Implementation fidelity of provider-initiated opt-out HIV testing of pregnant women attending antenatal clinics in Ghana: a multi-site process evaluation.

Implementation fidelity of provider-initiated opt-out HIV testing of pregnant women attending antenatal clinics in Ghana: a multi-site process evaluation. | 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 Implementation fidelity of provider-initiated opt-out HIV testing of pregnant women attending antenatal clinics in Ghana: a multi-site process evaluation. Isaac Amankwaa; PhD, RN, Robyn Maude; PhD, Joan Skinner; PhD This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4489352/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives The study aimed to assess the fidelity to the intended content of the WHO/UNAID's provider-initiated opt-out HIV testing policy in 12 antenatal clinics across three regions in Ghana. Specifically, the focus was on understanding the implementation of key components, including informed consent, confidentiality, counselling, and connection to care. Methods Carroll's conceptual framework of implementation fidelity guided the quantitative data collection in the 12 antenatal clinics across three regions in Ghana. We measured adherence through brief facility surveys, healthcare providers, pregnant women's self-reports and structured observation of counselling sessions. Descriptive statistical analysis was used to describe the sample and antenatal clinic characteristics. The percentage means and standard deviation (SD) of components delivered were used to calculate fidelity scores. Results Routine provider-initiated HIV testing was widely available in the 12 antenatal clinics. Although adherence to test coverage was high (98.1%), just under half (41.7%) of the clinics surveyed obtained informed consent through the recommended opt-out approach. Adherence to the content of consent, confidentiality, counselling, and connection to care was low (38%) for direct observation, moderate (54%) for pregnant woman self-reports and moderately high (78.9%) for healthcare provider self-reports. Conclusions There is evidence of low to moderate fidelity to the intended content of the provider-initiated HIV testing in the 12 antenatal clinics. Gaps in the content delivery could limit the achievement of rights-based testing and may explain the lack of impact in the HIV testing efforts. Nursing Health Policy Infectious Diseases Preventive Medicine Pregnant women antenatal clinic implementation fidelity opt-out HIV testing Figures Figure 1 Figure 2 Figure 3 Background Globally, in 2022, an estimated 1.5 million children were living with HIV ( 1 ). Children acquire HIV infection primarily through mother-to-child transmission (MTCT) ( 2 ). MTCT can be interrupted if a woman becomes aware of her HIV-positive status and adheres to the prevention of mother-to-child transmission (PMTCT) interventions ( 3 ). For this reason, HIV testing has become a critical pathway for HIV prevention strategies ( 4 ). Efforts to improve HIV testing uptake led to provider-initiated HIV testing and counselling (PITC) in 2007 by UNAIDS/WHO ( 5 ). In PITC, the responsibility for initiating HIV testing is shifted from the individual to the healthcare practitioner ( 6 ). Three categories of PITC exist: symptom-based (testing specific individuals or subpopulations symptomatic of HIV), opt-in (an individual actively accepts to be tested for HIV), and opt-out (the provider informs an individual that HIV testing is routine/standard of care, and consent is assumed unless the individual declines explicitly (opt-out) ( 7 ). Ghana implemented 'opt-out' HIV testing in all prenatal clinics in 2008 after adopting the WHO/UNAIDS PMTCT guideline ( 8 ). Concerns have been raised on whether a policy targeting women to achieve a public health interest of increased test uptake would be compatible with preserving human rights ( 9 , 10 ). It has also been argued that healthcare providers may not be able to obtain authentic informed consent in a setting characterised by a power imbalance, unfavourable gender norms, overcrowded clinics with no private spaces and staff shortages ( 9 , 11 – 13 ). It is suggested that over time, routinely testing women for HIV may lessen healthcare providers' awareness of related ethical issues ( 14 ). An analysis of HIV testing policies from 19 countries revealed an inconsistent and poor policy description in policy documents ( 10 ). This situation may lead to the healthcare provider misinterpreting the policy during the delivery. Despite these concerns, mainstream HIV testing research has remained outcome oriented. These studies have demonstrated variable test acceptance ranging from 94–24% ( 15 ). Many women testing positive do not enter PMTCT services ( 16 , 17 ), nor disclose their new status ( 18 ). The wide acceptance rate and lack of impact may suggest that the HIV testing process in ANC (e.g. providers' understanding of opt-out and how they offer the test) determines women's decision about the test ( 19 ). Evaluators address this evidence gap through implementation fidelity, which involves comparing the intervention as contained in policy documents and the intervention as delivered ( 20 ). Implementation fidelity helps uncover the intervention's strengths and weaknesses ( 21 ). It forestalls Type III errors in evaluation, where one mistakenly attributes a lack of effect to the intervention without considering the implementation quality ( 22 ). To our knowledge, this is the first study to examine the implementation fidelity of the opt-out HIV testing intervention in antenatal settings. The findings would contribute to the world's attempt to use antenatal HIV testing to attain zero HIV infection by 2030 ( 23 ). We aim to gain insights into whether women's rights are (or are not) addressed in the antenatal HIV testing programme in Ghana's antenatal clinics. The adherence dimensions addressed were coverage and content . The study addressed these two questions: a. to what extent do healthcare providers understand and adhere to the opt-out approach when offering HIV testing? b. to what extent do healthcare providers adhere to the recommended 5Cs when offering HIV testing? Evaluation methodology and methods Conceptual framework Inspired by the Medical Research Council’s Guidance on process evaluation of complex interventions, our process evaluation draws on the modified version of the conceptual framework of implementation fidelity (24). The framework's principal component is the assessment of adherence to the intervention, defined as the degree to which the intervention has been delivered as intended. Adherence is conceptualised as coverage, content, frequency, and duration. Fidelity is high if the programme implementation adheres to the original intervention model (i.e. the opt-out approach and the core human rights principles). We maintained adherence to the intervention's content, coverage, and potential moderators used in the original framework. This study reports on adherence to the coverage and content of the intervention. Description of the antenatal-based opt-out HIV testing intervention In ANC groups, a midwife delivers a 15–20-minute pre-test session information session that covers general pregnancy, the testing process, HIV transmission, and the meaning of the results. Further details are offered individually if needed. In the consultation rooms, the midwife reaffirms prior information and informs women about routine HIV testing, with consent presumed unless explicitly refused (opt-out). Women consenting undergo rapid testing, with negative results receiving brief post-test guidance. Positive results prompt extensive counselling and antiretroviral therapy offer. (see Figure 2). Study setting This cross-sectional study was conducted between August 2018 and April 2019 in 12 antenatal clinics distributed across three regions (Ashanti, Tano South and Bono East). We employed a criterion-based sampling (26) to purposively select the 12 antenatal clinics that offered HIV testing as part of routine antenatal care. These clinics consented in writing to be part of the study. The approach allowed a priori consideration of clinic features deemed essential in answering the process evaluation questions. It also ensured a maximum variation of key characteristics such as clinic size, patient-provider ratio and geographical location (27). The included clinics had HIV testing services that were fully (n=4) or partially integrated (n=5) or standalone clinics (n=3) but within the same building as the antenatal clinic. We defined private clinics as those owned by individuals and religious bodies. Data collection Tools for assessing adherence to core elements We used structured direct observation and self-reports by the healthcare provider and pregnant women to measure adherence. A provider and pregnant women's self-report and structured observation checklist were developed from the core elements adapted from the 'Guide for Monitoring and Evaluating National HIV Testing and Counselling Programmes' (28) and a review of Ghana's policy documents. The self-reports and the observation checklist incorporated the same 16 core elements expected to be delivered by the clinician in the ANC. The questionnaire asked providers to indicate whether they implemented the identified components as contained in the testing guidelines. We then asked women if they had received the intervention. We ensured the content validity of the survey instrument by inviting an expert from the National AIDS Control Programme’s (NACP) staff who verified that the final tool reflected the content contained in Ghana’s policy documents. We adapted the questionnaires to the target groups by pre-testing them on a sample similar to the target group. Brief facility survey and review of antenatal clinic register The 12 antenatal clinic managers answered a brief facility survey using the antenatal clinic audit tool for this study. Questions included routine ANC and HIV testing activities, counselling and testing approach, staff numbers, and estimated time for delivering clinic activities. A review of the antenatal clinic register complemented this data. Pregnant women self-report survey A woman was eligible if pregnant, 18 years of age or over, making their first or second ANC visit and could give informed consent. We excluded women whose test came back positive for HIV on the day due to the shock that accompanies a positive HIV. We also excluded women with medical conditions that required further management. The sample size was estimated using the formula n = (Z^2 * P * (1-P)) / (E^2). Where n is the sample size, Z is the confidence level of 95%, P is the proportion of women of fertility age (23%), and 5% precision (expressed as 0.05). The sample size was calculated to be n = (1.96^2 * 0.23 * (1-0.23)) / (0.05^2), resulting in a sample size of approximately 422 pregnant women. Based on the average number of pregnant women who visited each antenatal clinic during the previous ten months, a proportional allocation of each clinic’s total sample size was calculated (see Table 1). A total of 483 questionnaires were distributed using convenient sampling. Table 1: sample size estimation for pregnant women survey Facility Calculated total sample size (N) Average monthly antenatal attendance (x) Sub-sample (x/300*N) Actual sample obtained Sample after exclusion of incomplete questionnaires Facility 1 422 110 24 30 27 Facility 2 422 142 31 37 34 Facility 3 422 298 64 68 66 Facility 4 422 276 60 63 61 Facility 5 422 142 31 51 40 Facility 6 422 89 19 24 21 Facility 7 422 87 19 20 19 Facility 8 422 384 83 87 82 Facility 9 422 153 33 35 32 Facility 10 422 97 21 27 26 Facility 11 422 121 26 28 27 Facility 12 422 58 13 13 13 Total - 1957 422 483 448 Healthcare provider self-report survey We invited all healthcare providers directly involved in HIV testing at the ANC to participate in the survey and to have their HIV testing consultations observed. Staff became aware that we would assess the delivery of the HIV testing intervention and not their professional competence or judge their practice. We further emphasised the study's confidentiality and that we would aggregate all findings, with the hospital's and individuals' names omitted. Healthcare providers consented without signing a consent form, in line with the anonymity measures previously discussed. We delivered questionnaires in envelopes, and providers dropped them in the provided at the end of their shift. A researcher administered direct structured observation. Testing and counselling sessions observed were purposively selected based on the provider and women's willingness for an observer to be in the consulting room. The confidentiality agreement extended to the observer not communicating any observed practice with the provider's supervisor. Healthcare providers who consented signed an informed consent form. Data analysis Self-report and structured observation data were entered, cleaned, and validated using Microsoft Excel. We created datasets and keyed information into Excel sheets. A total of 35 (7.2%) pregnant women survey questionnaires were either not answered or had more than 50% missing data and were therefore excluded, leaving 448 valid questionnaires to be analysed. We recorded no missing data for the provider surveys. After resolving discrepancies, data were exported to SPSS V25 (29) for further analysis. The study used descriptive statistics (frequency, median, ranges, standard deviation, and percentages) to describe the characteristics of the study sample and general clinic characteristics. The analysis of adherence levels followed analytic procedures used by Toomey (29). The differences in continuous data were assessed using the one-way analysis of variance (ANOVA) and Kruskal-Wallis tests where appropriate. The levels of agreement between methods and inter-rater reliability of the observed and collected data were assessed using percentage concordance. Overall mean fidelity of content and fidelity scores according to a government authority, level of integration and percentage means adherence scores were obtained by calculating total actual scores as a percentage of the total possible score. High fidelity levels were interpreted as previously reported in the literature, with 80%–100% adherence interpreted as 'high' fidelity, 51%–79% as 'moderate' and 0%–50% as 'low' fidelity (30). Finally, the relationship