waiting time was a hindrance to child follow up. This is because of long queue at the clinic especially for working class mothers. Time spent waiting for a health worker can act as a barrier to utilisation of health services, and it can determine the quality of services rendered to clients. 18 CONCLUSION The reviewed literature indicated that globally, many studies have been conducted on factors influencing the uptake of PMTCT services by pregnant women. However, information on understanding infant retention to HIV care during the postpartum period and determinants of LTFU is limited. Therefore, it was essential to conduct this study. 19 CHAPTER THREE: RESEARCH METHODOLOGY 3.0 INTRODUCTION This chapter presents how the study was conducted. This is done by providing the study design, setting, the population and how they were sampled, how data were collected, stored and managed, how validity and reliability were assured, and the ethical considerations. 3.1 STUDY DESIGN A descriptive cross sectional quantitative study design was used. This design was chosen because the required data could be obtained at one specific point in time. The quantitative component enabled comparison and analysis of many different variables. 3.2 STUDY SETTING The study was conducted in Lusaka district of Zambia, at three urban health centres namely; Kalingalinga, Mtendere and Kabwata. The facilities were randomly selected among other urban health centres in the district that offer both preventive and curative services with Maternal, Neonatal and Child Health (MNCH) services. 3.3 STUDY POPULATION The study population comprised of caretakers whose children had been registered for eMTCT services as well as nurses, midwives and HIV counsellors offering eMTCT services. The target population comprised of caretakers whose children were registered for eMTCT services at the three study setting, as well as the nurses, midwives and HIV counsellors offering eMTCT services there. 3.4 ELIGIBILITY CRITERIA 3.4.1 Inclusion Criteria In this study the inclusion criteria were: 20  Parents and Caretakers aged 18 years and above. This is because participation was by consent. In line with the Helsinki Declaration Code of Ethics, participant aged below 18 require parents or guardians assent to participate in any study.  Nurses, midwives and HIV Counsellors who had work experience of at least 6 months in eMTCT. 3.4.2 Exclusion Criteria The exclusion criteria were:  Caretakers whose HIV exposed infants were unwell.  Nurses, midwives and HIV counsellors who were currently not working in eMTCT.  Nurses, midwives and HIV counsellors who were on leave during the time of data collection.  Caretakers, nurses, midwives and HIV counsellors who did not consent to participate in the study. 3.5 SAMPLING TECHNIQUE Purposive sampling was used to select the caretakers. This was to allow diversity among respondents, such as; marital status, clients who are LTFU, gender, age, education level and work experience. Due to limited numbers, convenience sampling was used to select nurses, midwives and HIV counsellors. 3.6 SAMPLE SIZE 3.6.1 Sample size for caretakers The sample size for caretakers was calculated using Krejcie and Morgan (1970) formula for calculating sample size of a finite population. n =Z2 NP (1-P) d2 (N-1) + Z2P (1-P). Where: n = Required Sample size P = the proportion/prevalence (0.5) 21 Z = 1.96 standard normal variate at 95% confidence level d = ±5% = ± 0.05 is the degree of accuracy (5%), expressed as a proportion (0.05); It is margin of error N = Accessible study population Size (250) n = 1.962 x 250 x 0.5 (1- 0.5) 0.052 (250 -1) + 1.962 x 0.5 (1 – 0.5) n = 3.84 x 250 x 0.5 (0.5) 0.0025 x 249 + 3.84 x 0.5 x 0.5 n =160 caretakers 3.6.2 Sample size for nurses, midwives and Psychosocial Counsellors 23 health care providers took part in the study of which; 6 were registered midwives, 6 Psychosocial Counsellors, 1 Enrolled midwife, 9 Registered nurses and 1 Social worker. 3.7 DATA COLLECTION Data was collected by the researcher on 2nd September to 1st October 2020. 