Level of Quality of Option B+PMTCT Service Provision in Public Health Facilities in Mekelle Zone, Northern Ethiopia: Cross-sectional study

Level of Quality of Option B+PMTCT Service Provision in Public Health Facilities in Mekelle Zone, Northern Ethiopia: Cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Level of Quality of Option B+PMTCT Service Provision in Public Health Facilities in Mekelle Zone, Northern Ethiopia: Cross-sectional study Kiros Fenta Ajemu, Alem Desta This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.16861/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Jun, 2020 Read the published version in BMC Health Services Research → Version 3 posted 8 You are reading this latest preprint version Show more versions Abstract Background: Substantial improvements have been observed in the coverage and access to maternal health services in Ethiopia. However, quality of care has been lagging behind. Therefore, the aim of this study was to assess quality of Option B+ PMTCT service provision. Methods: Facility based cross sectional study was conducted from February to April 2016 in Northern Ethiopia. The quality of service delivery was assessed in 12 health facilities based on Donabedian input-process-output quality components. It employed mixed method approach involving both quantitative and qualitative data. Facilities were categorized rendering good input service quality if scored 100 % as per national guideline; whilst, 90 % and more for process and output quality components respectively. The emerged themes of factors for good and bad service quality from content analysis were then thematically fitted to donabedian themes. Results: Overall 2 of 12 (16.7%) facilities fulfilled all the three quality components according to predetermined judgment criteria. The input quality was better than their counterpart; in which it was judged as good in 33.3% of facilities. Besides, one fourth of them were realized process and output quality. We identified multiple barriers and facilitators for good and bad service quality in respective quality components influencing quality of care. Conclusion: Only 16.7% of facilities declared the overall quality in all three dimensions according to service delivery guideline. The desired level of quality will be realized if and only if the three quality components would be kept on eye side by side in line with identified facilitators and barriers for good and bad service quality. Health Economics & Outcomes Research Quality Option B+PMTCT HIV Positive Women Tigray Northern Ethiopia Figures Figure 1 Figure 2 Background Globally, MTCT of HIV accounts 90% new pediatric HIV infection [1]. Sub-Saharan Africa experienced the greatest share. Regarding these challenges, World Health Organization (WHO) had been started implementing different strategies (Option A, Option B, Option B + ) for optimizing PMTCT care and support for low and middle income countries since 2001[2]. Under Option A, women receive ante partum (starting at 14 weeks of gestation) and intra partum ARV prophylaxis to reduce the risk of drug resistance. Whereas, women receive triple ARVs starting as early as 14 weeks of gestation and this is continued during intra partum and through childbirth if not breastfeeding, or until 1 week after the cessation of all breastfeeding in case of Option B, [2, 3]. During PMTCT scale-up period under Option A, & B, significant achievements obtained by rolling back new pediatric HIV infection by 70% [3]. However, clinical and programmatic challenges of the above two interventions resulted near miss of 23% HIV positive women not to be enrolled in chronic HIV care and nearly 150,000 pediatric HIV infections were recorded. This was due to high turnaround time to receive HIV chronic care in health facilities because of the need of CD4 count for ART initiation and fragmented service provision in different entry points in addition to the routine maternal health care service. These resulted high attrition and lost to follow up of HIV positive pregnant and lactating women from chronic HIV care [3, 1]. For instance, 24.3% lost to follow up was reported from Cameroon [5], 20% in Malawi [6], and 28% from sub-Saharan African countries [3, 4] respectively. Similarly, it was a great challenge in Ethiopia in which only 10% of HIV positive pregnant and lactating women complete PMTCT program until exposed infant HIV confirmatory testing at 18 months of age [7]. Having these realities, WHO introduced a new alternative approach (Option B + ) which is fully integrated and simplified approach to PMTCT in 2012 [7,8]. This new strategy recommends offering of life-long antiretroviral therapy (ART) regardless of CD4 count and HIV positive women are administered triple ARVs starting as soon as diagnosed and continued for life in routine MNCH platforms which had both clinical and programmatic advantage in retaining mothers in HIV chronic HIV care especially in resource limited settings [6,8]. As evidence from Malawi [6, 9], due to the introduction of this new intervention, a five-fold increase was achieved in ART initiation and 88% client retention was reported in the first quarter of its implementation in 2011. In Ethiopia, it was rolled out in 2013 and currently implemented in 2495 health facilities in routine MNCH platform similarly in northern Ethiopia where the study was conducted and all health facilities were implementing it in similar context to the national level as a strategy for MTCT elimination in 2020 [7,10]. However, still only 60.6% of HIV positive pregnant and lactating women were enrolled in HIV chronic care during Option B+ in 2015[10]. Mothers were still faced a challenge to retain in the service. For instance, 16% over all LTF was reported in North East Ethiopia in which, (11.9%) at 6 months, (15.7%) at 12 months and (22.6%) at 24 months respectively [11]. Similarly, 14.8% was reported from Eastern Ethiopia [12] and 9.8% from northern Ethiopia [13]. As evidenced from different facility based studies [14-16], poor service quality was the main challenge. For instance, an evidence from [10], relay on input-process quality items in which some health facilities were made operational with necessary supply chain related problems, lack of service integration and poor service compliance with national technical standards . On the other hand, inadequacy of trained human resources and compliance of health care providers with national standards were documented as predictor factors that render service quality in Hadya Zone of Southern Ethiopia [14]. With regard to process quality component, poor counseling, room privacy, waiting time, and inadequate confidentiality were reported from Dessie referral hospital of northern Ethiopia [15]. Similarly of poor service adherence to national standards from Gebretsadiq Shawa Memorial Hospital, Kafa Zone, South West Ethiopia [16]. Improving quality of Option B + PMTCT was a priority agenda in the health sector transformation plan of Ethiopia to achieve three 90’s (90-90-90) in 2020[10]. Since, reviewed predictor variables reported for lagging service quality in the previous studies were input-process-output related factors, we preferred to use Donabedian model of input-process-output quality assessment framework [17]. Performance indicators of Option B+ in the national guideline were based on this model [17,18 ] including input quality items (human resource, infrastructure, drugs, medical supplies, and medical equipments, maternity registers and forms), process quality item (service provider’s adherence to service standards) and output quality item (service outputs and client satisfactions) respectively. The level of quality of Option B+ PMTCT was articulated considering three predetermined quality components (Input-Process-Output) in which each performance verification standards stated in the national guide line has been achieved during service provision in respective quality components[ 17,19] . This oversee an evidence for the overall service quality targeted in the country’s health sector transformation agenda [10]. However, no study tried to assess level of quality of Option B + PMTCT services provision with respect to the three predetermined quality components. Therefore, the study aimed to assess level of quality of Option B + PMTCT service provision in public health facilities in Mekelle Zone, Northern Ethiopia using Donabeidan quality assessment model. [Figure 1] Methods Aim The aim of the study was to assess the level of quality of OptionB + PMTCT and to explore reasons for good and bad service quality. Study design The study has been employed cross-sectional study in the public health facilities. It has involved mixed method approach using both quantitative and qualitative data collection methods. The study used Donabedian model of health care quality assessment framework [19]. The model was depicted in the figure below (Figure 1). Study setting and period The study was conducted in Mekelle zone, Tigray of Northern Ethiopia, 802KMs from Addis Ababa, the capital city of Ethiopia. It is among the top three high HIV prevalent and prioritized areas in Tigray region [20]. According to [21] census, the projected total population of Mekelle is 320,000. Zonal health tier system composed of 12 public health facilities. Of which, three of them are hospitals and nine health center. All health facilities had been providing OptionB + PMTCT under their MNCH continuum of care. The study period was from February to April 2016. Sampling and Sample size The study took place among 12 purposively selected public health facilities providing Option B + PMTCT under MNCH continuum of care. Similarly, 168 mother infant pairs were included for the study that had been completed Option B + follow up visits in the previous one year prior to data collection period. Besides, 12 HIV exposed infant follow up charts were subjected for chart review. The clients who participated for observation and interviews were a convenience sample while the service had been provided at selected facilities. The intention was to observe 10 sessions of Option B + service consultations from each facility during each round of data collection. However, this was not possible since too few women came for Option B + PMTCT services while data collectors were present at the facility. Therefore, none participatory observation was conducted on 60 clients five from each facility. After service consultation, a total of 30 volunteered clients were subjected for exit interview. We also conducted 12 in-depth interviews with healthcare providers until the required information saturation was achieved. Inclusion criteria to recruit study participants were considering those clients who were under continuous follow up in the previous year before data collection. In addition, their voluntarism during consenting process also considered. Patients who visited the health facilities for the first time and health care providers who worked for less than two years were excluded as they didn’t have prior experience with the health facility to provide valid information. Data collection and measurements Data collection was conducted in line with input-process-output quality assessment dimensions to evaluate service quality. Three data collectors were recruited for facility inventory, non-participatory observation and record review. Their professional qualification is Master Degree in public health. They had been also working for more than three years under MNCH continuum of care. For input service quality, 47 input performance standards were adopted from the national guide lines [17, 18] to assess input service quality. Facility inventory was conducted in 12 health facilities to ensure the availability of medical equipment , supplies, infection prevention materials, job aids , IEC materials, basic obstetric care supplies, maternity registers and forms for Option B + PMTCT service provision under MNCH continuum of care. See list of input quality verification variables (Additional file 1). A total of 43 performance verification standards articulated for assessing process quality dimension [16, 17]. Observation of Option B+ service consultation sessions under MNCH continuum of care was performed to assess client counselor interaction, adequacy, compliance and quality of the counseling sessions. See list of process quality verification variables (Additional file 1). Output quality was assessed using 13 items adopted from national guide line [17, 18]. Record review was conducted among 168 mother infant pair from maternity record. While, 12 HIV exposed infant follow up charts were reviewed to summarize service outputs of adult and pediatric HIV chronic. See list of process quality verification variables (Additional file 1). Overall service quality was assessed by combining input, process, and output service quality components. Facilities were categorized rendering good input service quality, if the average weighted score of input quality performance standards is 100 % [10], and 90% or more for process, output, and overall quality performance standards [10, 22]. See the score of each variable for respective quality components (Additional file 1). The interviews were conducted by lead principal investigator, assisted by research adviser. The interview took 30–40 minutes. Client exit interview was conducted after service consultation was finished. Concurrently, service providers who were under observation were subjected for an in-depth interview using semi structured interview guide. The aim was to explore their perception about reasons for good and bad service quality. Operational definitions Input dimension : this dimension was used to assess the availability of