between fidelity scores and the number of participants present was calculated using Spearman's correlation coefficient. P-values of less than 0.05 were interpreted as statistically significant. Ethical statement We received ethical approval from Victoria University of Wellington's Human Ethics Committee (25399) and Ghana Health Service Ethical Review Committee (GHS-ERC:009/11/17) The 12 prenatal clinics gave us written authorisation to use the facility and access their routine data. Pregnant women and healthcare professionals gave verbal consent after being informed of the study's goals, advantages, hazards, confidentiality, and voluntariness. Healthcare providers whose counselling sessions observed counselling gave written consent. We did not get informed permission from pregnant women because the observation focused on the provider. The healthcare provider asked the women if they wanted a researcher in the consulting room before monitoring any counselling session. No observation took place for women who disagreed and showed hesitation of counselling session being observed.. Results Distribution and profile of antenatal clinics Table 2 summarises the characteristics of the 12 ANCs. Clinics were owned by private (n=5) or government (n=7) entities. Privately-owned clinics were more likely to be semi-urban. The ANC's routinely collected data showed that in 2018, three of the clinics saw more than 2000, and these clinics were all government-owned and located in urban settings. Eight clinics, distributed equally among private and public hospitals, served 1000 to 2000 pregnant women annually. Public hospitals recorded a higher workload per week per clinical staff than their counterpart in private facilities. Table 2: Profile of clinics included in this study Clinic variable Government (n=7) Private (n=5) Location Urban, n (%) 5(71.4) 3(60) Semi-urban, n (%) 2(28.6) 2(40) Estimated clinic attendance >2000/month, n (%) 3(42.9) 0(0.0) 1000-2000/month, n (%) 4(57.1) 4(80) <1000/month, n (%) 0 (0.0) 1(20) Antenatal clinic-related services Focused ANC, n (%) 7(100) 4(80) A group health talk, n (%) 7(100) 5(100) History taking & physical examination, n (%) 7(100) 5(100) Lab services (e.g. syphilis, malaria, G6PD), n (%) 3(42.9) 3(60) Time spent in delivering health talk (mins), mean (SD) 19(3.7) 18(2.8) Size of a group for a health talk, mean (SD) 41(18) 61(11) HIV-related services The opt-out offer of HIV test, n (%) 7(100) 5(100) HIV service available 5 days/week, n (%) 6(85.7) 2(40) Rapid HIV testing, n (%) 7(100) 5(100) Information about HIV testing giving during health talk (Yes), n (%) 7(100) 5(100) Positive test results confirmed at ANC, n (%) 4(57.1) 1(20) Initiation of ART for pregnant women testing positive for HIV (Yes), n (%) 4(57.1) 1(20) HIV testing performed by ANC staff, n (%) 6(85.7) 1(20) HIV testing performed by dedicated staff outside the ANC, n (%) 2(28.6) 3(60) Human resource capacity Number clinicians (mean, range) 3(0-18) 2(0-4) Number of nurses (mean, range) 10 (3-30) 9(3-20) Number of HIV testing pregnant women/week (range) 426.3(260-1153) 392.3(175-459.3) Number of weekly HIV testing clients/staff (range) 60.7 (32.8-103.3) 33(27-41) SD=standard deviation; ANC=antenatal clinic; HIV=Human Immunodeficiency virus Source : ANC register/field notes Characteristics of pregnant women Of the 448 pregnant women who answered the exit survey, 326 (71.8%) were from publicly funded hospitals. The entire sample's mean age was 28.3 years (SD=5.63; range 16 to 44 years), with the majority (80%) being between 27 and 30 years. Most women were urban dwellers (60%), married (73%), had some form of employment (75%), and had more than one pregnancy (75%). About 11% of pregnant women had no formal education, while 17% had high school education and above. Women attending public clinics differed significantly from private clinics regarding age, residence, and marital status but not in the number of pregnancies and occupation. Table 3 summarises the characteristics of pregnant women. Table 3:Socio-demographic characteristics of pregnant women Government clinic n=326(71.8%) Private clinic n=122 (27.2%) p-value Mean age in years (SD) 28(6) 29(6) 0.0231 Place of residence, n (%) 0.0025 Urban 196(60) 77(63) Peri-urban 83(26) 42(34) Rural 41(13) (2) Marital status, n (%) 0.0035 Single 91(28) 16(13) Divorced 4(1) 2(2) Married 225(69) 104(85) Missing 6(2) 0(0) Number of pregnancies n(%) 0.2116 First pregnancy 80(25) 24(20) > 1 pregnancy 240(74) 98(80) Missing 6(2) 0(0) Occupation, n (%) 0.3543 Unemployed 61(19) 19(2) Student 19(6) 6(5) Employed 249(76) 97(80) Missing 6(2) 0(0) Educational level, n(%) 0.1421 No formal education 40(12) 10(8) Completed primary school 26(8) 7(6) Completed junior high school 124(38) 40(33) Completed senior high school 89(27) 35(29) Some diploma 24(5) 16(13) Characteristics of healthcare providers Table 4 summarises the characteristics of healthcare providers. Most providers were from government-operated ANCs, compared to 34% in privately-run clinics. Providers were mostly females (89%) with a median age of 29 (20-59). A little over half (61%) reported having attained a diploma in nursing education, with more respondents from private-run hospitals acquiring some degree. More than half (68.9%) identified as midwives. The rest were nurses (17%), nursing assistants (5%), medical officers (2%) and HIV counsellors (5%). Private hospitals reported a higher proportion of midwives than government hospitals (76% versus 67%). Overall, respondents had provided HIV testing services for a median duration of 2 years (1-14). No statistically significant difference existed between providers in private and government hospitals regarding sex, age, years of working experience and professional background. Table 4: Socio-demographic characteristics of providers Government n=100 (66.2%) Private n=51(33.8%) p-value Sex, 8 (%) 0.36112 Female 87(86.5) 47(91.7) Male 13(13.5) 4(8.3) Age (median, range ) 28(20-48) 30(23-59) Yrs. of HIV testing experience (median, range) 2(1-10) 2(1-14) Educational background, n (%) 0.4759 Senior High School 2(2) 0(0.0) Certificate 19(19) 9(18.0) Diploma 61 (61) 28(56.0) 1 st degree 17(17) 13(26) Professional background, n (%) 0.5244 Registered Midwife 67(67) 37(75.5) Registered Nurse 18(18) 8(16.3)) Medical Doctor 3(3.0) 0 (0.0) Nursing Assistant 7(7.0) 1(2.0) HIV counsellor 4(4.0) 3(6.1) Other (field technician) 1(1.0) 0(0.0) Adherence to coverage Coverage was conceptualised in this study as the opportunity for pregnant women to know their HIV status while visiting the antenatal clinic [6]. Data on clinic attendance was available for 8 clinics, showing a total of 80933 clinic attendance. Seventeen per cent (13760) were first-time attendees and therefore offered an HIV test. A total of 13505 (98.1%) accepted the test offer. Table 5 summarises the coverage of HIV testing in the 8 clinics. Table 5: Coverage and HIV prevalence of rapid HIV testing (2017) in 8 selected clinics Facilities Total Attendance for 2017 First attendance and offered HIV test % accepting and testing for HIV Facility 1 2000 1884 1884 Facility 2 27022 2652 2619 Facility 3 9426 1684 1684 Facility 4 20891 3307 3085 Facility 5 7234 984 984 Facility 6 4363 1453 1453 Facility 7 5596 1040 1040 Facility 8 4401 756 756 Totals (%) 80933(100%) 13760(17%) 13505(98.1% acceptance rate) Adherence to the content of the opt-out test offer The approach of the test offer did not always correspond with the guideline's recommendations (Table 5). Only 5 of the 12 clinics obtained informed consent through the opt-out approach, while 4 employed the opt-in approach. Three clinics employed a combination of opt-in and opt-out approaches. Despite the GAC and UNAIDS/WHO recommendations that removed the need for pre-test counselling, this study found that five ANCs employed some form of individual pre-test counselling. About half of the clinics adhered to this recommendation by delivering pre-test information in groups before an HIV test. No evidence of pre-test counselling or information delivery was observed in one clinic. Table 6: Healthcare provider adherence to the opt-out approach to test offer Approach of test offer N (%) Type of consent procedure Opt-in approach only 4(33.3) Opt-out approach only 5(41.7) Both opt-in and opt-out 3(25.0) Approach to informing women about the test Pre-test counselling only 5(41.7) Pre-test information only 6(50) Both pre-test counselling and information 0(0) Neither pre-test counselling nor information 1(8.3) Adherence to the content of consent, confidentiality, counselling, and connection to services Table 7 shows the frequency distribution of responses to each item on the adherence scale. There was significant bias (p-value <0.0001) observed for each response based on the type of ratter (direct observation and self-report). The 'Yes' response for each item was skewed towards self-reports (provider). A consistent response was observed for item 6 (agreed to test) between direct observation and self-report (provider) but not self-report (women). Also, consistency in adherence response between direct observation and self-report (women) was observed for item 12 (discussed partner testing) and item 14 (explained support services). Adherence to the requirement of informed consent scored low for direct observation ( M= 54.71, SD= 23.25), moderate for pregnant women's self-reports ( M = 54.71 SD= 13.45), and moderately high for healthcare providers' self-reports ( M= 85.06 , SD= 12.60). However, most healthcare providers felt they instituted adequate measures to ensure a private testing process, as almost all (95.4%) affirmed the confidential nature of the process. More than half (69.8%) of the women corroborated this finding. Similarly, explaining to women that providers would not share test results without their permission received a moderately high (78.1%) adherence rating from providers, moderate (54.3%) from women and exceptionally low (19.7%) by direct observation. Healthcare providers highly adhered to making women aware of what a negative test result meant. However, this was not the case in telling women about preventive strategies for HIV after testing negative, as just over half of the women (52.8%) reported receiving this information. Informing women of the need to bring a partner for testing was the least discussed post-test counselling by all the assessment methods, with only 31% of women saying that the healthcare provider offered this advice. The study saw a similar trend in non-adherence to the content of post-test counselling in explaining to women the possibility of a window period and retesting during the 34 th week, and allowing women to ask questions. Explaining support services was least adhered to as assessed by direct observation (6.5%) and pregnant women's self-reports (5.9%). More than half of pregnant women (52.8%) mentioned that providers advised them on preventive measures, compared to the observations (36.8%). Table 7:Frequency of response to each item on the adherence scale Item Variable Direct Observation N (%) Self-report, woman N (%) Self-report Provider N (%) A Consent 1 The HIV testing process explained 86 (54.8) 309 (70.1) 131 (89.1) * 2 Mother-to-child transmission explained. 58 (36.7) 297 (67.7) 129 (86.0) * 3 The meaning of positive & negative explained 73 (47.1) 274 (61.4) 132 (88.6) * 4 Women made aware of HIV preventive options 62 (39.2) 250 (56.9) 131 (90.3) * 5 The woman is allowed to ask questions 38 (24.1) 207 (47.2) 133 (90.5) * 6 A woman agreed to test 142 ( 91.0 ) 212 (48.0) 139 ( 93.9 ) * 7 Provider informed mother about her right to decline the test 36 (22.9) 141 (31.7) 81 (57.0) * ( Mean : SD) ( 45.1 ,23.25) ( 54.71 ,13.45) ( 85.06 ,12.60) B Confidentiality 8 Explained that results would not be shared 31 (19.7) 238 (54.3) 114 (78.1) * 9 Provider & client believed results kept confidential N/A 312 (69.8) 144 (95.4) * C Counselling 10 Meaning of results explained 146 ( 95.4 ) 389 ( 88.4 ) 122 ( 80.8 ) * 11 Advise on prevention 56 (36.8) 232 (52.8) 114 (76.0) * 12 Partner testing discussed 54 (34.4) 136 (31.0) 67 (46.2) * 13 Window period explained 36 (23.5) 232 (51.9) 115 (79.3) * (Mean: SD) (45.1,23.25) (45.1,23.25) (45.1,23.25) D Connection to care 14 Explain support services 10 (6.5) 26 (5.9) 107 (72.8) * 15 Allow time for questions 19 (12.4) 193 (43.9) 104 (69.8) *Statistically significant The mean percentage bias in adherence measure between direct observation and self-report (provider) was significantly higher compared with that observed between direct observation and self-report (women) (41.0 vs 16.8, p-value <0.0001). (See Figure 3) Table 7 shows the level of agreement between adherence measured by direct observation and self-reported adherence. Agreement between direct observation and self-report (women) in measuring low, moderate, and high adherence was 16.3%, 35.5% and 18.8%, respectively. Also, an agreement between direct observation and self-report (provider) in measuring low, moderate, and high adherence was 10.6%, 16.1% and 43.8%, respectively. Overall, the level of agreement between direct observation and self-report (women) in measuring adherence was very poor (kappa= -0.082). Similarly, the level of agreement between direct observation and self-report (provider) in measuring adherence was very poor (kappa= -0.034). Table 8: Measures of agreement between direct observations and self-reports (N=151) Direct observation Kappa coefficient Kendall's tau-b Low adherence Moderate adherence High adherence Self-report (women) -0.082 -0.208 Low adherence 17 (16.3) 7 (22.6) 9 (56.3) Moderate adherence 34 (32.7) 11 (35.5) 4 (25.0) High adherence 53 (51.0) 13 (41.9) 3 (18.8) Self-report (Provider) -0.034 0.049 Low adherence 11 (10.6) 1 (3.2) 0 Moderate adherence 29 (27.9) 5 (16.1) 9 (56.3) High adherence 64 (61.5) 25 (80.6) 7 (43.8) Table 9 shows fidelity results calculated from percentage adherence totals. Fidelity was found to be low in direct observation and self-report (women) assessment methods, with a mean score of 38.8% (range of 61.1%–95.8%) for direct observation and 54.0% for the self-report (women). The fidelity results for each method with scores ≥80% (cut-off for 'high' fidelity) are in bold. Significant differences between governing authority, level of integration and sub-category' individual fidelity scores were found. Fidelity was found to be moderately high (78.9%) for self-report (provider) Table 9: Adherence levels based on assessment methods used Direct observation % (SD) Self-report (Women) % (SD) Self-report (Providers) % (SD) Total mean adherence score (SD) 38.8 (22.7) a 54.0 (25.2) b 78.9 (16.0) c % mean adherence score per governing authority* Private 34.1 (19.7) a 49.7(23.2) b 78.7 (16.4) c Public 43.0 (24.4) a 55.6 (25.7) b 79.1 (15.8) c % Mean adherence score per level of integration Standalone 46.8 (28.1) a 67.5 (24.2) b 81.3 (15.0) c Partially integrated 34.2 (18.7) a 51.0 (21.0) b 79.9 (15.4) c Fully integrated 33.7 (14.0) a 42.1 (22.9) a 76.0 (17.1) b % mean adherence score by category^ Pre-test information 40.1 (36.2) a 59.8 (34.5) b 87.0 (25.4) c Informed consent 56.3 (25.7) a 39.5 (39.2%) b 72.9 (28.1) c Confidentiality NA 61.5 (36.6) 85.4 (23.5) Post-test counselling 35.5 (19.9) a 51.8 (23.1) b 73.1 (19.2) c Superscript values denote significant differences between categories according to (a vs b, p-value <0.000), (a vs c, p-value <0.0001), (b vs c, p-value <0.0001). *Significant differences between per governing authority according to DO (p-value <0.0001), Self-report (women, p-value <0.0001). ^ Values are compared using the Kruskal-Wallis test. N/A- not available (confidentiality had only one item). Discussion We assessed the adherence to the recommendations of the opt-out HIV testing process. The findings indicate that provider-initiated HIV testing was widely available in all 12 antenatal. We, however, found a considerable gap between the opt-out policy on paper and the observed practice, suggesting that healthcare providers have drifted considerably from the planned intervention delivery (without even knowing). Health practitioners seldom offered the test using the opt-out approach. The low to moderate fidelity means women 1) had inadequate information to make an informed choice, 2) were not empowered enough to make an autonomous decision, 3) experienced some form of non-confidentiality and 4) were not linked to the required care or services. Until this study, the HIV testing literature discourse was that opt-out HIV testing had increased HIV testing uptake ( 31 ). This study has revealed that in the 12 antenatal clinics in Ghana, and potentially in other Low- and Middle-Income Countries (LMICs), HIV testing practices deviate from policymakers' intentions. Moreover, healthcare providers are not adhering to the majority of the essential principles originally designed for pregnant women. The finding suggests that the opt-out HIV testing as a programme may not be credited with the increased testing uptake, neither can it be blamed for the lack of impact. This information would improve how policymakers decide about adopted policies and minimise the potential of wrongfully concluding and terminating a programme for being ineffective. The findings also suggest that decision-makers must be guided by the question, 'are pregnant women receiving the planned opt-out test's content? Answering this question may help clarify why so many women test positive for HIV but fail to enter care and why there are varying effect sizes and uptake across settings. Achieving 100% adherence or implementation fidelity was not possible in this study, which was expected ( 32 ). The finding is unsurprising, as evidence-based interventions are known to constantly undergo some modifications when transferred to a new context ( 33 ). In Malawi, Angotti ( 34 ) demonstrated how counsellors transformed guidelines because they found it challenging to execute due to socio-cultural differences between the Western countries where the policy originated and the Malawian context. Like this study, counsellors, in her study, found strict fidelity to the 3Cs recommendations of the PITC policy challenging ( 34 ). Understandably, it is not always possible, practical, or even desirable to model the implementation of the HIV testing policy as precisely as originally envisaged ( 35 ). What remains unclear is the extent to which frontline staff can modify a programme without deleting essential content ( 35 ). The adaptation process would require technical guidance and continuous feedback to policymakers to avoid compromising the core components needed to produce outcomes. Strengths and limitations This study is the first to assess the context-specific implementation process of opt-out HIV testing among pregnant women, particularly in Ghana. Like any study, the methods have inherent merits and demerits that should guide the interpretation of our findings ( 36 ). Adapting a framework and data collection tools was a threat to the internal and contextual validity of the findings ( 37 ). We applied content validity minimisation principles (e.g. having an expert verify the content of data collection tools). Self-reports also introduced recall and social desirability biases, seen in providers consistently overreporting adherence levels. The use of more than one data collection approaches, including direct observation, to collect data from more than one category of informants on the same phenomenon help triangulate the data to minimise this threat ( 38 ). Conclusions There is evidence of low to moderate fidelity to the intended content of the provider-initiated HIV testing in the 12 antenatal clinics. Gaps in the routine opt-out intervention content delivery could limit the achievement of rights-based testing and may explain the lack of impact in the HIV testing efforts. Declarations Acknowledgments The authors thank administrators, antenatal clinic managers, and survey respondents. In addition, the Ghana AIDS Commission and the National AIDS/STI Control Programme (NACP) offered expert input during the design and data collection stages. Conflict of interest The authors declare no conflict of interest. References Dirlikov E, Kamoga J, Talisuna SA, Namusobya J, Kasozi DE, Akao J et al (2023) Scale-up of HIV antiretroviral therapy and estimation of averted infections and HIV-related deaths—Uganda, 2004–2022. Morb Mortal Wkly Rep 72(4):90 Harrison NE, Oruka KE, Agbaim UC, Adegbite OA, Okeji N (2021) Evaluating the Knowledge of HIV Transmission and Prevention of Mother to Child Transmission (PMTCT) of HIV Among HIV-Positive Mothers Accessing Care in Military Hospital in Lagos, Nigeria. World Journal of Aids Horwood C, Vermaak K, Butler L, Haskins L, Phakathi S, Rollins N (2012) Elimination of paediric HIV in KwaZulu-Natal, South Africa: large-scale assessment of interventions for the prevention of mother-to-child transmission. Bull World Health Organ 90(3):168–175 Assefa Y, Gilks CF (2020) Ending the epidemic of HIV/AIDS by 2030: Will there be an endgame to HIV, or an endemic HIV requiring an integrated health systems response in many countries? Int J Infect Dis 100:273–277 WHO/UNAIDS (2007) Guidance on Provider initiated HIV Testing and Counselling in Health Facilities. WHO/UNAIDS, Geneva Kennedy CE, Fonner VA, Sweat MD, Okero FA, Baggaley R, O'Reilly KR (2013) Provider-initiated HIV testing and counseling in low- and middle-income countries: a systematic review. AIDS Behav 17(5):1571–1590 Ahmed S, Schwarz M, Flick RJ, Rees CA, Harawa M, Simon K et al (2016) Lost opportunities to identify and treat HIV-positive patients: Results from a baseline assessment of provider-initiated HIV testing and counselling (PITC) in Malawi. Trop Med Int Health 21(4):479–485 GAC (2008) National Guidelines for the Implementation of HIV Counseling and Testing in Ghana Evans N (2009) The nursing implications of routine provider-initiated HIV testing and counselling in sub-Saharan Africa: A critical review of new policy guidance from WHO/UNAIDS. Int J Nurs Stud 46(5):723–731 King E, Maman S, Wyckoff S, Pierce M, Groves A (2013) HIV testing for pregnant women: a rights-based analysis of national policies. Glob Public Health 8(3):326–341 Gruskin S, Cottingham J, Hilber AM, Kismodi E, Lincetto O, Roseman MJ (2008) Using human rights to improve maternal and neonatal health: history, connections and a proposed practical approach. Bull World Health Organ. ;86 Sakyi KS, Lartey MY, Kennedy CE, Dension JA, Mullany LC, Owusu PG et al (2020) Barriers to maternal retention in HIV care in Ghana: key differences during pregnancy and the postpartum period. BMC Pregnancy Childbirth 20(1):398 Bennett R (2007) Routine antenatal HIV testing and informed consent: an unworkable marriage? J Med Ethics 33(8):446–448 Rennie S, Behets F (2006) Desperately seeking targets: the ethics of routine HIV testing in low-income countries. Bull World Health Organisation. ;84 Roura M, Watson-Jones D, Kahawita TM, Ferguson L, Ross DA (2013) Provider-initiated testing and counselling programmes in sub-Saharan Africa: a systematic review of their operational implementation. AIDS 27(4):617–626 Dako-Gyeke P, Dornoo B, Ayisi Addo S, Atuahene M, Addo NA, Yawson AE (2016) Towards elimination of mother-to-child transmission of HIV in Ghana: an analysis of national programme data. Int J Equity Health 15(1):5 Baggaley R, Hensen B, Ajose O, Grabbe K, Wong V, Schilsky A (2012) From caution to urgency: the evolution of HIV testing and counseling in Africa. Bull World Health Organ. ;90 Poku RA, Owusu AY, Mullen PD, Markham C, McCurdy SA (2017) Considerations for purposeful HIV status disclosure among women living with HIV in Ghana. AIDS Care 29(5):541–544 Merchant RC, Waxman MJ (2010) HIV screening in health care settings: some progress, even more questions. JAMA 304(3):348–349 Hasson H, Blomberg S, Duner A (2012) Fidelity and moderating factors in complex interventions: a case study of a continuum of care program for frail elderly people in health and social care. Implement Sci 7:23 Meyers DC, Durlak JA, Wandersman A (2012) The quality implementation framework: a synthesis of critical steps in the implementation process. Am J Community Psychol 50(3–4):462–480 Basch CE, Sliepcevich EM, Gold RS, Duncan DF, Kolbe LJ (1985) Avoiding type III errors in health education program evaluations: a case study. Health Educ Q 12(4):315–331 UNAID'S Fact Sheets Fact sheet- World AIDS Day, 2019. Geneva2019 Carroll C, Patterson M, Wood S, Booth A, Rick J, Balain S (2007) A conceptual framework for implementation fidelity. Implement Sci 2(1):40 Chandisarewa W, Stranix-Chibanda L, Chirapa E, Miller A, Simoyi M, Mahomva A et al (2007) Routine offer of antenatal HIV testing (opt-out approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe. Bull World Health Organ. ;85 Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood KJAPMH (2015) Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. ;42 Medley AM, Kennedy CE (2010) Provider challenges in implementing antenatal provider-initiated HIV testing and counseling programs in Uganda. AIDS Educ Prev 22(2):87–99 WHO (2011) Guide for monitoring and evaluating national HIV testing and counselling (HTC) programmes, Field-test version. Geneva, Swtzerland Corp IBM (2017) inventorIBM SPSS Statistics for Windows. NY, USA Toomey E, Matthews J, Hurley DA (2017) Using mixed methods to assess fidelity of delivery and its influencing factors in a complex self-management intervention for people with osteoarthritis and low back pain. BMJ open 7(8):e015452–e Soh M, Hifumi T, Isokawa S, Otani N, Ishimatsu S (2020) The application of 6S in the care of COVID-19 patients: A Japanese perspective. Crit Care. ;24(1) Carvalho ML, Honeycutt S, Escoffery C, Glanz K, Sabbs D, Kegler MC (2013) Balancing fidelity and adaptation: implementing evidence-based chronic disease prevention programs. J Public Health Manag Pract 19(4):348–356 Søvik ML, Larsen T, Tjomsland H, Samdal O (2016) Evaluating the Implementation of the Empowering Coaching™ Programme: Balancing Fidelity and Adaptation. Health Educ 116(3):238–258 Angotti N (1982) Working Outside of the Box: How HIV Counselors in Sub-Saharan Africa Adapt Western HIV Testing Norms. Social science & medicine 2010;71(5):986 – 93 Durlak DPE (2008) Implementation Matters: A Review of Research on the Influence of Implementation on Program Outcomes and the Factors Affecting Implementation. Am J Community Psychol 41(3–4):327–350 Ihantola EM, Kihn LA (2011) Threats to validity and reliability in mixed methods accounting research. Qualitative Res Acc Manage 8(1):39–58 Latkin CA, Edwards C, Davey-Rothwell MA, Tobin KE (2017) The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore. Md Addict Behav 73:133–136 Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ (2014) The use of triangulation in qualitative research. Oncol Nurs Forum 41(5):545–547 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version 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. We do this by developing innovative software and high quality services for the global research community. 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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-4489352","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":307604526,"identity":"1a8aed93-3137-48dd-bfaf-f916b6722e70","order_by":0,"name":"Isaac Amankwaa; PhD, RN","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYBAC+QY4kw1E2BDWwobGTEMRIkrLYSK08B9++OEHg100/+y2NIkfNeflDe43MAJF7tjj1CKRZizZw5CcO+POsWOSPcduG244xsAMFHnGjFsLg4E0AwNzbsON9LYbPGy3GYFaGIAih3G6j43/+OffDAz1ufOBWm7++XfOHmQLUOQwD27v55iBzMzdcCPt2G3etgOJQC1sIBEJ3A7LKbPsMTieu/FGWvpv2b7k5JnHEtuAIocNcGmR7z+++caPiurceTfSjA3ffLOz7Tt8+DBQ5DDOEIMAVBMZG9BFRsEoGAWjYBSQCADt3VTpBc0N2gAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-7879-4731","institution":"Auckland University of Technology","correspondingAuthor":true,"prefix":"","firstName":"Isaac","middleName":"Amankwaa;","lastName":"Ph","suffix":"PhD"},{"id":307604527,"identity":"dd8505ff-d3d0-4f91-880c-fa5814be8098","order_by":1,"name":"Robyn Maude; PhD","email":"","orcid":"https://orcid.org/0000-0002-0749-6542","institution":"Victoria University of Wellington","correspondingAuthor":false,"prefix":"","firstName":"Robyn","middleName":"","lastName":"Maude","suffix":"PhD"},{"id":307604528,"identity":"07427121-2527-4bea-9af9-199303316fa9","order_by":2,"name":"Joan Skinner; PhD","email":"","orcid":"","institution":"Victoria University of Wellington","correspondingAuthor":false,"prefix":"","firstName":"Joan","middleName":"","lastName":"Skinner","suffix":"PhD"}],"badges":[],"createdAt":"2024-05-28 08:32:59","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4489352/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4489352/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57355098,"identity":"063cc38b-fbbd-435f-be36-e0c6234db2c4","added_by":"auto","created_at":"2024-05-29 13:58:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80650,"visible":true,"origin":"","legend":"\u003cp\u003eAn adapted conceptual framework of implementation fidelity (24)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4489352/v1/b56e4b4691a113e3bb9a8d93.png"},{"id":57354557,"identity":"f6aae6a7-4381-4a34-ba16-81b9f54f136c","added_by":"auto","created_at":"2024-05-29 13:50:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":105167,"visible":true,"origin":"","legend":"\u003cp\u003eRecommended ANC HIV testing activities (Source: Chandisarewa, Stranix-Chibanda (25))\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4489352/v1/ce9d6eed6318d71c5bbce054.png"},{"id":57354558,"identity":"2fa19cab-a233-457d-bad3-2ea1bc6b374e","added_by":"auto","created_at":"2024-05-29 13:50:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51527,"visible":true,"origin":"","legend":"\u003cp\u003eBiased in adherence measure between direct observations and self-report\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4489352/v1/6d70395cf535db4adc9925ff.png"},{"id":57356044,"identity":"dd69db32-d10b-41d9-bb43-b1d7f883db69","added_by":"auto","created_at":"2024-05-29 14:06:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1385600,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4489352/v1/c041c7ab-4a8c-4533-9e85-b9b29a6b9d41.