3.7.1 Data collection tool A semi-structured questionnaire (Appendix 3) was used to collect data from caretakers (Also translated in Nyanja (Appendix.7). The tool was adapted from Kabir (2016). A semi-structured questionnaire was used because its advantage of being able to collect information from a big sample in a short period of time (Goyal, 2013). The questionnaire had both open and close-ended questions. Open ended questions allowed respondents to provide more information regarding their understanding and opinions about the problem. A self-administered semi-structured questionnaire (Appendix 4) was used to collect data from the health care workers because all of them were literate. 22 3.7.2 Data collection technique After ethics approval and permission to carry out the study was granted by the relevant authorities, the researcher with assistance from the clerk checked registers so that residential addresses and mobile numbers for caretakers who are LTFU could be traced and data collection arrangements made. The researcher also provided information about the study to caretakers who had brought infants born from HIV+ patients for their various reviews. Each participant who was willing to participate was given a consent form (Appendix 2) to sign and more detailed information about the study provided through a Participant Information Sheet (Appendix 1). On the day of data collection, each respondent was greeted. Respondents chose the place where the preferred data to be collected from. Whichever place was chosen, the researcher ensured that privacy was maintained at all times. Since the questionnaire was written in English, those that could read and write, were given to fill in, while respondents who could not had questions read and translated in their preferred language, and responses were written for them by the researcher. After data was collected, each respondent was given a drink, thanked and transport refund of K30.00 was provided. 3.8 DATA MANAGEMENT AND STORAGE Unauthorised access to filled-in questionnaires was controlled by storing them in a lockable cupboard whose key was kept by the researcher. To maintain security, soft data was entered on a Password protected computer. To prevent loss of data, three copies were stored and an up-to- date anti-virus on the computer was maintained. 3.9 VALIDITY Data was collected using a validated questionnaire adapted from Kabir (2016). Questions were expressed in simple term, they were brief and precise. The questionnaire was examined by research supervisors for content and item validation, and a pilot study was conducted before embarking on the main study. During data collection at the end of each day, the answered questionnaires were checked for completeness to ensure that the information was properly collected. External validity was ensured by maintaining the required number of participants. 23 3.10 RELIABILITY Reliability was ensured by the use of a pretested semi-structured questionnaire. The questionnaire had both open and closed ended questions. The use of open ended questions provided clarity to close ended questions, and each respondent was given enough time to complete the questionnaire; nobody was rushed through. 3.11 ETHICAL CONSIDERATION Ethics approval (Appendix 10) was obtained from the University of Zambia Biomedical Research Ethics Committee (UNZABREC) and National Health Research Authority (Appendix 11). Permission to carry out the study was obtained from the Lusaka District Health Medical Directorate (LDHMD) (Appendix 12), as well as the in-charges of the health facilities where the study was conducted. Written consent was obtained by either a signature or thumb print from all participants after fully informing them about the study and that they were free to withdraw their participation at any point without facing any negative repurcations. No respondent withdrew. A Participant Information Sheet was utilised to provide detailed information about the study to each respondent. Due to the sensitive nature of the study, confidentiality and anonymity was assured and maintained. No names were used; instead codes were assigned for identification. Records were reviewed only by the researcher and/or Supervisor. 24 CHAPTER FOUR: DATA ANALYSIS AND PRESENTATION OF FINDINGS 4.0 INTRODUCTION This chapter provides information on how data was processed and analysed, and then analysed data from the study through frequency tables, bar graphs and cross tabulations were presented. 