human resources, materials, drugs, equipment, and supplies needed for Option B + PMTCT service provision [15]. Process dimension : this dimension used to reflect how service providers adhere to service standards during service consultation of Option B + PMTCT service in MNCH unit [16]. Output dimension : used to evaluate the ultimate service result of Option B + PMTCT service and patient satisfaction level [15]. Overall quality : this particular dimension was determined by combining predetermined three quality components; input, process, and output [13]. DBS result turnaround time: in this study this was used to assess the total time taken for DNAPCR virological test result from blood drawback to infant care at the health facility [16]. Data quality assurance To enhance data quality, data collectors who had experienced and trained on Option B + PMTCT were recruited for data collection. In addition, they were trained for two days on the nature of the tool, objective of the study and ways of approaching during interview, observation, record and chart review. We piloted the tools in two sites (health facilities), which were not among the included research sites, and the necessary adjustments were made based on these pilots. For instance two missed performance indicators of process quality components were modified. During the data collection period, there was a strict supervision and completed questionnaires were checked on a daily basis by principal investigator to assure the reliability of the data. Similarly, use of mixed method approach and direct observation assured the validity and objectivity of the data. Data management and analysis Quantitative data were coded, cleaned, and entered into EPI info version 7 and then exported and analyzed using SPSS version 21 software for windows. The percentage of verification criteria achieved was calculated. Descriptive statistics were used to describe the prevalence of input, process, and output related service quality verification standard for each facility. The principal investigator who had an experience on qualitative data analysis transcribed and translated the qualitative data with reference to the Tigrigna audio recordings for clarification. The coding framework followed the topic guide and texts were coded based on three categories (facilitators and barriers for good and bad service quality in respective three quality components) in which later three broad themes were emerged (facilitators and barriers for input service quality, facilitators and barriers for process service quality, facilitators and barriers for output service quality). Finally, thematic content analysis was conducted basing reviewed literature on similar studies [23-25] following data familiarization (reading and re-reading of the transcripts). Results The study was assessed based on Donabedian input-process-output service quality assessment model. The study health facilities were health centers (Mekelle , Semien , Kasech , Quiha , Adishmdihun , Aynalem, Serewat , Adiha, and Lachi ) and hospitals ( Mekelle , Quiha, and Ayder ) which has been providing Option B + PMTCT under MNCH continuum of care. The study showed that the overall level of service quality of Option B + PMTCT was rendered as good in one out of six(16.7%) of studied health facilities. Specifically, input service quality was judged as good in 33.3% of health facilities but only 25% of them realized good process and output service quality respectively (Figure 2). [Figure 2] Table 1: Summarized themes that emerged from the data analysis and their relationship to the predetermined categories that are reflective of Donabedian’s model. Categories Themes Sub-themes Input service quality Theme 1: Reasons for good input quality Good partnership Theme 2: Reasons for bad input quality Resource constraint Process service quality Theme 1: Reasons for good process quality Service integration ART initiation regardless of CD4 count Simplicity of ARV drug regimen Theme 2: Reasons for bad process quality Poor service compliance prolonged waiting time Work load Output service quality Theme 1: Reasons for good output quality Patient retention Theme 2: Reasons for bad output quality high DBS result turnaround time Regarding input service quality, the study revealed that majority of the health facilities were equipped with clinical care supplies and drugs for Option B + PMTCT service provision. Long life ARV regimen (TDF+3TC +EFV), and other basic obstetric care supplies for Option B + were not reported as stock out for the past one year (additional file one). However; critical input related items for Option B+ service provision were missed in considerable no of studied health facilities. Only, half of the health facilities kept on hand the necessary trained service providers, drugs for opportunistic infections, and DBS test kits necessary for the desired input service quality (Table 2). Table 2: Health facilities not fulfilling 100% of input service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia [N=12]. Input quality items No of facilities Percent Human resource and infrastructure Well ventilated waiting room 8 66.7 Well ventilated counseling room 8 66.7 Cleanness of counseling rooms 6 50 Trained service providers on OB + 6 50 Medical supplies Cotrimoxazole prophylaxis 8 66.7 DBS sample collection kit 7 58.3 Job aid IEC materials PMTCT broachers 7 58.3 PMTCT leaflets 5 41.7 Technical guide line 7 58.3 PMTCT cure card 8 66.7 Patient forms and registers Referral slips 8 66.7 Referral linkage slips 8 66.7 Appointment cards 8 66.7 Theme 1: Reasons for good input quality Majority of service providers recognized that building team work among program directors and district level experts enabled them to identify availability related factors on time. This is an identified contributing facilitator for facilities to be judged providing good input service quality (Figure 1). This is illustrated clearly by the following service provider: “…... we have been conducted weekly meetings with program managers and district level experts with availability related factors and prepare an action plan to resolve input related constraints on time ” (PMTCT service provider ≠12 ). Theme 2: Reasons for bad input quality Consistent with quantitative findings (Table 1), health workers expressed their opinion on shortage of trained human workforce and supply chain issues for Option B+ as a barrier for input related factor. Sometimes, trained staffs were also preferred to serve health care services other than MNCH unit as described below: “…… Imagine only two health care providers trained on Option B + and serving more than an average of 80 clients per day. Having this reality, how can we provide quality? Therefore, without allocating appropriate number of trained health care providers , only integrating the service to MNCH unit may not be successful ” ( PMTCT service provider ≠4 ) . “…… Some drug list used for opportunistic infection such as co-trimoxazole prophylactic therapy was reported as stock out for more than six months in the past year lack of transportation was a reason given for us when requested ” (PMTCT service provider≠8 ). With regards to process quality, some prominent key interventions had been missed during service consultation. Option B+ ARV drug adherence counseling and partner notification were offered in 58.3% of the health facilities. Some of the common limitations to the quality of maternity services included that women were greeted on arrival in 58.3% of the health facilities. Prolonged waiting time was also an issue observed during service consultation. It had been noted that health service providers in majority of health facilities were observed not adhered to service standards while providing service consultation (Table 3). Table 3: Health facilities not fulfilling 90% of process service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia [N=12]. Process quality items No of facilities Percent Facility suitable opening hour 8 66.7 Client greeting and welcoming 7 58.3 Introducing himself to clients 7 58.3 Waiting time to the counselor 6 50 Adequacy of counseling session 6 50 Counselor confidence during counseling 7 58.3 Conduct history taking 8 66.7 Conduct physical examination 8 66.7 Screening for opportunistic infection 8 66.7 Discus issues of reproductive health 8 66.7 Support for disclosure 7 58.3 Reviewing need of partner notification 7 58.3 Reviewing ARV drug adherence 7 58.3 Reviewing about safe sex practice 8 66.7 Reviewing of HIV infection 8 66.7 Screening for substance abuse 6 50 Discus issues of psychosocial support 7 58.3 Counseling for nutritional support 8 66.7 Screening for STI 8 66.7 Screening for cervical cancer 8 66.7 Calling clients by name 6 50 Encouraging women to ask questions 6 50 Reviewing mothers understanding 6 50 Conduct child growth assessment 7 58.3 Review issues of child immunization 8 66.7 Reviewing issues of infant feeding 8 66.7 Initiating cotrimoxazole therapy 9 75 Review TB risk assessment 8 66.7 Conduct virological test at 6 weeks of age 6 50 Conduct anti-body test at 18 months of age 6 50 Theme 1: Reasons for good process quality Task shifting to scale up Option B + by integrating the delivery of Option B + ART initiation as one service package in MNCH unit, initiation of ARV regardless of CD4 count, and simplicity of ARV regimen was greatly appreciated by majority of service providers and clients during an interview: “…... discrimination is not my concern for the past two years after the adoption of Option B + . I am confident enough to attend my follow up visit together with HIV negative mothers in MNCH clinic. This is because; we all received our follow up care in one room and with the same health professionals ” ( PMTCT client ≠ 18). “ ……Before the introduction of Option B + PMTCT high lost (3%) and dropout rate (4%) was documented in our facility. The main reason forwarded by majority of the clients was repeated appointments for CD4 count for ART initiation but after its adoption, patient high patient retention was documented ” (PMTCT service provider ≠ 2). “…... the drug provided for me during PMTCT visit was comfortable and easy to use. I selected a fixed time at 7:00 PM and I have been taking the drug usually with a specified time and I don’t want to miss even a fraction of seconds ” (PMTCT client≠ 21). “…… During the time of Option A and B, multiple ARV drugs were prescribed and patients were complained about the situation but now patient were easily adhere to the regimen and no more need of continuous adherence support ” (PMTCT service provider ≠5). Theme 2: Reasons for bad process quality Majority of service providers had good experience regarding Option B + . However, one health care provider reported her experience of considering CD4 count as criteria for initiating ART which resulted poor service compliance with service standards. Some other providers criticized its integration as creating workload and prolonged waiting time as described as follows: “…... I am not aware of prescribing ARV drugs regardless of CD4 count and I appointed two PMTCT clients for CD4 investigation before prescribing the drug ” (PMTCT service provider ≠10 ). “…... before the introduction of Option B + mother living with HIV were under follow up in ART clinic but now they had been enrolled in MNCH clinic during their maternal and child health care visit which resulted additional work load in our health facility ” (PMTCT service provide≠3). “…... my great concern during my PMTCT follow up visit was issue of timing to get the service on time since there was delayed service as a result I have been thinking to miss the opportunity ”( PMTCT client ≠19). As an Option B+ service output, majority; 91.7% of mother infant pair were alive and in their first line recommended treatment regimen in the past one year. However; high DBS result turnaround time and low patient satisfaction level were vital issues which needed great attention while the service has been provided (Table 4). Table 4: Health facilities not fulfilling 90% of output service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia [N=12]. Output quality items No of facilities Percent Client satisfaction per standard 7 58.3 Clients with good treatment adherence 8 66.7 Clients involved partner testing 5 41.7 Early infant diagnosis for virological test 6 50 Confirmatory antibody test 7 58.3 DBS result turnaround time per standard 4 33.3 Enrolling HIV positive pediatrics to HIV chronic care 8 66.7 Perform CD4 count as base line during their initial visit 7 58.3 Perform CD4 count at least one as follow up visit 6 50 Theme 1: Reasons for good output quality As described by majority of service providers, client’s belief in the efficacy of ARVs, absence of stigma and discrimination were facilitators for high patient retention as articulated below: “…... before the introduction of option B + high patient lost and drop out were documented but now Option B + was highly accepted by patents ” (PMTCT service provide≠5). Theme 2: Reasons for bad output quality Big issue forwarded by almost all participants was high turnaround time for DNAPCR virological test result communication which was arrived within 4-6 months time period at the health facility from the central testing unit as explained below: “…... I am always worried regarding delay of my new borne baby’s HIV virological test result. As you have seen, am receiving exposed infant test result today after six month. Unfortunately, I am very much happy today since his result non-reactive. But the past six months were painful for me ” (PMTCT client ≠28). “…... I am always communicating using mobile phone with laboratory experts in the central testing unit an