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eImplementation fidelity of provider-initiated opt-out HIV testing of pregnant women attending antenatal clinics in Ghana: a multi-site process evaluation.\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, in 2022, an estimated 1.5\u0026nbsp;million children were living with HIV (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). Children acquire HIV infection primarily through mother-to-child transmission (MTCT) (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). MTCT can be interrupted if a woman becomes aware of her HIV-positive status and adheres to the prevention of mother-to-child transmission (PMTCT) interventions (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). For this reason, HIV testing has become a critical pathway for HIV prevention strategies (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). Efforts to improve HIV testing uptake led to provider-initiated HIV testing and counselling (PITC) in 2007 by UNAIDS/WHO (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e). In PITC, the responsibility for initiating HIV testing is shifted from the individual to the healthcare practitioner (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). Three categories of PITC exist: symptom-based (testing specific individuals or subpopulations symptomatic of HIV), opt-in (an individual actively accepts to be tested for HIV), and opt-out (the provider informs an individual that HIV testing is routine/standard of care, and consent is assumed unless the individual declines explicitly (opt-out) (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eGhana implemented \u0026apos;opt-out\u0026apos; HIV testing in all prenatal clinics in 2008 after adopting the WHO/UNAIDS PMTCT guideline (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). Concerns have been raised on whether a policy targeting women to achieve a public health interest of increased test uptake would be compatible with preserving human rights (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). It has also been argued that healthcare providers may not be able to obtain authentic informed consent in a setting characterised by a power imbalance, unfavourable gender norms, overcrowded clinics with no private spaces and staff shortages (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e). It is suggested that over time, routinely testing women for HIV may lessen healthcare providers\u0026apos; awareness of related ethical issues (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e). An analysis of HIV testing policies from 19 countries revealed an inconsistent and poor policy description in policy documents (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). This situation may lead to the healthcare provider misinterpreting the policy during the delivery.\u003c/p\u003e\n\u003cp\u003eDespite these concerns, mainstream HIV testing research has remained outcome oriented. These studies have demonstrated variable test acceptance ranging from 94\u0026ndash;24% (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). Many women testing positive do not enter PMTCT services (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e), nor disclose their new status (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). The wide acceptance rate and lack of impact may suggest that the HIV testing process in ANC (e.g. providers\u0026apos; understanding of opt-out and how they offer the test) determines women\u0026apos;s decision about the test (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). Evaluators address this evidence gap through implementation fidelity, which involves comparing the intervention as contained in policy documents and the intervention as delivered (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). Implementation fidelity helps uncover the intervention\u0026apos;s strengths and weaknesses (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). It forestalls Type III errors in evaluation, where one mistakenly attributes a lack of effect to the intervention without considering the implementation quality (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTo our knowledge, this is the first study to examine the implementation fidelity of the opt-out HIV testing intervention in antenatal settings. The findings would contribute to the world\u0026apos;s attempt to use antenatal HIV testing to attain zero HIV infection by 2030 (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). We aim to gain insights into whether women\u0026apos;s rights are (or are not) addressed in the antenatal HIV testing programme in Ghana\u0026apos;s antenatal clinics. The adherence dimensions addressed were coverage and \u003cem\u003econtent\u003c/em\u003e. The study addressed these two questions:\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003ea. to what extent do healthcare providers understand and adhere to the opt-out approach when offering HIV testing?\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003eb.\u0026nbsp;\u003c/span\u003e\u003cspan\u003eto what extent do healthcare providers adhere to the recommended 5Cs when offering HIV testing?\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e"},{"header":"Evaluation methodology and methods","content":"\u003ch2\u003eConceptual framework\u003c/h2\u003e\n\u003cp\u003eInspired by the Medical Research Council\u0026rsquo;s Guidance on process evaluation of complex interventions, our process evaluation draws on the modified version of the conceptual framework of implementation fidelity (24). The framework\u0026apos;s principal component is the assessment of adherence to the intervention, defined as the degree to which the intervention has been delivered as intended. Adherence is conceptualised as coverage, content, frequency, and duration. Fidelity is high if the programme implementation adheres to the original intervention model (i.e. the opt-out approach and the core human rights principles). We maintained adherence to the intervention\u0026apos;s content, coverage, and potential moderators used in the original framework. This study reports on adherence to the coverage and content of the intervention.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eDescription of the antenatal-based opt-out HIV testing intervention\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eIn ANC groups, a midwife delivers a 15\u0026ndash;20-minute pre-test session information session that covers general pregnancy, the testing process, HIV transmission, and the meaning of the results. Further details are offered individually if needed. In the consultation rooms, the midwife reaffirms prior information and informs women about routine HIV testing, with consent presumed unless explicitly refused (opt-out). Women consenting undergo rapid testing, with negative results receiving brief post-test guidance. Positive results prompt extensive counselling and antiretroviral therapy offer. (see Figure 2).\u003c/p\u003e\n\u003ch2\u003eStudy setting\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis cross-sectional study was conducted between August 2018 and April 2019 in 12 antenatal clinics distributed across three regions (Ashanti, Tano South and Bono East). We employed a criterion-based sampling (26) to purposively select the 12 antenatal clinics that offered HIV testing as part of routine antenatal care. These clinics consented in writing to be part of the study. The approach allowed a priori consideration of clinic features deemed essential in answering the process evaluation questions. It also ensured a maximum variation of key characteristics such as clinic size, patient-provider ratio and geographical location (27). The included clinics had HIV testing services that were fully (n=4) or partially integrated (n=5) or standalone clinics (n=3) but within the same building as the antenatal clinic. We defined private clinics as those owned by individuals and religious bodies.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003ch3\u003eTools for assessing adherence to core elements\u003c/h3\u003e\n\u003cp\u003eWe used structured direct observation and self-reports by the healthcare provider and pregnant women to measure adherence. A provider and pregnant women\u0026apos;s self-report and structured observation checklist were developed from the core elements adapted from the \u0026apos;Guide for Monitoring and Evaluating National HIV Testing and Counselling Programmes\u0026apos; (28) and a review of Ghana\u0026apos;s policy documents. The self-reports and the observation checklist incorporated the same 16 core elements expected to be delivered by the clinician in the ANC. The questionnaire asked providers to indicate whether they implemented the identified components as contained in the testing guidelines. We then asked women if they had received the intervention. We ensured the content validity of the survey instrument by inviting an expert from the National AIDS Control Programme\u0026rsquo;s (NACP) staff who verified that the final tool reflected the content contained in Ghana\u0026rsquo;s policy documents. \u0026nbsp;We adapted the questionnaires to the target groups by pre-testing them on a sample similar to the target group.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eBrief facility survey and review of antenatal clinic register\u003c/h3\u003e\n\u003cp\u003eThe 12 antenatal clinic managers answered a brief facility survey using the antenatal clinic audit tool for this study. Questions included routine ANC and HIV testing activities, counselling and testing approach, staff numbers, and estimated time for delivering clinic activities. A review of the antenatal clinic register complemented this data.\u003c/p\u003e\n\u003ch3\u003ePregnant women\u0026nbsp;self-report survey\u003c/h3\u003e\n\u003cp\u003eA woman was eligible if pregnant, 18 years of age or over, making their first or second ANC visit and could give informed consent. We excluded women whose test came back positive for HIV on the day due to the shock that accompanies a positive HIV. We also excluded women with medical conditions that required further management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sample size was estimated using the formula n = (Z^2 * P * (1-P)) / (E^2). \u0026nbsp;Where n is the sample size, Z is the confidence level of 95%, P is the proportion of women of fertility age (23%), and 5% precision (expressed as 0.05). The sample size was calculated to be n = (1.96^2 * 0.23 * (1-0.23)) / (0.05^2), resulting in a sample size of approximately 422 pregnant women. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on the average number of pregnant women who visited each antenatal clinic during the previous ten months, a proportional allocation of each clinic\u0026rsquo;s total sample size was calculated (see Table 1). A total of 483 questionnaires were distributed using convenient sampling.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1: sample size estimation for pregnant women survey\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"596\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eCalculated total sample size (N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003eAverage monthly antenatal attendance (x)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003eSub-sample (x/300*N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003eActual sample obtained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003eSample after exclusion of incomplete questionnaires\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eFacility 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44295302013423%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.798657718120804%\" valign=\"top\"\u003e\n \u003cp\u003e1957\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" valign=\"top\"\u003e\n \u003cp\u003e483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.624161073825505%\" valign=\"top\"\u003e\n \u003cp\u003e448\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch3\u003eHealthcare provider self-report survey\u003c/h3\u003e\n\u003cp\u003eWe invited all healthcare providers directly involved in HIV testing at the ANC to participate in the survey and to have their HIV testing consultations observed. Staff became aware that we would assess the delivery of the HIV testing intervention and not their professional competence or judge their practice. We further emphasised the study\u0026apos;s confidentiality and that we would aggregate all findings, with the hospital\u0026apos;s and individuals\u0026apos; names omitted. Healthcare providers consented without signing a consent form, in line with the anonymity measures previously discussed. We delivered questionnaires in envelopes, and providers dropped them in the provided at the end of their shift.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eA researcher administered direct structured observation.