title: Identifying factors associated with the uptake of prevention of mother to child HIV transmission programme in Tigray region, Ethiopia: a multilevel modeling approach.
abstract: BACKGROUND
  Prevention of mother to child HIV transmission (PMTCT) remains a challenge in low and middle-income countries. Determinants of utilization occur--and often interact--at both individual and community levels, but most studies do not address how determinants interact across levels. Multilevel models allow for the importance of both groups and individuals in understanding health outcomes and provide one way to link the traditionally distinct ecological- and individual-level studies. This study examined individual and community level determinants of mother and child receiving PMTCT services in Tigray region, Ethiopia.
  
  
  METHODS
  A multistage probability sampling method was used for this 2011 cross-sectional study of 220 HIV positive post-partum women attending child immunization services at 50 health facilities in 46 districts. In view of the nested nature of the data, we used multilevel modeling methods and assessed macro level random effects.
  
  
  RESULTS
  Seventy nine percent of mothers and 55.7% of their children had received PMTCT services. Multivariate multilevel modeling found that mothers who delivered at a health facility were 18 times (AOR = 18.21; 95% CI 4.37,75.91) and children born at a health facility were 5 times (AOR = 4.77; 95% CI 1.21,18.83) more likely to receive PMTCT services, compared to mothers delivering at home. For every addition of one nurse per 1500 people, the likelihood of getting PMTCT services for a mother increases by 7.22 fold (AOR = 7.22; 95% CI 1.02,51.26), when other individual and community level factors were controlled simultaneously. In addition, district-level variation was low for mothers receiving PMTCT services (0.6% between districts) but higher for children (27.2% variation between districts).
  
  
  CONCLUSIONS
  This study, using a multilevel modeling approach, was able to identify factors operating at both individual and community levels that affect mothers and children getting PMTCT services. This may allow differentiating and accentuating approaches for different settings in Ethiopia. Increasing health facility delivery and HCT coverage could increase mother-child pairs who are getting PMTCT. Reducing the distance to health facility and increasing the number of nurses and laboratory technicians are also important variables to be considered by the government.
authors.affiliation: School of Public Health, University of the Western Cape, Cape town, South Africa. darfiroerjabo@yahoo.com.
authors.forename: Wondwossen
authors.initials: W
authors.lastname: Lerebo
authors.forename: Steven
authors.initials: S
authors.lastname: Callens
authors.forename: Debra
authors.initials: D
authors.lastname: Jackson
authors.forename: Christina
authors.initials: C
authors.lastname: Zarowsky
authors.forename: Marleen
authors.initials: M
authors.lastname: Temmerman
mesh_terms: D000328:Adult; D003153:Community Health Services; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D005002:Ethiopia; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006297:Health Services Accessibility; D006801:Humans; D017589:Immunization Programs; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008427:Maternal Health Services; D015233:Models, Statistical; D011247:Pregnancy; D055815:Young Adult
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