issue of DBS result delay but they told me that the machine was under maintenance” (PMTCT service provider≠ 7). Discussion The primary aim of this study was to evaluate the level of quality of option B + PMTCT and to explore factors for good and bad service quality in Mekelle Zone of Northern Ethiopia. Evaluation was conducted based on three quality components suggested in the Donabedian model and under the umbrella of the national guidelines for Option B + PMTCT service provision in Ethiopia [17, 19]. Accordingly, the study result showed that the overall level of service quality of Option B + PMTCT was rendered as good in one out of six(16.7%) of studied health facilities. Specifically, 33.3% were judged as providing good in terms of input quality but only 25% for the process and output service quality respectively. However, it important to note that the three quality components are interlinked to each other and the effect of one component had its own impact on the other [19]. This finding was by far from pre-determined national target in 2020 [10] and evidences from Southern Ethiopia [14, 30]. The reason for such discrepancies might be due to stretched nature of the second health sector transformation plan and methodological difference in which only client interview was conducted to assess client satisfaction in the later two studies. Regarding input quality, it was found better provided than its counterparts. The study showed that only, 33.3 % of the studied health facilities had the necessary inputs to provide quality delivery service. It was relatively lower when compared to some other African countries [31-33]. This discrepancy might be due to variation in national guideline and performance targets that lead variation in service quality. However, the study revealed the finding was almost consistent with a report from Northern and South West Ethiopia [13, 16]. Use of the same quality assessment model (Donabedian) might lead this consistency. From the qualitative finding, poor inventory of resources was a big issue that lead availability related constraints in which similar results have been also observed in Southern parts of Ethiopia [30]. This availability related barrier had an impact on the remaining quality components due to the nature of their interrelation [19]. The study also revealed that only one fourth of the study health facilities fulfilled service adherence to process related service delivery of Option B+ according to the national guideline. This finding was comparable with evidence from Northern and South West Ethiopia [13, 16]. But lower when compared with evidence from Malawi [28]. Variation of the finding in the later study might be due to their good experience in implementing the service since it was an area in which Option B + PMTCT first piloted internationally [29]. Identified barriers for process related factors during an interview were poor service adherence to service standards, work load, and prolonged waiting time which were similarly reported from [30, 34, 35]. This process related factors had serious implications in compromising the overall quality of care currently aspired in 2020[10, 19]. Similar to process quality, the study showed good service quality was archived in one fourth of the studied health facilities in terms of service utilization and satisfaction of mothers for Option B + PMTCT. Patient satisfaction is one of the desired items in the measure of output service quality [19]. The overall client satisfaction about the service was reported low (58.3%) which had an impact on service output quality. Qualitative finding suggested that high turnaround time for DBS result communication and prolonged waiting time to get the service genuinely forecasted that significantly affect service output. This finding seems very plausible and significantly associated with other evidences [22, 36-38]. Conclusions The overall level of quality of Option B+PMTCT was optimal in insignificant number of facilities. Only, 16.7% of health facilities recognized achieving the overall service quality based on three quality components. To realize the current aspired level of service quality in the country’s health sector transformation plan, the three quality components will be kept on eye side by side. Since the three quality components are interrelated and the effect of one component had an impact on the other [19]. We found multiple factors that influenced positively and negatively service quality. Team works, service integration, ART initiation regardless of CD4 count are identified facilitators for improving service quality. On the other hand, shortage of trained staffs, service task shift to other unit of care after training, high DBS result turnaround time were common identified barriers that hinder service improvement. Study limitations The model used in this study had its own drawbacks that considered only linear assumption that do not infer casual relationships. In measuring process quality, over estimations of findings could happen due to either Hawthorn or social desirability biases during service observations. Use of small sample size may affect finding generalizablity but in process evaluation generazablity is not an issue. In addition, rigor statistical test was not done since it was program based process evaluation and use of sophisticated statistical analysis is not a must unlike outcome evaluation [39]. List Of Abbreviations MTCT: Mother to Child Transmission; DBS: Dried blood spot test; HIV: Human -Immune -Virus; MNCH: Maternal, Neonatal, and Child Health; ART: Antiretroviral Therapy; ARV: Antiretroviral Medication; PMTCT: Prevention of Mother-to-Child Transmission; WHO: World Health Organization; IEC: Information, Education, and communication Declarations Ethical approval and consent to participate The study protocol was reviewed and approved by Mekelle University School of Public Health ethical review board with a reference and approval no (MUEB/2016). Permission was also received from Tigray Regional Health Bureau and respective health facilities. Similarly, data collection was conducted if and only if an informed consent was given from the participants. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed for the study were available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The study is funded by Mekelle University School of Public Health donated for master thesis research for government sponsored students. Additional fund also allocated from Tigray Regional Health Bureau donated by Italian Cooperation for public health research. The funders had no role in the study design, data collection, and analysis, decision to publish, or preparation of the manuscript. Authors’ contributions KF and AD designed the study; KF was developed the protocol, data analysis, interpretation, and preparing the first draft of the manuscript. All authors were involved in commenting, revising, and approving the final version of the manuscript. Acknowledgments The authors would like to thank Tigray Regional Health Bureau, Mekelle University School of Public Health, and study team for their support and contribution to the study. The authors are also grateful to the study participants. 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Addis Ababa: FMOH; 2013 accessed in https://aidsfree.usaid.gov/sites/default/files/ethiopia_natl_gl_2014.pdf Federal Democratic Republic of Ethiopia Ministry of Health (FDRE MOH). National guidelines for Prevention of Mother-to – Child Transmission of HIV in Ethiopia. Addis Ababa: FMOH; 2007 accessed in https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legal document/wcms_125389.pdf Donabedian, A. (1988) the Quality of Care: How Can It Be Assessed? Journal of the AmericanMedicalAssociation,260,17431748.http://dx.doi.org/10.1001/jama.1988.03410120089033 Tigary Regional Health Bureau (2007): Annual Health Profile ,Tigray, Northern Ethiopia ECSA (2018). Ethiopian household consumption expenditure (HCE) survey statically reportfile:///C:/Users/THRI/Downloads/HCE%202016%20Statistical%20Report%20Tigray%20region.pdf Girum, T., Wasie, A. & Worku, A. Trend of HIV/AIDS for the last 26 years and predicting achievement of the 90–90-90 HIV prevention targets by 2020 in Ethiopia: a time series analysis. BMC Infect Dis 18 , 320 (2018) doi:10.1186/s12879-018-3214-6 Graneheim UH. L.B.Q.c.a.i.n.r.c., procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004; 24(2):105–12. Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesizing qualitative and quantitative evidence: a rev Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007; 19(6):349–57. Oyuncu, A., Dufour, M.K., McCoy, S.I. et al. Protocol for the evaluation of the population-level impact of Zimbabwe’s prevention of mother-to-child HIV transmission program option B+: a community based serial cross-sectional study. BMC Pregnancy Childbirth 19 , 15 (2019) doi:10.1186/s12884-018-2146-x Herce, Michael E et al. “Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study.” BMC infectious diseases 15 328. 12 Aug. 2015, doi:10.1186/s12879-015-1065-y Herce, Michael E et al. “Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study.” BMC infectious diseases 15 328. 12 Aug. 2015, doi:10.1186/s12879-015-1065-y Kalua T, Tippett Barr BA, van Oosterhout JJ, et al. Lessons Learned from Option B+ in the Evolution Toward "Test and Start" From Malawi, Cameroon, and the United Republic of Tanzania. J Acquir Immune Defic Syndr . 2017;75 Suppl 1(Suppl 1):S43–S50. doi:10.1097/QAI.0000000000001326 Tesfaye, D.J., Hibistu, D.T., Abebo, T.A. et al. Option B plus antiretroviral therapy adherence and associated factors among HIV positive pregnant women in Southern Ethiopia. BMC Pregnancy Childbirth 19, 82 (2019) doi:10.1186/s12884-019-2228-4 Kim YM, Chilila M, Shasulwe H, et al. Evaluation of a quality improvement intervention to prevent mother-to-child transmission of HIV (PMTCT) at Zambia defence force facilities. BMC Health Serv Res . 2013; 13:345. Published 2013 Sep 8. doi:10.1186/1472-6963-13-345 Rosenberg NE, Pettifor AE. Taking Malawi's option B+ programme from a B+ to an A. Lancet HIV . 2018;5(12):e672–e673. doi:10.1016/S2352-3018(18)30320-5 Kalua T, Tippett Barr BA, van Oosterhout JJ, et al. Lessons Learned From Option B+ in the Evolution Toward "Test and Start" From Malawi, Cameroon, and the United Republic of Tanzania. J Acquir Immune Defic Syndr . 2017;75 Suppl 1(Suppl 1):S43–S50. doi:10.1097/QAI.0000000000001326 DiCarlo, A.L., Gachuhi, A.B., Mthethwa-Hleta, S. et al. Healthcare worker experiences with Option B+ for prevention of mother-to-child HIV transmission in eSwatini: findings from a two-year follow-up study. BMC Health Serv Res 19, 210 (2019) doi:10.1186/s12913-019-3997-1 Sanga, E.S., Mukumbang, F.C., Mushi, A.K. et al. Understanding factors influencing linkage to HIV care in a rural setting, Mbeya, Tanzania: qualitative findings of a mixed methods study. BMC Public Health 19, 383 (2019) doi:10.1186/s12889-019-6691-7 Bernhart, M.H., Wiadnyana, I.G., Wihardjo, H. and Pohan, I. (1999) Patient Satisfaction in Developing Countries. Social Science & Medicine, 48, 989-996. http://dx.doi.org/10.1016/S0277-9536(98)00376-1 Westaway, M.S., Rheeder, P., Van Zyl, D.G. and Seager, J.R. (2003) Interpersonal and Organizational Dimensions of Patient Satisfaction: The Moderating Effects of Health Status. International Journal for Quality in Health Care, 15, 337-344. http://dx.doi.org/10.1093/intqhc/mzg042 Andaleeb, S.S.: Service Quality Perceptions and Patient Satisfaction: A Study of Hospitals in Developing Coun- N. B. Bayou, Y. E. Tsehay OALibJ | DOI:10.4236/oalib.1101499 10 May 2015 | Volume 2 | e1499 tries. Social Science & Medicine, 52, 1359-1370. http://dx.doi.org/10.1016/S0277-9536(00)00235-5 Moore G, Audrey S, Barker M, et al. Process evaluation in complex public health intervention studies: the need for guidance. Journal of epidemiology and community health 2014; 68(2):101-02. Supplementary Files OptionBXLdetailqualityscore.xls Cite Share Download PDF Status: Published Journal Publication published 17 Jun, 2020 Read the published version in BMC Health Services Research → Version 3 posted Review # 2 received at journal 15 Mar, 2020 Review # 1 received at journal 29 Feb, 2020 Reviewer # 2 agreed at journal 16 Feb, 2020 Reviewer # 1 agreed at journal 14 Feb, 2020 Reviewers invited by journal 13 Feb, 2020 Editor assigned by journal 12 Feb, 2020 Submission checks completed at journal 11 Feb, 2020 Editor invited by journal 11 Feb, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7499","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":349424,"identity":"50df2e46-07f5-4eb1-9e11-da9c53a21e2c","order_by":1,"name":"Kiros Fenta Ajemu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYBACCWYQaQMimA+A+DJEakljYOBhYEsA8XkIa2GAa+ExADEJa5Fs53348EeCTZ49+5nPr27UWPAwsB8+ugGfFmlmdmNjnoS0Yh6e3G3WOceADuNJS7uBT4scMxubNOOPw4k9DLnbjHPYgFokeMwIapH8kfA/sYf/zTPjnH9EaJEGapHgSTiQ2CORw/w4t40ILZLNbMxAvyQn9tx4Zsac2yfBw0bILxLnjzECQ8wusb0/+fHnnG91cvzsh4/h1YIM2MCRxEaschBg/kCK6lEwCkbBKBg5AACrBD33CUbthQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-7608-0284","institution":"Tigray Health Research Institute","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Kiros","middleName":"Fenta","lastName":"Ajemu","suffix":""},{"id":349425,"identity":"a9af6c10-62a3-4a51-831b-08d92a6295c4","order_by":2,"name":"Alem Desta","email":"","orcid":"","institution":"Mekelle University School of Puplic Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alem","middleName":"","lastName":"Desta","suffix":""}],"badges":[],"createdAt":"2019-11-01 