\u003c/h3\u003e\n\u003cp\u003eTesting and counselling sessions observed were purposively selected based on the provider and women\u0026apos;s willingness for an observer to be in the consulting room. The confidentiality agreement extended to the observer not communicating any observed practice with the provider\u0026apos;s supervisor. Healthcare providers who consented signed an informed consent form.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eSelf-report and structured observation data were entered, cleaned, and validated using Microsoft Excel. We created datasets and keyed information into Excel sheets. A total of 35 (7.2%) pregnant women survey questionnaires were either not answered or had more than 50% missing data and were therefore excluded, leaving 448 valid questionnaires to be analysed. We recorded no missing data for the provider surveys. After resolving discrepancies, data were exported to SPSS V25 (29) for further analysis. The study used descriptive statistics (frequency, median, ranges, standard deviation, and percentages) to describe the characteristics of the study sample and general clinic characteristics. The analysis of adherence levels followed analytic procedures used by\u0026nbsp;Toomey (29). The differences in continuous data were assessed using the one-way analysis of variance (ANOVA) and Kruskal-Wallis tests where appropriate. The levels of agreement between methods and inter-rater reliability of the observed and collected data were assessed using percentage concordance. Overall mean fidelity of content and fidelity scores according to a government authority, level of integration and percentage means adherence scores were obtained by calculating total actual scores as a percentage of the total possible score. High\u0026nbsp;fidelity levels were interpreted as previously reported in the literature, with 80%\u0026ndash;100% adherence interpreted as\u0026nbsp;\u0026apos;high\u0026apos; fidelity, 51%\u0026ndash;79% as \u0026apos;moderate\u0026apos; and 0%\u0026ndash;50% as\u0026nbsp;\u0026apos;low\u0026apos; fidelity\u0026nbsp;(30). Finally, the relationship between fidelity\u0026nbsp;scores and the number of participants present\u0026nbsp;was calculated using\u0026nbsp;Spearman\u0026apos;s correlation coefficient. P-values of less than 0.05 were interpreted as statistically significant.\u003c/p\u003e\n\u003ch2\u003eEthical statement\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWe received ethical approval from Victoria University of Wellington\u0026apos;s Human Ethics Committee (25399) and Ghana Health Service Ethical Review Committee (GHS-ERC:009/11/17) The 12 prenatal clinics gave us written authorisation to use the facility and access their routine data. Pregnant women and healthcare professionals gave verbal consent after being informed of the study\u0026apos;s goals, advantages, hazards, confidentiality, and voluntariness. Healthcare providers whose counselling sessions observed counselling gave written consent. We did not get informed permission from pregnant women because the observation focused on the provider. The healthcare provider asked the women if they wanted a researcher in the consulting room before monitoring any counselling session. No observation took place for women who disagreed and showed hesitation of counselling session being observed..\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eDistribution and profile of antenatal clinics\u003c/h2\u003e\n\u003cp\u003eTable 2 summarises the characteristics of the 12 ANCs. Clinics were owned by private (n=5) or government (n=7) entities. Privately-owned clinics were more likely to be semi-urban. The ANC\u0026apos;s routinely collected data showed that in 2018, three of the clinics saw more than 2000, and these clinics were all government-owned and located in urban settings. Eight clinics, distributed equally among private and public hospitals, served 1000 to 2000 pregnant women annually. Public hospitals recorded a higher workload per week per clinical staff than their counterpart in private facilities.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2: Profile of clinics included in this study\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.52090032154341%\" colspan=\"2\" valign=\"top\" style=\"width: 56.0595%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eClinic variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003eGovernment\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(n=7)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003ePrivate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n=5)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.52090032154341%\" colspan=\"2\" valign=\"top\" style=\"width: 56.0595%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eUrban, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e5(71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e3(60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eSemi-urban, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e2(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e2(40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.52090032154341%\" colspan=\"2\" valign=\"top\" style=\"width: 56.0595%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated clinic attendance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003e\u0026gt;2000/month, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e3(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003e1000-2000/month, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e4(57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e4(80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003e\u0026lt;1000/month, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e1(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.52090032154341%\" colspan=\"2\" valign=\"top\" style=\"width: 56.0595%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntenatal clinic-related services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eFocused ANC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e7(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e4(80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eA group health talk, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e7(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e5(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eHistory taking \u0026amp; physical examination, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e7(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e5(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eLab services (e.g. syphilis, malaria, G6PD), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e3(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e3(60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eTime spent in delivering health talk (mins), mean (SD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e19(3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e18(2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eSize of a group for a health talk, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e41(18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e61(11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.52090032154341%\" colspan=\"2\" valign=\"top\" style=\"width: 56.0595%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIV-related services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eThe opt-out offer of HIV test, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e7(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e5(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eHIV service available 5 days/week, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e6(85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e2(40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eRapid HIV testing, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e7(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e5(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eInformation about HIV testing giving during health talk (Yes), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e7(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e5(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003ePositive test results confirmed at ANC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e4(57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e1(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eInitiation of ART for pregnant women testing positive for HIV (Yes), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e4(57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e1(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eHIV testing performed by ANC staff, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e6(85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e1(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eHIV testing performed by dedicated staff outside the ANC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e2(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e3(60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.52090032154341%\" colspan=\"2\" valign=\"top\" style=\"width: 56.0595%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHuman resource capacity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.881028938906752%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eNumber clinicians (mean, range)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e3(0-18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e2(0-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eNumber of nurses (mean, range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e10 (3-30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e9(3-20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eNumber of HIV testing pregnant women/week (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e426.3(260-1153)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e392.3(175-459.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.508856682769726%\" valign=\"top\" style=\"width: 4.3123%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"53.94524959742351%\" valign=\"top\" style=\"width: 51.7472%;\"\u003e\n \u003cp\u003eNumber of weekly HIV testing clients/staff (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e60.7 (32.8-103.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.908212560386474%\" valign=\"top\" style=\"width: 16.171%;\"\u003e\n \u003cp\u003e33(27-41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD=standard deviation; ANC=antenatal clinic; HIV=Human Immunodeficiency virus\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource\u003c/strong\u003e: ANC register/field notes\u003c/p\u003e\n\u003ch2\u003eCharacteristics of pregnant women\u003c/h2\u003e\n\u003cp\u003eOf the 448 pregnant women who answered the exit survey, 326 (71.8%) were from publicly funded hospitals. The entire sample\u0026apos;s mean age was 28.3 years (SD=5.63; range 16 to 44 years), with the majority (80%) being between 27 and 30 years. Most women were urban dwellers (60%), married (73%), had some form of employment (75%), and had more than one pregnancy (75%). About 11% of pregnant women had no formal education, while 17% had high school education and above. Women attending public clinics differed significantly from private clinics regarding age, residence, and marital status but not in the number of pregnancies and occupation.\u0026nbsp;Table 3\u0026nbsp;summarises the characteristics of pregnant women.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;3:Socio-demographic characteristics of pregnant women\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"596\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.711409395973153%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.825503355704697%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGovernment clinic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=326(71.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.335570469798657%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrivate clinic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=122 (27.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.12751677852349%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.711409395973153%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age in years (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.825503355704697%\" valign=\"top\"\u003e\n \u003cp\u003e28(6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.335570469798657%\" valign=\"top\"\u003e\n \u003cp\u003e29(6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.12751677852349%\" valign=\"top\"\u003e\n \u003cp\u003e0.0231\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.711409395973153%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of residence, n (%) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.825503355704697%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.335570469798657%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.12751677852349%\" valign=\"top\"\u003e\n \u003cp\u003e0.0025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e196(60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e77(63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003ePeri-urban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e83(26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e42(34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e41(13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.711409395973153%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status, n (%) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.825503355704697%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.335570469798657%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.12751677852349%\" valign=\"top\"\u003e\n \u003cp\u003e0.0035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eSingle\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e91(28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e16(13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eDivorced\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e4(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e2(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e225(69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e104(85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e6(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.46218487394958%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of pregnancies n(%) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e0.2116\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eFirst pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e80(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e24(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; 1 pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e240(74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e98(80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e6(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.711409395973153%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation, n (%) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.825503355704697%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.335570469798657%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.12751677852349%\" valign=\"top\"\u003e\n \u003cp\u003e0.3543\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e61(19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e19(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e19(6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e6(5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e249(76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e97(80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e6(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.711409395973153%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational level, n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.825503355704697%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.335570469798657%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.12751677852349%\" valign=\"top\"\u003e\n \u003cp\u003e0.1421\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e40(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e10(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eCompleted primary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e26(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e7(6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eCompleted junior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e124(38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e40(33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eCompleted senior \u0026nbsp;high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e89(27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e35(29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.394957983193276%\" valign=\"top\"\u003e\n \u003cp\u003eSome diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.865546218487395%\" valign=\"top\"\u003e\n \u003cp\u003e24(5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.3781512605042%\" valign=\"top\"\u003e\n \u003cp\u003e16(13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.159663865546218%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch2\u003eCharacteristics of healthcare providers\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eTable 4\u0026nbsp;summarises the characteristics of healthcare providers. Most providers were from government-operated ANCs, compared to 34% in privately-run clinics. Providers were mostly females (89%) with a median age of 29 (20-59). A little over half (61%) reported having attained a diploma in nursing education, with more respondents from private-run hospitals acquiring some degree. More than half (68.9%) identified as midwives. The rest were nurses (17%), nursing assistants (5%), medical officers (2%) and HIV counsellors (5%). Private hospitals reported a higher proportion of midwives than government hospitals (76% versus 67%). Overall, respondents had provided HIV testing services for a median duration of 2 years (1-14). No statistically significant difference existed between providers in private and government hospitals regarding sex, age, years of working experience and professional background.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;4: Socio-demographic characteristics of providers\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.5%\" colspan=\"2\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGovernment n=100 (66.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrivate n=51(33.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"88.01996672212978%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex, 8 (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.980033277870216%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 0.36112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e87(86.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e47(91.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e13(13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e4(8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.5%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (median, range\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e28(20-48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e30(23-59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.5%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYrs. of HIV testing experience (median, range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e2(1-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e2(1-14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"88.01996672212978%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational background, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.980033277870216%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 0.4759\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eSenior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e2(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eCertificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e19(19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e9(18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e61 (61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e28(56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e17(17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e13(26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"88.01996672212978%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional background, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.980033277870216%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 0.5244\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eRegistered Midwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e67(67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e37(75.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eRegistered Nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e18(18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e8(16.3))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eMedical Doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e3(3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eNursing Assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e7(7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1(2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eHIV counsellor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e4(4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e3(6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.6666666666666665%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"42.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eOther (field technician)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cbr\u003e\u003c/h2\u003e\n\u003ch2\u003eAdherence to coverage\u003c/h2\u003e\n\u003cp\u003eCoverage was conceptualised in this study as the opportunity for pregnant women to know their HIV status while visiting the antenatal clinic [6]. Data on clinic attendance was available for 8 clinics, showing a total of 80933 clinic attendance.\u0026nbsp;Seventeen per cent (13760)\u0026nbsp;were first-time attendees and therefore offered an HIV test.\u0026nbsp;A total of\u0026nbsp;13505 (98.1%) accepted the test offer.\u0026nbsp;Table 5\u0026nbsp;summarises the coverage of HIV testing in the 8 clinics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;5: Coverage and HIV prevalence of rapid HIV testing (2017) in 8 selected clinics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacilities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Attendance for 2017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst attendance and offered HIV test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e% accepting and testing for HIV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e1884\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e1884\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e27022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e2652\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e2619\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility 3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e9426\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e1684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e1684\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e20891\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e3307\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e3085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility 5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e7234\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e984\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility 6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e4363\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e1453\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e1453\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility 7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e5596\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e1040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e1040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility 8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e4401\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e756\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e756\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.15702479338843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotals (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.958677685950413%\" valign=\"top\"\u003e\n \u003cp\u003e80933(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.93388429752066%\" valign=\"top\"\u003e\n \u003cp\u003e13760(17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.950413223140497%\" valign=\"top\"\u003e\n \u003cp\u003e13505(98.1% acceptance rate)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAdherence to the content of the opt-out test offer\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe approach of the test offer did not always correspond with the guideline\u0026apos;s recommendations (Table 5). Only 5 of the 12 clinics obtained informed consent through the opt-out approach, while 4 employed the opt-in approach. Three clinics employed a combination of opt-in and opt-out approaches. Despite the GAC and UNAIDS/WHO recommendations that removed the need for pre-test counselling, this study found that five ANCs employed some form of individual pre-test counselling. About half of the clinics adhered to this recommendation by delivering pre-test information in groups before an HIV test. No evidence of pre-test counselling or information delivery was observed in one clinic.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;6: Healthcare provider adherence to the opt-out approach to test offer\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63084922010398%\" colspan=\"2\" valign=\"top\" style=\"width: 52.8053%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApproach of test offer\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.998266897746968%\" valign=\"top\" style=\"width: 10.0747%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"95.84055459272098%\" colspan=\"3\" valign=\"top\" style=\"width: 73.8232%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eType of consent procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.679376083188908%\" valign=\"top\" style=\"width: 3.6477%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.95147313691508%\" valign=\"top\" style=\"width: 49.3312%;\"\u003e\n \u003cp\u003eOpt-in approach only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.998266897746968%\" valign=\"top\" style=\"width: 10.0747%;\"\u003e\n \u003cp\u003e4(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.679376083188908%\" valign=\"top\" style=\"width: 3.6477%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.95147313691508%\" valign=\"top\" style=\"width: 49.3312%;\"\u003e\n \u003cp\u003eOpt-out approach only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.998266897746968%\" valign=\"top\" style=\"width: 10.0747%;\"\u003e\n \u003cp\u003e5(41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.679376083188908%\" valign=\"top\" style=\"width: 3.6477%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.95147313691508%\" valign=\"top\" style=\"width: 49.3312%;\"\u003e\n \u003cp\u003eBoth opt-in and opt-out\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.998266897746968%\" valign=\"top\" style=\"width: 10.0747%;\"\u003e\n \u003cp\u003e3(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"95.84055459272098%\" colspan=\"3\" valign=\"top\" style=\"width: 73.8232%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eApproach to informing women about the test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.679376083188908%\" valign=\"top\" style=\"width: 3.6477%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.95147313691508%\" valign=\"top\" style=\"width: 49.3312%;\"\u003e\n \u003cp\u003ePre-test counselling only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.998266897746968%\" valign=\"top\" style=\"width: 10.0747%;\"\u003e\n \u003cp\u003e5(41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.679376083188908%\" valign=\"top\" style=\"width: 3.6477%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.95147313691508%\" valign=\"top\" style=\"width: 49.3312%;\"\u003e\n \u003cp\u003ePre-test information only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.998266897746968%\" valign=\"top\" style=\"width: 10.0747%;\"\u003e\n \u003cp\u003e6(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.679376083188908%\" valign=\"top\" style=\"width: 3.6477%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.95147313691508%\" valign=\"top\" style=\"width: 49.3312%;\"\u003e\n \u003cp\u003eBoth pre-test counselling and information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.998266897746968%\" valign=\"top\" style=\"width: 10.0747%;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.679376083188908%\" valign=\"top\" style=\"width: 3.6477%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.95147313691508%\" valign=\"top\" style=\"width: 49.3312%;\"\u003e\n \u003cp\u003eNeither pre-test counselling nor information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.998266897746968%\" valign=\"top\" style=\"width: 10.0747%;\"\u003e\n \u003cp\u003e1(8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch2\u003eAdherence to the content of consent, confidentiality, counselling, and connection to services\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eTable 7\u0026nbsp;shows the frequency distribution of responses to each item on the adherence scale. There was significant bias (p-value \u0026lt;0.0001) observed for each response based on the type of ratter (direct observation and self-report). The \u0026apos;Yes\u0026apos; response for each item was skewed towards self-reports (provider). A consistent response was observed for item 6 (agreed to test) between direct observation and self-report (provider) but not self-report (women). Also, consistency in adherence response between direct observation and self-report (women) was observed for item 12 (discussed partner testing) and item 14 (explained support services).