4.1 DATA PROCESSING AND ANALYSIS The collected data was screened for completeness, followed by categorisation of open ended questions, and numerical codes were assigned to each category. Closed ended questions were also assigned numerical codes. Data were then entered in the computer and double-checked before analysis using SPSS version 22.0. Frequencies were obtained, cross tabulations and lastly logistic regression was used to test associations between dependent variable and the independent variables. The cut off point for statistical significance was set at 5%, p-values of 0.05 or less were considered statistically significant. 4.2 DATA PRESENTATION The findings have been presented in form of frequency tables, bar graphs and cross tabulations in four sections which are: socio-demographic characteristics of the respondents, caretakers’ knowledge about eMTCT, environmental and service-related factors. 4.2.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF CARETAKERS This section presents the socio-demographic characteristics of caretakers, which included age of HIV exposed infants, gender and age of caretaker, relationship between caretaker and infant, marital status, level of education, occupation and religion. It also comprises of gender of health care providers, work experience and trainings done. Table 4.1: Socio-demographic characteristics of caretakers (n=160) Demographic characteristics Frequency Percentage (%) Gender of caretaker Male 17 11.0 Female 143 89.0 Total 160 100 Age of caretaker 18-29 Years 30 18.8 30-39 Years 82 51.3 25 Table 4.1 shows that 89.0 % (143) of the caretakers were female. Half 51.3% (82) were aged between 30 to 49 years, 62.5% (100) were married, and 68.8% (110) were biological mothers to the infants. 40-49 Years 33 20.6 50-59 Years 15 9.3 Total 160 100 Relationship between caretaker and infant Mother 110 68.8 Father 19 11.9 Grandmother 27 16.8 Aunt 4 2.5 Total 160 100 Marital status Single 34 21.3 Married 100 62.5 Widowed 7 4.3 Divorced/Separated 19 11.9 Total 160 100 Level of Education No formal education 3 1.9 Primary 52 32.5 Secondary 85 53.1 Tertiary 20 12.5 Total 160 100 Occupation of Caretakers Employed 11 6.9 Housewife 28 17.5 Self employed 101 63.1 Unemployed 20 12.5 Total 160 100 Religion for Caretakers Christian 160 100.0 26 Table 4.2: Socio-demographic characteristics of health care providers (n=25) Socio demographic characteristics Frequency Percentage Gender Female 22 88.0 Male 3 12.0 Total 25 100 Professional qualification Enrolled Midwife 1 4.0 Psychosocial counsellor 6 24.0 Registered midwife 6 24.0 Registered nurse 9 36 Social Worker 1 4.0 Total 25 100 Work experience 6-11 months 9 37.5 1-5 years 10 41.7 6-10 years 2 8.3 11-15 years 2 8.3 Total 25 100 Trainings VCT 25 100 PMTCT 24 96 Breastfeeding 23 52 Young infant feeding 6 24 Comprehensive ART 4 16 DBS Collection 2 8.0 Couple counselling in HIV and TB 1 4.0 Table 4.2 shows that 88.0% (20) of the health care providers were female and 12% (3) were registered nurses (RNs). All the health workers 100% (25) had been trained in VCT at least once and less than half 41.7% (10) had work experience of 1 to 5 years. 27 4.2.2 CARETAKERS’ KNOWLEDGE ABOUT eMTCT Table 4.3: Caretakers’ knowledge about eMTCT (n=160) Knowledge about eMTCT Frequency Percentage Are you aware of the existence of MTCT of HIV Yes 160 100 No 0 0 Total 160 100 Are you aware of PMTCT HIV Yes 160 100 No 0 0 Total 160 100 Source of information Health workers 110 68.8 Mass media 26 16.2 Friends and relatives 24 15 Total 160 100 How to prevent MTCT after birth Modified infant feeding 11 6.9 Stop breastfeeding before teething 13 8.1 ARV drugs given to mother and baby 136 85 Total 160 100 Which services provided during follow up care Counselling 21 13 Vaccination 2 1.3 HIV Testing 129 80.6 Collection of ARVs 4 2.5 Growth monitoring 4 2.5 Total 160 100 How MTCT can be prevented after birth Modified infant feeding 11 6.9 Stop breastfeeding before teething 13 8.1 ARV drugs given to mother and baby 136 85 Total 160 100 When follow up care begins At 6 weeks 142 88.7 do not know 18 11.3 Total 160 100 When follow up care stops When first HIV test is negative 11 6.9 When infant stops breastfeeding at 2 years old 109 68.1 28 Do not know 40 25.0 Total 160 100 Table 4.3 shows that all 100% (160) caretakers were aware about the existence