14:14:29","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.2.16861/v3","doiUrl":"https://doi.org/10.21203/rs.2.16861/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-020-05429-6","type":"published","date":"2020-06-17T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":490961,"identity":"a29f0ed0-3250-4baf-9b34-15178715144f","added_by":"auto","created_at":"2020-02-13 17:51:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":120736,"visible":true,"origin":"","legend":"Conceptual framework for assessing quality of OptionB+PMTCT adopted from [17-19]","description":"","filename":"1.PNG","url":"https://assets-eu.researchsquare.com/files/b8f076b3-4ffa-4535-88f1-e169c13b12dd/v3/1.PNG"},{"id":490962,"identity":"918c076c-aae8-49f8-93d1-df11bd3f9774","added_by":"auto","created_at":"2020-02-13 17:51:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40446,"visible":true,"origin":"","legend":"Summary of OptionB+PMTCT service quality in studied health facilities in Mekelle Zone, Northern Ethiopia.","description":"","filename":"2.PNG","url":"https://assets-eu.researchsquare.com/files/b8f076b3-4ffa-4535-88f1-e169c13b12dd/v3/2.PNG"},{"id":13488974,"identity":"fead553c-9c32-494d-acbe-e985e1eae8b1","added_by":"auto","created_at":"2021-09-16 22:17:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":640487,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7499/v3/db8371a7-fd04-4e5d-8e85-8a2e03df724b.pdf"},{"id":490960,"identity":"1a25b622-af3b-4cd5-96cc-9535e3bec02c","added_by":"auto","created_at":"2020-02-13 17:51:52","extension":"xls","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":44544,"visible":true,"origin":"","legend":"","description":"","filename":"OptionBXLdetailqualityscore.xls","url":"https://assets-eu.researchsquare.com/files/b8f076b3-4ffa-4535-88f1-e169c13b12dd/v3/Option B+ XL ( detail quality score).xls"}],"financialInterests":"","formattedTitle":"Level of Quality of Option B+PMTCT Service Provision in Public Health Facilities in Mekelle Zone, Northern Ethiopia: Cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, MTCT of HIV accounts 90% new pediatric HIV infection [1]. Sub-Saharan Africa experienced the greatest share. Regarding these challenges, World Health Organization (WHO) had been started implementing different strategies (Option A, Option B, Option B\u003csup\u003e+\u003c/sup\u003e) for optimizing PMTCT care and support for low and middle income countries since 2001[2]. Under Option A, women receive ante partum (starting at 14 weeks of gestation) and intra partum ARV prophylaxis to reduce the risk of drug resistance. Whereas,\u0026nbsp; women receive triple ARVs starting as early as 14 weeks of gestation and this is continued during intra partum and through childbirth if not breastfeeding, or until 1 week after the cessation of all breastfeeding in case of Option B, [2, 3].\u003c/p\u003e\n\u003cp\u003eDuring PMTCT scale-up period under Option A, \u0026amp; B, significant achievements obtained by rolling back new pediatric HIV infection by 70% [3]. However, clinical and programmatic challenges of the above two interventions resulted near miss of 23% HIV positive women not to be enrolled in chronic HIV care and nearly 150,000 pediatric HIV infections were recorded. This was due to high turnaround time to receive HIV chronic care in health facilities because of the need of CD4 count for ART initiation and fragmented service provision in different entry points in addition to the routine maternal health care service. These resulted high attrition and lost to follow up of HIV positive pregnant and lactating women from chronic HIV care [3, 1]. For instance, 24.3% lost to follow up was reported from Cameroon [5], 20% in Malawi [6], and 28% from sub-Saharan African countries [3, 4] respectively. Similarly, it was a great challenge in Ethiopia in which only 10% of HIV positive pregnant and lactating women complete PMTCT program until exposed infant HIV confirmatory testing at 18 months of age [7].\u003c/p\u003e\n\u003cp\u003eHaving these realities, WHO introduced a new alternative approach (Option B\u003csup\u003e+\u003c/sup\u003e) which is fully integrated and simplified approach to PMTCT in 2012 [7,8]. This new strategy recommends offering of life-long antiretroviral therapy (ART) regardless of CD4 count and HIV positive women are administered triple ARVs starting as soon as diagnosed and continued for life in routine MNCH platforms which had both clinical and programmatic advantage in retaining mothers in HIV chronic HIV care especially in resource limited settings [6,8]. As evidence from Malawi [6, 9], due to the introduction of this new intervention, a five-fold increase was achieved in ART initiation and 88% client retention was reported in the first quarter of its implementation in 2011.\u003c/p\u003e\n\u003cp\u003eIn Ethiopia, it was rolled out in 2013 and currently implemented in 2495 health facilities in routine MNCH platform similarly in northern Ethiopia where the study was conducted and all health facilities were implementing it in similar context to the national level as a strategy for MTCT elimination in 2020 [7,10]. However, still only 60.6% of HIV positive pregnant and lactating women were enrolled in HIV chronic care during Option B+ in 2015[10]. Mothers were still faced a challenge to retain in the service. For instance, 16% over all LTF was reported in North East Ethiopia in which, (11.9%) at 6 months, (15.7%) at 12 months and (22.6%) at 24 months respectively [11]. Similarly, 14.8% was reported from Eastern Ethiopia [12] and 9.8% from northern Ethiopia [13]. As evidenced from different facility based studies [14-16], poor service quality was the main challenge. For instance, an evidence from [10], relay on input-process quality items in which some health facilities were made operational with necessary supply chain related problems, lack of service integration and poor service compliance with national technical standards . On the other hand, inadequacy of trained human resources and compliance of health care providers with national standards were documented as predictor factors that render service quality in Hadya Zone of Southern Ethiopia [14]. With regard to process quality component, poor counseling, room privacy, waiting time, and inadequate confidentiality were reported from Dessie referral hospital of northern Ethiopia [15]. Similarly of poor service adherence to national standards from Gebretsadiq Shawa Memorial Hospital, Kafa Zone, South West Ethiopia [16].\u003c/p\u003e\n\u003cp\u003eImproving quality of Option B\u003csup\u003e+\u003c/sup\u003ePMTCT was a priority agenda in the health sector transformation plan of Ethiopia to achieve three 90\u0026rsquo;s (90-90-90) in 2020[10]. Since, reviewed predictor variables reported for lagging service quality in the previous studies were input-process-output related factors, we preferred to use Donabedian model of input-process-output quality assessment framework [17]. Performance indicators of Option B+ in the national guideline were based on this model [17,18 ] including input quality items (human resource, infrastructure, drugs, medical supplies, and medical equipments, maternity registers and forms), process quality item (service provider\u0026rsquo;s adherence to service standards) and output quality item (service outputs and client satisfactions) respectively. The level of quality of Option B+ PMTCT was articulated considering three predetermined quality components (Input-Process-Output) in which each performance verification standards stated in the national guide line has been achieved during service provision in respective quality components[ 17,19] . This oversee an evidence for the overall service quality targeted in the country\u0026rsquo;s health sector transformation agenda [10]. However, no study tried to assess level of quality of Option B\u003csup\u003e+\u003c/sup\u003ePMTCT services provision with respect to the three predetermined quality components. Therefore, the study aimed to assess level of quality of Option B\u003cstrong\u003e\u003csup\u003e+\u003c/sup\u003e\u003c/strong\u003ePMTCT service provision in public health facilities in Mekelle Zone, Northern Ethiopia using Donabeidan quality assessment model.\u003c/p\u003e\n\u003cp\u003e[Figure 1]"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eAim \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of the study was to assess the level of quality of OptionB\u003csup\u003e+\u003c/sup\u003ePMTCT and to explore reasons for good and bad service quality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has been employed cross-sectional study in the public health facilities. It has involved mixed method approach using both quantitative and qualitative data collection methods. The study used Donabedian model of health care quality assessment framework [19]. The model was depicted in the figure below (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting and period\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in Mekelle zone, Tigray of Northern Ethiopia, 802KMs from Addis Ababa, the capital city of Ethiopia. It is among the top three high HIV prevalent and prioritized areas in Tigray region [20]. According to [21] census, the projected total population of Mekelle is 320,000. Zonal health tier system composed of 12 public health facilities. Of which, three of them are hospitals and nine health center. All health facilities had been providing OptionB\u003csup\u003e+\u003c/sup\u003ePMTCT under their MNCH continuum of care. The study period was from February to April 2016.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and Sample size \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study took place among 12 purposively selected public health facilities providing Option B\u003csup\u003e+\u003c/sup\u003ePMTCT under MNCH continuum of care. Similarly, 168 mother infant pairs were included for the study that had been completed Option B\u003csup\u003e+\u003c/sup\u003e follow up visits in the previous one year prior to data collection period. Besides, 12 HIV exposed infant follow up charts were subjected for chart review. The clients who participated for observation and interviews were a convenience sample while the service had been provided at selected facilities. The intention was to observe 10 sessions of Option B\u003csup\u003e+\u003c/sup\u003e service consultations from each facility during each round of data collection. However, this was not possible since too few women came for Option B\u003csup\u003e+\u003c/sup\u003ePMTCT services while data collectors were present at the facility. Therefore, none participatory observation was conducted on 60 clients five from each facility. After service consultation, a total of 30 volunteered clients were subjected for exit interview. We also conducted 12 in-depth interviews with healthcare providers until the required information saturation was achieved.\u003c/p\u003e\n\u003cp\u003eInclusion criteria to recruit study participants were considering those clients who were under continuous follow up in the previous year before data collection. In addition, their voluntarism during consenting process also considered.\u0026nbsp; Patients who visited the health facilities for the first time and health care providers who worked for less than two years were excluded as they didn\u0026rsquo;t have prior experience with the health facility to provide valid information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection and measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection was conducted in line with input-process-output quality assessment dimensions to evaluate service quality. Three data collectors were recruited for facility inventory, non-participatory observation and record review. Their professional qualification is Master Degree in public health. They had been also working for more than three years under MNCH continuum of care.\u003c/p\u003e\n\u003cp\u003eFor input service quality, 47 input performance standards were adopted from the national guide lines [17, 18] to assess input service quality. Facility inventory was conducted in 12 health facilities to ensure the availability of medical equipment , supplies, infection prevention materials, job aids , IEC materials, basic obstetric care supplies, \u0026nbsp;maternity registers and forms for Option B\u003csup\u003e+\u003c/sup\u003ePMTCT service provision under MNCH continuum of care. See list of input quality verification variables (Additional file 1).\u003c/p\u003e\n\u003cp\u003eA total of 43 performance verification standards articulated for assessing process quality dimension [16, 17]. Observation of Option B+ service consultation sessions under MNCH continuum of care was performed to assess client counselor interaction, adequacy, compliance and quality of the counseling sessions. See list of process quality verification variables (Additional file 1).\u003c/p\u003e\n\u003cp\u003eOutput quality was assessed using 13 items adopted from national guide line [17, 18]. Record review was conducted among 168 mother infant pair from maternity record. While, 12 HIV exposed infant follow up charts were reviewed to summarize service outputs of adult and pediatric HIV chronic. See list of process quality verification variables (Additional file 1).\u003c/p\u003e\n\u003cp\u003eOverall service quality was assessed by combining input, process, and output service quality components. Facilities were categorized rendering good input service quality, if the average weighted score of input quality performance standards is 100 % [10], and 90% or more for process, output, and overall quality performance standards [10, 22]. See the score of each variable for respective quality components (Additional file 1).