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdherence to the requirement of informed consent scored low for direct observation (\u003cem\u003eM=\u003c/em\u003e54.71,\u003cem\u003e\u0026nbsp;SD=\u003c/em\u003e23.25), moderate for pregnant women\u0026apos;s self-reports (\u003cem\u003eM\u003c/em\u003e= 54.71 \u003cem\u003eSD=\u003c/em\u003e13.45), and moderately high for healthcare providers\u0026apos; self-reports (\u003cem\u003eM=\u003c/em\u003e85.06\u003cem\u003e, SD=\u0026nbsp;\u003c/em\u003e12.60). However, most healthcare providers felt they instituted adequate measures to ensure a private testing process, as almost all (95.4%) affirmed the confidential nature of the process. More than half (69.8%) of the women corroborated this finding. Similarly, explaining to women that providers would not share test results without their permission received a moderately high (78.1%) adherence rating from providers, moderate (54.3%) from women and exceptionally low (19.7%) by direct observation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealthcare providers highly adhered to making women aware of what a negative test result meant. However, this was not the case in telling women about preventive strategies for HIV after testing negative, as just over half of the women (52.8%) reported receiving this information. Informing women of the need to bring a partner for testing was the least discussed post-test counselling by all the assessment methods, with only 31% of women saying that the healthcare provider offered this advice. The study saw a similar trend in non-adherence to the content of post-test counselling in explaining to women the possibility of a window period and retesting during the 34\u003csup\u003eth\u003c/sup\u003e week, and allowing women to ask questions.\u0026nbsp;Explaining support services was least adhered to as assessed by direct observation (6.5%) and pregnant women\u0026apos;s self-reports (5.9%). More than half of pregnant women (52.8%) mentioned that providers advised them on preventive measures, compared to the observations (36.8%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;7:Frequency of response to each item on the adherence scale\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDirect Observation\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-report, woman\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-report Provider\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eThe HIV testing process explained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e86 (54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e309 (70.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e131 (89.1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eMother-to-child transmission explained.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e58 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e297 (67.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e129 (86.0) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eThe meaning of positive \u0026amp; negative explained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e73 (47.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e274 (61.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e132 (88.6) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eWomen made aware of HIV preventive options\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e62 (39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e250 (56.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e131 (90.3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eThe woman is allowed to ask questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e38 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e207 (47.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e133 (90.5) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eA woman agreed to test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e142 (\u003cstrong\u003e91.0\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e212 (48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e139 (\u003cstrong\u003e93.9\u003c/strong\u003e) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eProvider informed mother about her right to decline the test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e36 (22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e141 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e81 (57.0) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.603305785123967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.107438016528924%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;(\u003cstrong\u003eMean\u003c/strong\u003e: SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e(\u003cstrong\u003e45.1\u003c/strong\u003e,23.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.03305785123967%\" valign=\"top\"\u003e\n \u003cp\u003e(\u003cstrong\u003e54.71\u003c/strong\u003e,13.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.206611570247935%\" valign=\"top\"\u003e\n \u003cp\u003e(\u003cstrong\u003e85.06\u003c/strong\u003e,12.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eConfidentiality\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eExplained that results would not be shared\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e31 (19.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e238 (54.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e114 (78.1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eProvider \u0026amp; client believed results kept confidential\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e312 (69.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e144 (95.4) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCounselling\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eMeaning of results explained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e146 (\u003cstrong\u003e95.4\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e389 (\u003cstrong\u003e88.4\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e122 (\u003cstrong\u003e80.8\u003c/strong\u003e) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eAdvise on prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e56 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e232 (52.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e114 (76.0) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003ePartner testing discussed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e54 (34.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e136 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e67 (46.2) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eWindow period explained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e36 (23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e232 (51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e115 (79.3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003e(Mean: SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e(45.1,23.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e(45.1,23.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e(45.1,23.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eConnection to care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eExplain support services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e10 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e26 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e107 (72.8) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.6158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.854304635761586%\" valign=\"top\"\u003e\n \u003cp\u003eAllow time for questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23841059602649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e19 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e193 (43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2317880794702%\" valign=\"top\"\u003e\n \u003cp\u003e104 (69.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Statistically significant\u003c/p\u003e\n\u003cp\u003eThe mean percentage bias in adherence measure between direct observation and self-report (provider) was significantly higher compared with that observed between direct observation and self-report (women) (41.0 vs 16.8, p-value \u0026lt;0.0001). (See Figure 3)\u003c/p\u003e\n\u003cp\u003eTable 7\u0026nbsp;shows the level of agreement between adherence measured by direct observation and self-reported adherence. Agreement between direct observation and self-report (women) in measuring low, moderate, and high adherence was 16.3%, 35.5% and 18.8%, respectively. Also, an agreement between direct observation and self-report (provider) in measuring low, moderate, and high adherence was 10.6%, 16.1% and 43.8%, respectively. Overall, the level of agreement between direct observation and self-report (women) in measuring adherence was very poor (kappa= -0.082). Similarly, the level of agreement between direct observation and self-report (provider) in measuring adherence was very poor (kappa= -0.034).\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;8: Measures of agreement between direct observations and self-reports\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"584\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.801369863013697%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N=151)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.06164383561644%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eDirect observation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67123287671233%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eKappa coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.465753424657535%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eKendall\u0026apos;s tau-b\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.855018587360593%\" valign=\"top\"\u003e\n \u003cp\u003eLow adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.572490706319705%\" valign=\"top\"\u003e\n \u003cp\u003eModerate adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.572490706319705%\" valign=\"top\"\u003e\n \u003cp\u003eHigh adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.801369863013697%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-report (women)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.212328767123287%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67123287671233%\" valign=\"top\"\u003e\n \u003cp\u003e-0.082\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.465753424657535%\" valign=\"top\"\u003e\n \u003cp\u003e-0.208\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.801369863013697%\" valign=\"top\"\u003e\n \u003cp\u003eLow adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.212328767123287%\" valign=\"top\"\u003e\n \u003cp\u003e17 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e7 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e9 (56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67123287671233%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.465753424657535%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.801369863013697%\" valign=\"top\"\u003e\n \u003cp\u003eModerate adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.212328767123287%\" valign=\"top\"\u003e\n \u003cp\u003e34 (32.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e11 (35.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e4 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67123287671233%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.465753424657535%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.801369863013697%\" valign=\"top\"\u003e\n \u003cp\u003eHigh adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.212328767123287%\" valign=\"top\"\u003e\n \u003cp\u003e53 (51.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e13 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e3 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67123287671233%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.465753424657535%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.801369863013697%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-report (Provider)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.212328767123287%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67123287671233%\" valign=\"top\"\u003e\n \u003cp\u003e-0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.465753424657535%\" valign=\"top\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.801369863013697%\" valign=\"top\"\u003e\n \u003cp\u003eLow adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.212328767123287%\" valign=\"top\"\u003e\n \u003cp\u003e11 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67123287671233%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.465753424657535%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.801369863013697%\" valign=\"top\"\u003e\n \u003cp\u003eModerate adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.212328767123287%\" valign=\"top\"\u003e\n \u003cp\u003e29 (27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e5 (16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e9 (56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67123287671233%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.465753424657535%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.801369863013697%\" valign=\"top\"\u003e\n \u003cp\u003eHigh adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.212328767123287%\" valign=\"top\"\u003e\n \u003cp\u003e64 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e25 (80.