of MTCT and PMTCT of HIV. Half of them, 68.8% (110) obtained information about MTCT and eMTCT from health care providers; more than half caretakers 85% (136) mentioned ARV drugs to mother and baby as a way of preventing MTCT of HIV after birth; more than three quarters of the caretakers 88.7% (142) mentioned 6 weeks as a time when follow up care begins; and more than three quarters 109 (68.1) said that follow up care stops when an infant stop breastfeeding at 2 years old. Overall knowledge levels of caretakers The study findings revealed that more than half, 67.5% (108) of the caretakers had high knowledge levels, and 32.5% (52) displayed moderate knowledge, with none exhibiting low knowledge. Overall knowledge levels of health care providers about eMTCT More than half 69.6% (16) health care providers had high knowledge levels on eMTCT, while less than half 30.4% (7) had moderate knowledge levels. 4.2.3 SECTION C: ENVIRONMENTAL AND SERVICE-RELATED FACTORS This section comprises of caretaker’s data on environmental and service related factors. Caretakers were asked questions on place of birth, prophylaxis at birth, distance to the health facility, transport affordability, and reasons for discontinuing follow up. Health care providers were also asked questions on availability of logistics and factors likely to influence LTFU HIV exposed infants. 29 Table 4.4: Environmental related factors (n=160) Independent variables Frequency Percentage Place of birth Yes 149 93.1 No 11 6.9 Total 160 100 Prophylaxis at Birth Yes 160 100 No 0 0 Total 160 100 Distance to health facility Yes 135 84.4 No 25 15.6 Total 160 100 Transport affordability Yes 134 83.7 No 26 16.3 Total 160 100 Table 4.4 shows that, 6.9% (11) were home births, all 100% (160) HIV exposed infants received prophylaxis from birth up to 6 weeks, more than half caretakers 135 (84.4%) of the caretakers lived within 5kms to the health facility, and 16.3% (26) could not afford transport cost to health facility. 4.2.4: SERVICE-RELATED FACTORS FROM CARETAKERS’ PERSPECTIVE Table 4.5: Service-related factors Factor Frequency Percentage Attitude of health providers Reception by health providers Very good 114 71.3 Good 33 20.6 Poor 13 8.1 Total 160 100 Supportive health providers Yes 147 91.9 No 13 8.1 Total 160 100 Enough time spent with health workers Sometimes 46 28.7 30 Always 114 71.3 Total 160 100 Health providers explain in a way that is easy to understand Sometimes 24 15 Always 136 35.1 Total 160 100 Health providers show respect No 24 15 Yes 136 85 Total 160 100 Waiting time 5-10 minutes 48 30 11-20 minute 11 6.8 21-30 minutes 44 27.5 More than 30 minutes 57 35.6 Total 160 100 Table 4.5 shows that, more than half caretakers 71.3% (114) said health care providers Reception give a very good reception, half 71.3 % (114) of the caretakers mentioned that Sometimes health care providers spent enough time with them, more than Half 85% (136) caretakers said health care providers always explain in a way that is easy to understand, more than three quarters 85% (136) said that health care providers showed them no respect whenever they went for follow up care, and 32.0% (47) caretakers stated that they waited for more than 30 minutes before being attended to. Overall Attitude of health care providers from caretakers’ perspective Half 52.5% (84) caretakers said that health care providers had negative attitude, while 47.5% (76) caretakers said health care providers had positive attitude. 31 Waiting time from caretakers’ perspective The study revealed that some caretakers 36.9% (59) said waiting time did not influence decision to stop follow up care while 101% (63.1) said waiting time influenced decision to discontinue follow-up care. Table 4.6: Waiting time from health care providers’ perspective (n=25) Waiting time Frequency Percentage 1 hour 30 minutes to 2 hours 9 36.0 30 minutes to 1 hour 7 28.0 Less than 30 minutes 7 28.0 Total 23 100 Table 4.6 shows that 36.0% (9) of the health care providers said caretakers wait for 1 hour 30 minutes to 2 hours at the health facility before being attended to. Table 4.7: Reasons caretakers gave for discontinuing follow up care (n=131) Reasons Frequency Percentage Busy with work 6 4.5 Caretaker unwell 6 4.5 Forgot 37 28.0 Not aware 56 42.4 Out of town 26 19.7 Total 