title: "You Know You Are Sick, Why Do You Carry A Pregnancy Again?" Applying the Socio-Ecological Model to Understand Barriers to PMTCT Service Utilization in Western Kenya.
abstract: OBJECTIVE
  Throughout most of sub-Saharan Africa (SSA), prevention of mother-to-child transmission (PMTCT) services are readily available. However, PMTCT programs in SSA have had suboptimal performance compared to other regions of the world. The main objective of this study is to explore the socio-ecological and individual factors influencing the utilization of PMTCT services among HIV-positive pregnant women in western Kenya using a social ecological model as our analytical lens.
  
  
  METHODS
  Data were collected using in-depth interviews with 33 HIV-infected women attending government health facilities in rural western Kenya. Women with HIV-infected infants aged between 6 weeks to 6 months with a definitive diagnosis of HIV in the infant, as well as those with an HIV-negative test result in the infant were interviewed between November 2012 and June 2013. Coding and analysis of the transcripts followed grounded theory tenets. Coding reports were discussed in a series of meetings held among the authors. We then employed constant comparative analysis to discover dominant individual, family, society and structural determinants of PMTCT use.
  
  
  RESULTS
  Barriers to women's utilization of PMTCT services fell within the broad constructs of the socio-ecological model of individual, family, society and structural determinants. Several themes cut across the different steps of PMTCT cascade and relate to different constructs of the socio-ecological model. These themes include: self-motivation, confidence and resilience, family support, absence or reduced stigma, right provider attitude and quality of health services provided. We also found out that these factors ensured enhanced maternal health and HIV negative children.
  
  
  CONCLUSIONS
  The findings of this study suggest that a woman's social environment is an important determinant of MTCT. PMTCT Interventions must comprehensively address multiple factors across the different ecological levels. More research is however required for the development of multi-component interventions that combine strategies at different ecological levels.
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya.
authors.forename: Maricianah
authors.initials: M
authors.lastname: Onono
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya.
authors.forename: Zachary
authors.initials: Z
authors.lastname: Kwena
authors.affiliation: Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, USA.
authors.forename: Janet
authors.initials: J
authors.lastname: Turan
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.affiliation: Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
authors.affiliation: Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, South Africa.
authors.forename: Glenda E
authors.initials: GE
authors.lastname: Gray
keywords: HIV/AIDS; PMTCT cascade; Pregnant women; Social-ecological model; Sub-Saharan Africa