\u003c/p\u003e\n\u003cp\u003eThe interviews were conducted by lead principal investigator, assisted by research adviser. The interview took 30\u0026ndash;40 minutes. Client exit interview was conducted after service consultation was finished. Concurrently, service providers who were under observation were subjected for an in-depth interview using semi structured interview guide. The aim was to explore their perception about reasons for good and bad service quality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational definitions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInput dimension\u003c/strong\u003e: this dimension was used to assess the availability of human resources, materials, drugs, equipment, and supplies needed for Option B\u003csup\u003e+\u003c/sup\u003e PMTCT service provision [15].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcess dimension\u003c/strong\u003e: this dimension used to reflect how service providers adhere to service standards during service consultation of Option B\u003csup\u003e+\u003c/sup\u003ePMTCT service in MNCH unit [16].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutput dimension\u003c/strong\u003e: used to evaluate the ultimate service result of Option B\u003csup\u003e+\u003c/sup\u003ePMTCT service and patient satisfaction level [15].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOverall quality\u003c/strong\u003e: this particular dimension was determined by combining predetermined three quality components; input, process, and output [13].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDBS result turnaround time: \u003c/strong\u003ein this study this was used to assess the total time taken for DNAPCR virological test result from blood drawback to infant care at the health facility [16].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData quality assurance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo enhance data quality, data collectors who had experienced and trained on Option B\u003csup\u003e+\u003c/sup\u003ePMTCT were recruited for data collection. In addition, they were trained for two days on the nature of the tool, objective of the study and ways of approaching during interview, observation, record and chart review. We piloted the tools in two sites (health facilities), which were not among the included research sites, and the necessary adjustments were made based on these pilots. For instance two missed performance indicators of process quality components were modified. During the data collection period, there was a strict supervision and completed questionnaires were checked on a daily basis by principal investigator to assure the reliability of the data. Similarly, use of mixed method approach and direct observation assured the validity and objectivity of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData management and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data were coded, cleaned, and entered into EPI info version 7 and then exported and analyzed using SPSS version 21 software for windows. The percentage of verification criteria achieved was calculated. Descriptive statistics were used to describe the prevalence of input, process, and output related service quality verification standard for each facility.\u003c/p\u003e\n\u003cp\u003eThe principal investigator who had an experience on qualitative data analysis transcribed and translated the qualitative data with reference to the Tigrigna audio recordings for clarification. The coding framework followed the topic guide and texts were coded based on three categories (facilitators and barriers for good and bad service quality in respective three quality components) in which later three broad themes were emerged (facilitators and barriers for input service quality, facilitators and barriers for process service quality, facilitators and barriers for output service quality). Finally, thematic content analysis was conducted basing reviewed literature on similar studies [23-25] following data familiarization (reading and re-reading of the transcripts).\u003c/p\u003e"},{"header":"Results","content":"\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eThe study was assessed based on Donabedian input-process-output service quality assessment model. The study health facilities were health centers (Mekelle , Semien , Kasech , Quiha\u0026nbsp; , Adishmdihun , Aynalem, Serewat , Adiha, and Lachi ) and hospitals ( Mekelle , Quiha, and Ayder ) which has been providing \u0026nbsp;Option B\u003csup\u003e+\u003c/sup\u003ePMTCT under MNCH continuum of care. \u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eThe study showed that the overall level of service quality of Option B\u003csup\u003e+\u003c/sup\u003ePMTCT was rendered as good in one out of six(16.7%) of studied health facilities. Specifically, input service quality was judged as good in 33.3% of health facilities but only 25% of them realized good process and output service quality respectively (Figure 2).\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e[Figure 2]\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eTable 1:\u003c/span\u003e\u003c/strong\u003e \u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eSummarized themes that emerged from the data analysis and their relationship to the predetermined categories that are reflective of Donabedian\u0026rsquo;s model.\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width: 499.5pt; margin-left: -.05in; border-collapse: collapse; border: none;\" width=\"666\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eCategories\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eThemes \u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border: solid windowtext 1.0pt; border-left: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eSub-themes\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border: none; border-left: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eInput service quality\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 1:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003e Reasons for good input quality\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border: none; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eGood partnership \u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border-top: none; border-left: solid windowtext 1.0pt; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 2:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003e Reasons for bad\u0026nbsp; input quality\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border-top: none; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eResource constraint\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border: none; border-left: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eProcess service quality\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 1:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003e Reasons for good process quality\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border: none; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eService integration \u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border: none; border-left: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border: none; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eART initiation regardless of CD4 count\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border: none; border-left: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border: none; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eSimplicity of ARV drug regimen\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border: none; border-left: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 2:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003e Reasons for bad\u0026nbsp; process quality\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border: none; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003ePoor service compliance\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border: none; border-left: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border: none; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eprolonged waiting time\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border-top: none; border-left: solid windowtext 1.0pt; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border-top: none; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eWork load\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border: none; border-left: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eOutput\u0026nbsp; service quality\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 1:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003e Reasons for good output quality\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border: none; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003ePatient retention \u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 121.25pt; border-top: none; border-left: solid windowtext 1.0pt; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"162\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 193.75pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"258\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 2:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003e Reasons for\u0026nbsp; bad\u0026nbsp; output quality\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 184.5pt; border-top: none; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"246\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: normal;\"\u003e\u003cspan style=\"font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black;\"\u003ehigh DBS result turnaround time\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12pt; line-height: 200%; font-family: 'Times New Roman', serif;\"\u003eRegarding\u003c/span\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e input service quality, the study revealed that majority of the health facilities were equipped with clinical care supplies and drugs for Option B\u003csup\u003e+\u003c/sup\u003ePMTCT service provision. Long life ARV regimen (TDF+3TC +EFV), and other basic obstetric care supplies for Option B\u003csup\u003e+\u003c/sup\u003e were not reported as stock out for the past one year (additional file one). However; critical input related items for Option B+ service provision were missed in considerable no of studied health facilities. Only, half of the health facilities kept on hand the necessary trained service providers, drugs for opportunistic infections, and DBS test kits necessary for the desired input service quality (Table 2). \u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eTable 2:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e Health facilities not fulfilling 100% of input service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia [N=12].\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width: 446.25pt; margin-left: 4.65pt; border-collapse: collapse;\" width=\"595\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eInput quality items\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eNo of facilities\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003ePercent\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 347.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" colspan=\"2\" width=\"463\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eHuman resource and infrastructure\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eWell ventilated\u0026nbsp; waiting room\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eWell ventilated\u0026nbsp; counseling room\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eCleanness of counseling rooms\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eTrained service providers on OB\u003csup\u003e+\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eMedical supplies\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eCotrimoxazole prophylaxis\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eDBS sample collection kit\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eJob aid IEC materials\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003ePMTCT broachers\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003ePMTCT leaflets\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e5\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e41.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eTechnical guide line\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003ePMTCT cure card\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003ePatient forms and registers\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReferral slips\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReferral linkage slips\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 178.0pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"237\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eAppointment cards\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 169.25pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"226\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 99.0pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"132\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 1:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003e \u003cstrong\u003eReasons for good input quality\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eMajority of service providers recognized that building team work among program directors and district level experts enabled them to identify availability related factors on time. This is an identified contributing facilitator for facilities to be judged providing good input service quality (Figure 1). This is illustrated clearly by the following service provider:\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026ldquo;\u0026hellip;... \u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003ewe have been conducted weekly meetings with program managers and district level experts with availability related factors and prepare an action plan to resolve input related constraints on time\u003c/span\u003e\u003c/em\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026rdquo;\u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e (PMTCT service provider \u0026ne;12 ).