131 100 Table 4.7 shows that most 42.4% (56) of caretakers were not aware they needed to continue with follow up care, while 28.0% (37) forgot to take the infant for follow up care. General Availability of logistics for eMTCT Health workers were asked about availability of logistics. More than half of health care providers 72.0% (18) said that logistics for eMTCT were adequately available, while 28.0 % (7) said that they were not adequately available. Some 39.1% (9) of health care providers said that all specific logistics were available, 21.7% (5) said test kits and medicine were out of stock sometimes, 30.4% (7) mentioned that airtime to call clients was not available, and while 8.7% (2) mentioned that there was no transport to use in the follow up of clients. 8% (2) Mentioned non-disclosure of results, 8% (2) mentioned long distance 32 to the health facility while 8% (2) of health workers mentioned two negative PCR results influence of LTFU. 4.3 ASSOCIATIONS BETWEEN VARIABLES LTFU was correlated with each independent variable, to establish statistical significance Table 4.8: Association between respondents’ demographical characteristics and LTFU (n=160) Independent variable LTFU Total P-value <0.05 Yes No Gender of caretaker 0.038 Female 80 17 97 Male 51 12 63 Total 131 29 160 Age of caretaker 0.477 18-29 Years 23 7 30 30-39 Years 66 16 82 40-49 Years 28 5 33 50-59 Years 14 1 15 Total 131 29 160 Relationship between caretaker and infant 0.052 Mother 89 24 110 Father 16 3 19 Grandmother 24 3 27 Aunt 2 2 4 Total 131 29 160 Marital status 0.036 Single 26 8 34 Married 81 19 100 Widowed 7 0 7 Divorced/Separated 17 2 19 Total 131 29 160 Level of Education 0.184 No formal education 3 0 3 Primary 45 7 52 33 Secondary 67 18 85 Tertiary 16 4 20 Total 131 29 160 Occupation of Caretakers 0.130 Employed 9 2 11 Housewife 22 6 28 Self employed 24 17 101 Unemployed 16 4 20 Total 131 29 160 Table 4.8 shows that the association between gender (p-value 0.038) and marital status of caretaker (p-value 0.036) and LTFU were statistically significant. The association between age of caretaker (p-value 0.477), relationship between caretaker and infant (p-value 0.052), level of education (p-value 0.184), occupation (p-value 0.130) and LTFU were not statistical significant. Table 4.9: Association between knowledge of caretakers and LTFU (n=160) Independent variable LTFU Total P-value <0.05 Yes No Knowledge Levels 0.160 High 89 19 108 Moderate 42 10 52 Low 0 0 0 Total 131 29 160 Table 4.9 shows that the association between knowledge and LTFU was not statistically significant (p-value 0.160) 34 Table 4.10: Association between environmental factors and LTFU (n=160) Independent variable LTFU Total P-value <0.05 Yes No Place of Birth 0.001 Yes 120 11 131 No 29 0 29 Total 131 29 160 Prophylaxis given at birth 0.102 Yes 131 29 160 No 0 0 0 Total 131 29 160 Distance to health facility 0.001 Yes 106 29 135 No 25 0 25 Total 131 29 160 Transport Affordability 0.000 Yes 105 29 134 No 26 0 26 Total 131 29 160 Table 4.10 shows that the association between LTFU and place of birth (p-value 0.001), distance to health facility (p-value 0.001) and transport affordability (p-value 0.000) was statistically significant, whereas as that between LTFU and prophylaxis given at birth was not (p-value 0.102). Table 4.11: Association between service related factors and LTFU (n=160) Independent variable LTFU Total P-value <0.05 Yes No Staff attitude 0.016 Negative 68 16 84 Positive 63 13 76 Total 131 29 160 Waiting time 0.008 No 86 15 101 Yes 45 14 59 Total 131 29 160 35 Table 4.11 shows that the association between LTFU and staff attitude (p-value 0.016) and waiting time (p-value 0.008) were statistically significant. 4.14 BINARY LOGISTIC REGRESSION OF FACTORS ASSOSSCITED WITH LTFU Binary logistic regression analysis was used to determine the true predictors of LTFU as well as to control for confounding factors. All the variables that were statistically significant were analysed. Table 4.12: Binary Logistic Regression Analysis Independent variable Odds Ratio P-value Cl-95% Gender of caretaker Male 3.794 0.999 0.0432,2.2246 Female 0.440 0.040 0.287,0.966 Age of caretaker 18-29 Years 2.157 0.718 0.33,139.645 30-39 Years 0.944 0.976 0.22,39.739 40-49 Years 2.063 0.630 0.108,39.423 50-59 Years 0.6