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.924657534246576%\" valign=\"top\"\u003e\n \u003cp\u003e7 (43.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67123287671233%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.465753424657535%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 9\u0026nbsp;shows fidelity results calculated from percentage adherence totals. Fidelity was found to be low in direct observation and self-report (women) assessment methods, with a mean score of 38.8% (range of 61.1%\u0026ndash;95.8%) for direct observation and 54.0% for the self-report (women). The fidelity results for each method with scores \u0026ge;80% (cut-off for \u0026apos;high\u0026apos; fidelity) are in bold. Significant differences between governing authority, level of integration and sub-category\u0026apos; individual fidelity scores were found. Fidelity was found to be moderately high (78.9%) for self-report (provider)\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;9: Adherence levels based on assessment methods used\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eDirect observation\u003c/p\u003e\n \u003cp\u003e% (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-report (Women)\u003c/p\u003e\n \u003cp\u003e% (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-report (Providers)\u003c/p\u003e\n \u003cp\u003e% (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cp\u003eTotal mean adherence score (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e38.8 (22.7)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e54.0 (25.2)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e78.9 (16.0)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"84.43708609271523%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e% mean adherence score per governing authority*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePrivate\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e34.1 (19.7)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e49.7(23.2)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e78.7 (16.4)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePublic\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e43.0 (24.4)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e55.6 (25.7)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e79.1 (15.8)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"84.43708609271523%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e% Mean adherence score per level of integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eStandalone\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e46.8 (28.1)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e67.5 (24.2)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e81.3\u003c/strong\u003e (15.0)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePartially integrated\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e34.2 (18.7)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e51.0 (21.0)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e79.9 (15.4)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eFully integrated\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e33.7 (14.0)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e42.1 (22.9)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e76.0 (17.1)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cp\u003e% mean adherence score by category^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePre-test information\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e40.1 (36.2)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e59.8 (34.5)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e87.0 (25.4)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eInformed consent\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e56.3 (25.7)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e39.5 (39.2%)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e72.9 (28.1)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eConfidentiality\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e61.5 (36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e85.4\u003c/strong\u003e (23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.50993377483444%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePost-test counselling\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e35.5 (19.9)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e51.8 (23.1)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e73.1 (19.2)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSuperscript values denote significant differences between categories according to (a vs b, p-value \u0026lt;0.000), (a vs c, p-value \u0026lt;0.0001), (b vs c, p-value \u0026lt;0.0001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*Significant differences between per governing authority according to DO (p-value \u0026lt;0.0001), Self-report (women, p-value \u0026lt;0.0001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e^ Values are compared using the Kruskal-Wallis test. N/A- not available (confidentiality had only one item). \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe assessed the adherence to the recommendations of the opt-out HIV testing process. The findings indicate that provider-initiated HIV testing was widely available in all 12 antenatal. We, however, found a considerable gap between the opt-out policy on paper and the observed practice, suggesting that healthcare providers have drifted considerably from the planned intervention delivery (without even knowing). Health practitioners seldom offered the test using the opt-out approach. The low to moderate fidelity means women 1) had inadequate information to make an informed choice, 2) were not empowered enough to make an autonomous decision, 3) experienced some form of non-confidentiality and 4) were not linked to the required care or services.\u003c/p\u003e\u003cp\u003eUntil this study, the HIV testing literature discourse was that opt-out HIV testing had increased HIV testing uptake (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This study has revealed that in the 12 antenatal clinics in Ghana, and potentially in other Low- and Middle-Income Countries (LMICs), HIV testing practices deviate from policymakers' intentions. Moreover, healthcare providers are not adhering to the majority of the essential principles originally designed for pregnant women. The finding suggests that the opt-out HIV testing as a programme may not be credited with the increased testing uptake, neither can it be blamed for the lack of impact. This information would improve how policymakers decide about adopted policies and minimise the potential of wrongfully concluding and terminating a programme for being ineffective. The findings also suggest that decision-makers must be guided by the question, 'are pregnant women receiving the planned opt-out test's content? Answering this question may help clarify why so many women test positive for HIV but fail to enter care and why there are varying effect sizes and uptake across settings.\u003c/p\u003e\u003cp\u003eAchieving 100% adherence or implementation fidelity was not possible in this study, which was expected (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The finding is unsurprising, as evidence-based interventions are known to constantly undergo some modifications when transferred to a new context (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In Malawi, Angotti (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) demonstrated how counsellors transformed guidelines because they found it challenging to execute due to socio-cultural differences between the Western countries where the policy originated and the Malawian context. Like this study, counsellors, in her study, found strict fidelity to the 3Cs recommendations of the PITC policy challenging (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Understandably, it is not always possible, practical, or even desirable to model the implementation of the HIV testing policy as precisely as originally envisaged (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). What remains unclear is the extent to which frontline staff can modify a programme without deleting essential content (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The adaptation process would require technical guidance and continuous feedback to policymakers to avoid compromising the core components needed to produce outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study is the first to assess the context-specific implementation process of opt-out HIV testing among pregnant women, particularly in Ghana. Like any study, the methods have inherent merits and demerits that should guide the interpretation of our findings (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Adapting a framework and data collection tools was a threat to the internal and contextual validity of the findings (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). We applied content validity minimisation principles (e.g. having an expert verify the content of data collection tools). Self-reports also introduced recall and social desirability biases, seen in providers consistently overreporting adherence levels. The use of more than one data collection approaches, including direct observation, to collect data from more than one category of informants on the same phenomenon help triangulate the data to minimise this threat (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere is evidence of low to moderate fidelity to the intended content of the provider-initiated HIV testing in the 12 antenatal clinics. Gaps in the routine opt-out intervention content delivery could limit the achievement of rights-based testing and may explain the lack of impact in the HIV testing efforts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments \u003c/h2\u003e\n\u003cp\u003eThe authors thank administrators, antenatal clinic managers, and survey respondents. In addition, the Ghana AIDS Commission and the National AIDS/STI Control Programme (NACP) offered expert input during the design and data collection stages.\u003c/p\u003e\n\u003ch2\u003eConflict of interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDirlikov E, Kamoga J, Talisuna SA, Namusobya J, Kasozi DE, Akao J et al (2023) Scale-up of HIV antiretroviral therapy and estimation of averted infections and HIV-related deaths\u0026mdash;Uganda, 2004\u0026ndash;2022. Morb Mortal Wkly Rep 72(4):90\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarrison NE, Oruka KE, Agbaim UC, Adegbite OA, Okeji N (2021) Evaluating the Knowledge of HIV Transmission and Prevention of Mother to Child Transmission (PMTCT) of HIV Among HIV-Positive Mothers Accessing Care in Military Hospital in Lagos, Nigeria. 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Md Addict Behav 73:133\u0026ndash;136\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ (2014) The use of triangulation in qualitative research. Oncol Nurs Forum 41(5):545\u0026ndash;547\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Victoria University of Wellington","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pregnant women, antenatal clinic, implementation fidelity, opt-out HIV testing","lastPublishedDoi":"10.21203/rs.3.rs-4489352/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4489352/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThe study aimed to assess the fidelity to the intended content of the WHO/UNAID's provider-initiated opt-out HIV testing policy in 12 antenatal clinics across three regions in Ghana. Specifically, the focus was on understanding the implementation of key components, including informed consent, confidentiality, counselling, and connection to care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e Carroll's conceptual framework of implementation fidelity guided the quantitative data collection in the 12 antenatal clinics across three regions in Ghana. We measured adherence through brief facility surveys, healthcare providers, pregnant women's self-reports and structured observation of counselling sessions. Descriptive statistical analysis was used to describe the sample and antenatal clinic characteristics. The percentage means and standard deviation (SD) of components delivered were used to calculate fidelity scores.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eRoutine provider-initiated HIV testing was widely available in the 12 antenatal clinics. Although adherence to test coverage was high (98.1%), just under half (41.7%) of the clinics surveyed obtained informed consent through the recommended opt-out approach. Adherence to the content of consent, confidentiality, counselling, and connection to care was low (38%) for direct observation, moderate (54%) for pregnant woman self-reports and moderately high (78.9%) for healthcare provider self-reports.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThere is evidence of low to moderate fidelity to the intended content of the provider-initiated HIV testing in the 12 antenatal clinics. Gaps in the content delivery could limit the achievement of rights-based testing and may explain the lack of impact in the HIV testing efforts.\u003c/p\u003e","manuscriptTitle":"Implementation fidelity of provider-initiated opt-out HIV testing of pregnant women attending antenatal clinics in Ghana: a multi-site process evaluation.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-29 13:50:37","doi":"10.21203/rs.3.rs-4489352/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a57966e-21f5-4169-9c56-538215ee2da8","owner":[],"postedDate":"May 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":32488149,"name":"Nursing"},{"id":32488150,"name":"Health Policy"},{"id":32488151,"name":"Infectious Diseases"},{"id":32488152,"name":"Preventive Medicine"}],"tags":[],"updatedAt":"2024-05-29T13:50:37+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-29 13:50:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4489352","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4489352","identity":"rs-4489352","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}