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eTheme 2: Reasons for bad input quality \u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eConsistent with quantitative findings (Table 1), health workers expressed their opinion on shortage of trained human workforce and supply chain issues for Option B+ as a barrier for input related factor. Sometimes, trained staffs were also preferred to serve health care services other than MNCH unit as described below:\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u0026ldquo;\u0026hellip;\u0026hellip;\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-family: 'Times New Roman',serif;\"\u003eImagine only two health care providers trained on Option B\u003csup\u003e+\u003c/sup\u003e and serving more than an average of 80 clients per day. Having this reality, how can we provide quality? Therefore, without allocating appropriate number of trained health care providers , only integrating the service to MNCH unit may not be successful\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e\u003c/span\u003e\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e (\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003ePMTCT service provider \u0026ne;4\u003cstrong\u003e)\u003c/strong\u003e.\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u0026ldquo;\u0026hellip;\u0026hellip;\u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eSome drug list used for opportunistic infection such as \u0026nbsp;co-trimoxazole prophylactic therapy was reported as stock out for more than\u003c/span\u003e\u003c/em\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e \u003cem\u003esix months\u003c/em\u003e \u003cem\u003ein the past year lack of transportation\u003c/em\u003e \u003cem\u003ewas a reason given for us when requested \u003c/em\u003e\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e\u003cem\u003e(PMTCT service \u0026nbsp;provider\u0026ne;8\u0026nbsp; ).\u003c/em\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eWith regards to process quality, some prominent key interventions had been missed during service consultation. Option B+ ARV drug adherence counseling and partner notification were offered in 58.3% of the health facilities. Some of the common limitations to the quality of maternity services included that women were greeted on arrival in 58.3% of the health facilities. Prolonged waiting time was also an issue observed during service consultation. It had been noted that health service providers in majority of health facilities were observed not adhered to service standards while providing service consultation (Table 3).\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 150%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;\"\u003eTable 3:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;\"\u003e Health facilities not fulfilling 90% of process service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia [N=12].\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width: 446.25pt; margin-left: 4.65pt; border-collapse: collapse;\" width=\"595\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eProcess quality items\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eNo of facilities\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003ePercent\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eFacility suitable opening hour\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eClient greeting and welcoming\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eIntroducing himself to clients\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eWaiting time to the counselor\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eAdequacy of counseling session\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eCounselor confidence during counseling\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eConduct history taking\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eConduct physical examination\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eScreening for opportunistic infection\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eDiscus issues of reproductive health\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eSupport for disclosure\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReviewing need of partner notification\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReviewing ARV drug adherence\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReviewing about safe sex practice\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReviewing of HIV infection\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eScreening for substance abuse\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eDiscus issues of psychosocial support\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eCounseling for nutritional support\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eScreening for STI\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eScreening for cervical cancer\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eCalling clients by name \u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eEncouraging women to ask questions\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReviewing mothers understanding\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eConduct child growth assessment\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReview issues of child immunization\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReviewing issues of infant feeding\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eInitiating cotrimoxazole therapy\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e9\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e75\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eReview TB risk assessment\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eConduct virological test at 6 weeks of age\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 213.0pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"284\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eConduct anti-body test at 18 months of age\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 152.25pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"203\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81.0pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"108\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 1:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003e \u003cstrong\u003eReasons for good process quality\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eTask shifting to scale up Option B\u003csup\u003e+\u003c/sup\u003e by integrating the delivery of Option B\u003csup\u003e+\u003c/sup\u003e ART initiation as one service package in MNCH unit, initiation of ARV regardless of CD4 count, and simplicity of ARV regimen was greatly appreciated by majority of service providers and clients during an interview:\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026ldquo;\u0026hellip;... \u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003ediscrimination is not my concern for the past two years after the adoption of Option B\u003csup\u003e+\u003c/sup\u003e. I am confident enough to attend my follow up visit together with HIV negative mothers in MNCH clinic. This is because; we all received our follow up care in one room and with the same health professionals\u003cstrong\u003e\u0026rdquo; (\u003c/strong\u003ePMTCT client \u0026ne; 18).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026ldquo;\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026hellip;\u0026hellip;Before the introduction of Option B\u003csup\u003e+\u003c/sup\u003e PMTCT high lost (3%) and dropout rate (4%) was documented in our facility. The main reason forwarded by majority of the clients was repeated appointments for CD4 count for ART initiation but after its adoption, patient high patient retention was documented \u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e (PMTCT service\u0026nbsp; provider \u0026ne; 2).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026ldquo;\u0026hellip;... \u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003ethe drug provided for me during PMTCT visit was comfortable and easy to use. I selected a fixed time at 7:00 PM and I have been taking the drug usually with a specified time and I don\u0026rsquo;t want to miss even a fraction of seconds\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e (PMTCT client\u0026ne; 21).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026ldquo;\u0026hellip;\u0026hellip;\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eDuring the time of Option A and B, multiple ARV drugs were prescribed and patients were complained about the situation but now patient were easily adhere to the regimen and no more need of\u0026nbsp; continuous adherence support\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e(PMTCT service provider \u0026ne;5).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 2:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003e \u003cstrong\u003eReasons for bad process quality\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eMajority of service providers had good experience regarding Option B\u003csup\u003e+\u003c/sup\u003e. However, one health care provider reported her experience of considering CD4 count as criteria for initiating ART which resulted poor service compliance with service standards. Some other providers criticized its integration as creating workload and prolonged waiting time as described as follows:\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026ldquo;\u0026hellip;... \u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;I am not aware of prescribing ARV drugs regardless of CD4 count and I appointed two PMTCT clients for CD4 investigation before prescribing the drug\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e(PMTCT service \u0026nbsp;provider \u0026ne;10 ).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u0026ldquo;\u0026hellip;... \u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003ebefore the introduction of Option B\u003csup\u003e+\u003c/sup\u003e mother living with HIV were under follow up in ART clinic but now they had been enrolled in MNCH clinic during their maternal and child health care visit which\u0026nbsp; resulted additional work load\u003c/span\u003e\u003c/em\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e \u003cem\u003ein our health facility\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e (PMTCT service \u0026nbsp;provide\u0026ne;3).\u003c/em\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 57.0pt;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u0026ldquo;\u0026hellip;... \u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003emy great concern during my PMTCT follow up visit was issue of timing to get the service on time since there was delayed service as a result I have been thinking to miss the opportunity\u003cstrong\u003e\u0026rdquo;(\u003c/strong\u003ePMTCT client \u0026ne;19).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eAs an Option B+ service output, majority; 91.7% of mother infant pair were alive and in their first line recommended treatment regimen in the past one year. However; high DBS result turnaround time and low patient satisfaction level were vital issues which needed great attention while the service has been provided (Table 4). \u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 150%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;\"\u003eTable 4:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;\"\u003e Health facilities not fulfilling 90% of output service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia [N=12].\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width: 477.75pt; margin-left: 4.65pt; border-collapse: collapse;\" width=\"637\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 15.75pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eOutput quality items\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eNo of facilities\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003ePercent\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eClient satisfaction per standard\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eClients with good treatment adherence\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eClients\u0026nbsp; involved partner testing\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e5\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e41.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eEarly infant diagnosis for virological test\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eConfirmatory antibody test\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eDBS result turnaround time per standard\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e4\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e33.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003eEnrolling HIV positive pediatrics to HIV chronic care\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e66.7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003ePerform CD4 count as base line during their initial visit\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e7\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e58.3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 15.0pt;\"\u003e\n\u003ctd style=\"width: 284.25pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"379\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003ePerform CD4 count at least one as follow up visit \u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 1.5in; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"144\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.5pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"114\"\u003e\n\u003cp style=\"margin-bottom: .0001pt; text-align: center; line-height: 150%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif; color: black;\"\u003e50\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 1:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003e \u003cstrong\u003eReasons for good output quality\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eAs described by majority of service providers, client\u0026rsquo;s belief in the efficacy of ARVs, absence of stigma and discrimination were facilitators for high patient retention as articulated below:\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u0026ldquo;\u0026hellip;... \u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003ebefore the introduction of option B\u003csup\u003e+\u003c/sup\u003e high patient lost and drop out were documented but now Option B\u003csup\u003e+\u003c/sup\u003e was highly accepted by patents\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e (PMTCT service provide\u0026ne;5).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003eTheme 2:\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; color: black;\"\u003e \u003cstrong\u003eReasons for bad output quality\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eBig issue forwarded by almost all participants was high turnaround time for DNAPCR virological test result communication which was arrived within 4-6 months time period at the health facility from the central testing unit as explained below:\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026ldquo;\u0026hellip;... \u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eI am always worried regarding delay of my new borne baby\u0026rsquo;s HIV virological test result. As you have seen, am receiving exposed infant test result today after six month. Unfortunately, I am very much happy today since his result non-reactive. But the past six months were painful for me\u003cstrong\u003e\u0026rdquo; \u003c/strong\u003e(PMTCT client \u0026ne;28).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp style=\"text-align: justify; line-height: 200%; tab-stops: 308.7pt;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u0026ldquo;\u0026hellip;... \u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eI am always communicating using mobile phone with laboratory experts in the central testing unit an issue of DBS result delay but they told me that the machine was under maintenance\u0026rdquo; (PMTCT service provider\u0026ne; 7).\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary aim of this study was to evaluate the level of quality of option B\u003csup\u003e+\u003c/sup\u003ePMTCT and to explore factors for good and bad service quality in Mekelle Zone of Northern Ethiopia. Evaluation was conducted based on three quality components suggested in the Donabedian model and under the umbrella of the national guidelines for Option B\u003csup\u003e+\u003c/sup\u003ePMTCT service provision in Ethiopia [17, 19].\u003c/p\u003e\n\u003cp\u003eAccordingly, the study result showed that the overall level of service quality of Option B\u003csup\u003e+\u003c/sup\u003ePMTCT was rendered as good in one out of six(16.7%) of studied health facilities. Specifically, 33.3% were judged as providing good in terms of input quality but only 25% for the process and output service quality respectively. However, it important to note that the three quality components are interlinked to each other and the effect of one component had its own impact on the other [19].\u003c/p\u003e\n\u003cp\u003eThis finding was by far from pre-determined national target in 2020 [10] and evidences from Southern Ethiopia [14, 30]. The reason for such discrepancies might be due to stretched nature of the second health sector transformation plan and methodological difference in which only client interview was conducted to assess client satisfaction in the later two studies.\u003c/p\u003e\n\u003cp\u003eRegarding input quality, it was found better provided than its counterparts. The study showed that only, 33.3 % of the studied health facilities had the necessary inputs to provide quality delivery service. It was relatively lower when compared to some other African countries [31-33]. This discrepancy might be due to variation in national guideline and performance targets that lead variation in service quality. However, the study revealed the finding was almost consistent with a report from Northern and South West Ethiopia [13, 16].\u0026nbsp; Use of the same quality assessment model (Donabedian) might lead this consistency. \u0026nbsp;From the qualitative finding, poor inventory of resources was a big issue that lead availability related constraints in which similar results have been also observed in Southern parts of Ethiopia [30]. This availability related barrier had an impact on the remaining quality components due to the nature of their interrelation [19].\u003c/p\u003e\n\u003cp\u003eThe study also revealed that only one fourth of the study health facilities fulfilled service adherence to process related service delivery of Option B+ according to the national guideline. This finding was comparable with evidence from Northern and South West Ethiopia [13, 16]. \u0026nbsp;But lower when compared with evidence from Malawi [28]. Variation of the finding in the later study might be due to their good experience in implementing the service since it was an area in which Option B\u003csup\u003e+\u003c/sup\u003ePMTCT first piloted internationally [29]. Identified barriers for process related factors during an interview were poor service adherence to service standards, work load, and prolonged waiting time which were similarly reported from [30, 34, 35]. This process related factors had serious implications in compromising the overall quality of care currently aspired in 2020[10, 19].\u003c/p\u003e\n\u003cp\u003eSimilar to process quality, the study showed good service quality was archived in one fourth of the studied health facilities in terms of service utilization and satisfaction of mothers for Option B\u003csup\u003e+\u003c/sup\u003ePMTCT. Patient satisfaction is one of the desired items in the measure of output service quality [19]. The overall client satisfaction about the service was reported low (58.3%) which had an impact on service output quality. Qualitative finding suggested that high turnaround time for DBS result communication and prolonged waiting time to get the service genuinely forecasted that significantly affect service output.\u0026nbsp; This finding seems very plausible and significantly associated with other evidences [22, 36-38].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe overall level of quality of Option B+PMTCT was optimal in insignificant number of facilities. Only, 16.7% of health facilities recognized achieving the overall service quality based on three quality components. To realize the current aspired level of service quality in the country\u0026rsquo;s health sector transformation plan, the three quality components will be kept on eye side by side. Since the three quality components are interrelated and the effect of one component had an impact on the other [19]. We found multiple factors that influenced positively and negatively service quality. Team works, service integration, ART initiation regardless of CD4 count are identified facilitators for improving service quality. On the other hand, shortage of trained staffs, service task shift to other unit of care after training, high DBS result turnaround time were common identified barriers that hinder service improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy limitations \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe model used in this study had its own drawbacks that considered only linear assumption that do not infer casual relationships. In measuring process quality, over estimations of findings could happen due to either Hawthorn or social desirability biases during service observations. Use of small sample size may affect finding generalizablity but in process evaluation generazablity is not an issue. In addition, rigor statistical test was not done since it was program based process evaluation and use of sophisticated statistical analysis is not a must unlike outcome evaluation [39].\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eMTCT: Mother to Child Transmission; DBS: Dried blood spot test; HIV: Human -Immune -Virus; MNCH: Maternal, Neonatal, and Child Health; ART: Antiretroviral Therapy; ARV: Antiretroviral Medication; PMTCT: Prevention of Mother-to-Child Transmission; WHO: World Health Organization; IEC: Information, Education, and communication\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by Mekelle University School of Public Health ethical review board with a reference and approval no (MUEB/2016). Permission was also received from Tigray Regional Health Bureau and respective health facilities. Similarly, data collection was conducted if and only if an informed consent was given from the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed for the study were available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study is funded by Mekelle University School of Public Health donated for master thesis research for government sponsored students. Additional fund also allocated from Tigray Regional Health Bureau donated by Italian Cooperation for public health research. The funders had no role in the study design, data collection, and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKF and AD designed the study; KF was developed the protocol, data analysis, interpretation, and preparing the first draft of the manuscript. All authors were involved in commenting, revising, and approving the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Tigray Regional Health Bureau, Mekelle University School of Public Health, and study team for their support and contribution to the study. The authors are also grateful to the study participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChildren and HIV. Factsheet July 2016. Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland; 2016 [Internet]. 2016 [cited 2017 Jan18]. \u003cem\u003eAvailablefrom:http://www.unaids.org/sites/default/files/media_asset/FactSheet_Children_en.pdf\u003c/em\u003e\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Towards universal access: Scaling up of HIVAIDS intervention in the health sector, Geneva: WHO; 2016.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach. 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(1999) Patient Satisfaction in Developing Countries. Social Science \u0026amp; Medicine, 48, 989-996. \u003ca href=\"http://dx.doi.org/10.1016/S0277-9536(98)00376-1\"\u003ehttp://dx.doi.org/10.1016/S0277-9536(98)00376-1\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eWestaway, M.S., Rheeder, P., Van Zyl, D.G. and Seager, J.R. (2003) Interpersonal and Organizational Dimensions of Patient Satisfaction: The Moderating Effects of Health Status. International Journal for Quality in Health Care, 15, 337-344. \u003ca href=\"http://dx.doi.org/10.1093/intqhc/mzg042\"\u003ehttp://dx.doi.org/10.1093/intqhc/mzg042\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eAndaleeb, S.S.: Service Quality Perceptions and Patient Satisfaction: A Study of Hospitals in Developing Coun- N. B. Bayou, Y. E. Tsehay OALibJ | DOI:10.4236/oalib.1101499 10 May 2015 | Volume 2 | e1499 tries. Social Science \u0026amp; Medicine, 52, 1359-1370. \u003ca href=\"http://dx.doi.org/10.1016/S0277-9536(00)00235-5\"\u003ehttp://dx.doi.org/10.1016/S0277-9536(00)00235-5\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eMoore G, Audrey S, Barker M, et al. Process evaluation in complex public health intervention studies: the need for guidance. Journal of epidemiology and community health 2014; 68(2):101-02.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Quality, Option B+PMTCT, HIV Positive Women, Tigray, Northern Ethiopia","lastPublishedDoi":"10.21203/rs.2.16861/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.16861/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Substantial improvements have been observed in the coverage and access to maternal health services in Ethiopia. However, quality of care has been lagging behind. Therefore, the aim of this study was to assess quality of Option B+ PMTCT service provision. \u003c/p\u003e\u003cp\u003eMethods: Facility based cross sectional study was conducted from February to April 2016 in Northern Ethiopia. The quality of service delivery was assessed in 12 health facilities based on Donabedian input-process-output quality components. It employed mixed method approach involving both quantitative and qualitative data. Facilities were categorized rendering good input service quality if scored 100 % as per national guideline; whilst, 90 % and more for process and output quality components respectively. The emerged themes of factors for good and bad service quality from content analysis were then thematically fitted to donabedian themes. \u003c/p\u003e\u003cp\u003eResults: Overall 2 of 12 (16.7%) facilities fulfilled all the three quality components according to predetermined judgment criteria. The input quality was better than their counterpart; in which it was judged as good in 33.3% of facilities. Besides, one fourth of them were realized process and output quality. We identified multiple barriers and facilitators for good and bad service quality in respective quality components influencing quality of care. \u003c/p\u003e\u003cp\u003eConclusion: Only 16.7% of facilities declared the overall quality in all three dimensions according to service delivery guideline. The desired level of quality will be realized if and only if the three quality components would be kept on eye side by side in line with identified facilitators and barriers for good and bad service quality.\u003c/p\u003e","manuscriptTitle":"Level of Quality of Option B+PMTCT Service Provision in Public Health Facilities in Mekelle Zone, Northern Ethiopia: Cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-02-13 17:51:51","doi":"10.21203/rs.2.16861/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-03-15T12:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"editorInvitedReview","content":"","date":"2020-02-29T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"reviewerAgreed","content":"","date":"2020-02-16T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-02-14T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-02-13T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-02-12T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-02-11T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-02-11T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-01-08 22:00:37","doi":"10.21203/rs.2.16861/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-02-04T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nTitle of article: Level of Quality of Option B+PMTCT Service Provision in Public Health Facilities in Mekelle Zone, Northern Ethiopia: Cross-sectional study\nAuthors: Kiros Fenta Alemu, Alem Desta\nRe-revision: The authors have taken much time to address the comments raised and showed good progress on the manuscript. Yet, further major revision is needed to accept the manuscript for publication, especially the qualitative inquiry need much improvement.\nAbstract\n The abstract part needs further improvement. The use of SPSS was not prominent task in the methods (the sample size was 12 and with no advanced statistical applications). Something has to be said about the qualitative inquiry results thematically.\nLiterature review\n My previous comments have been addressed in this part. If possible review\nMethods\nDesign, sampling, sample size, data collection, analysis\n Thanks for the justification about the statistical rigor in process evaluation. So, you need to cite a reference.\n I wish your study was qualitative method supplemented with quantitative methods. Then you can analyze through deduction process and present thematically by the donabedian themes and describe the orders and categories numerically (# %). Here in your manuscript the methods lack statistical rigor (in adequate sample size the sample size, no statistical tests) and the qualitative methods seem to be overlooked. Thus, Hence, if you have the FGD, observation and KII data.\nResults\n You described the health facilities in the introductory part, it is good.\n Look, in your result part the qualitative data have more trustworthy messages because the methods and the matter of study is suited to qualitative inquiry. It looks good now. Thus, please consider the qualitative method in all parts to be mixed method (qualitative supplemented with quantitative); in abstract, literature, methods (description about analysis, result and discussion part).\n Too many themes… you need more deduction in you data. The sub titles should be the themes and then the categories and then orders. Factor study should be overlooked here. Then supplement with frequency distribution of the categories/orders, in the former case variables, based on the findings in health facilities. If you do like this the manuscript will not be criticized for statistical rigors and trustworthiness.\n Can PMTCT client say these words such as 'MNCH continuum of care', 'vertically standalone PMTCT service in ART unit', in this quote? (Line 254-259). It is to say that FGD and KII data have to be transcribed and quoted verbatim.\n\"…discrimination is not my concern for the past two years after the adoption of Option B am confident enough to attend my follow up visit together with HIV negative mothers in underlined MNCH continuum of care. This is because; we all received our follow up care in one room and with the same health professional and this is a good opportunity for us. Therefore, I preferred this service package rather than previous vertically standalone PMTCT service in ART unit\" (PMTCT client).\n Quotes need to be precise and less proportion related to the other description.\n Yet, the result part has to be revised in such a way that can inform scientific community a new scientific knowledge.\nDiscussion and conclusion\n Need correction based on the revision made on the result part.\n"},{"type":"decision","content":"Major revision","date":"2020-02-04T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-01-19T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **Unable to assess**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n\nComments to Author:\n---\nThank you for this scholarly paper.\nComments to authors:\nI suggest try and update some of the references they are too dated??- prefer those published after 2010.\nYou did a good job. In abstract, I suggest you not to repeat what has been already said in the text. Therefore, revise it.\nIn background: I am happy with flow and coherence you did in background section of text. I suggest you to define Level of Quality of Option B+PMTCT Service Provision and discuss its attributes and revise based on this.\nConceptual framework\nLine 104 to 105: I appreciate your effort and make sure that all variables are in your literature.\nMethods\nThey need to declare the inclusion and exclusion criteria that they used.\nThey need to explain how they can assure the reliability and objectivity of the data.\nStudy setting and period\nLine 118 to119: For the total population better you search for up to date national census.\nSampling and sample size\nline123: you did say nothing about quantitative part like Sampling procedures, sampling techniques and number of sample size you used. Take a look. Again sample size in qualitative section you used.\nData collection and measurements: I am not clear with how did you achieve client exit interview as they may be exhausted after consultation and there is high chance of non-response rate as it is time taking being in-depth interview. Besides to this, you didn't indicate time taken during interview.\nLine 119 to 140: Three data collectors were recruited for facility inventory, non-participatory observation and record review. Please, indicate what professional background they were, and their educational level.\n\nOperational definitions\nLine 166 to 175: please indicate on how you came with these operational definitions; indicate references. Have noticed Operational definitions Vs definition of terms????????????????\nData quality assurance\nLine 182 to 183: The tools were piloted and necessary modifications were made. During the data collection period: kindly indicate on how many subjects you conducted pilot study and what modifications you did.\nLine 184:…...... and completed questionnaires were checked on a daily basis by principal investigators. How many of you were principal investigators???????????\nData management and analysis\nLINE 186:------------------- entered into EPI info version 7 and then transferred: kindly replace word transferred by exported.\nLine: The main study themes were reasons for good and bad quality. Please, operationalize what good and bad quality is.\nLine 191 to 192: All authors (Kiros Fenta Ajemu and Alem Desta)...........'as you are two better to say both authors.............\nResults: So long the result was that I couldn't read and grasp. They need to summarize it again.\nDiscussion: The authors need to write the discussion in a traditional way: main results, concordant and discordant findings with the literature, explanations of the above, limitations, strengths and implications of the study.\n\n\n\n\n"},{"type":"reviewerAgreed","content":"","date":"2020-01-07T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-01-06T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-01-06T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-01-06T12:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2020-01-05T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-01-05T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2019-11-05 22:02:01","doi":"10.21203/rs.2.16861/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2019-12-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2019-12-06T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests' below**\n\nComments to Author:\n---\nTitle of article: Level of Quality of Option B+PMTCT Service Provision in Public Health Facilities in Mekelle Zone, Northern Ethiopia: Cross-sectional study\nAuthors: Kiros Fenta Alemu, Alem Desta\nThe paper dealt with 'Level of Quality of Option B+PMTCT Service Provision in Public Health Facilities in Mekelle Zone, Northern Ethiopia'. The study used mainly cross sectional study design. But also quantitative method was also deployed specially in the data collection phase. Donabedian model of quality assessment was used to determine the quality of health services in health facilities. Only 16.7% of health facilities were found to render good quality health service. Thus, the study is understandable.\nCitation\n Citation is based on the journal's requirement i.e. Vancouver reference style.\nStudy purpose\n The purpose of the study was clearly stated in the back ground part.\nLiterature review\n The problem and gap in knowledge was described adequately. Besides, some findings from literatures conducted in other settings were reviewed.\n The framework in relation quality of option B+ was not clearly depicted so that one can understand what the Donabedian model being used look like and tress the results later.\nMethods\nDesign, sampling, sample size, data collection, analysis\n The methodologies used are described adequately.\n The data collection procedures are well described.\n The analysis part is adequately described.\n Reference for line 106 to 107 (you need to cite it)\n Description for sampling … not adequate …. Techniques of sampling and sample size determination procedure (the units, the population) for both qualitative \u0026 quantitative are not clear …\n Review tense … example line 125 … methods should be written in past tense\n Line 117 and 134 are redundant\n No sample for the chart review … how many charts were reviewed?\n A lot of operational definitions expected. But not stated.\n I was unable to get the standards used. (the technical guideline, FHI, USAID)\n Over all the study lack statistical rigor.\n\nResults\n Information about the health facilities is expected to described in the introductory part.\n Only prevalence of variables was presented. Factors attributed to good and bad quality health service were not studied /presented. No statistical applications used. The dependent variable may be level of quality of service. The reasons for being good quality were not studied.\n These all might be dealt in qualitative exploration. But the results for qualitative data were not presented. Nothing said about the focus group discussion and observation findings. And there was no need to describe it in the methodology part.\n The result part has to be revised in such a way that can informs scientific community a new scientific knowledge.\nDiscussion and conclusion\n Using donabedian model has pros and cons. However, the limitations of the study were not clearly stated.\n"},{"type":"reviewerAgreed","content":"","date":"2019-11-08T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2019-11-07T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **'I declare that I have no competing interests'.**\n\nComments to Author:\n---\n*Are the methods appropriate and well described?\nNo,\nIt requires some methodological revisions like analysis method used, data quality assurance methods, declare whether you have used Epi Data entry or not ...\n*Does the work include the necessary controls?\nNo,\nIndicate how did you exactly manage confounding variables?\n*Are the conclusions drawn adequately supported by the data shown?\nNo,\nShould be rewritten as you copied and pasted from abstract section.\n*Quality of written English\nRequires substantial English language editing."},{"type":"reviewerAgreed","content":"","date":"2019-11-06T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-11-05T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-11-01T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-10-31T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-10-10T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2019-10-09T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8c38d262-eb3e-4194-a5ad-a14c17ca92cc","owner":[],"postedDate":"February 13th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":48104,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2020-06-22T13:53:40+00:00","versionOfRecord":{"articleIdentity":"rs-7499","link":"https://doi.org/10.1186/s12913-020-05429-6","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2020-06-17 12:00:00","publishedOnDateReadable":"June 17th, 2020"},"versionCreatedAt":"2020-02-13 17:51:51","video":"","vorDoi":"10.1186/s12913-020-05429-6","vorDoiUrl":"https://doi.org/10.1186/s12913-020-05429-6","workflowStages":[]},"version":"v3","identity":"rs-7499","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-7499","version":["v3"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}