Assessing changes in knowledge and factors influencing behavior related to Zika prevention among women receiving antenatal care in Latin America

The objectives of this study were to determine whether the quality improvement (QI) intervention supported by the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project was associated with a change in women’s knowledge of Zika prevention behaviors in four countries supported by ASSIST in the Zika response: Dominican Republic, Guatemala, Nicaragua, and Paraguay.  The study sought to understand antenatal care (ANC) clients’ perspectives on which aspects of the intervention most influenced women’s desire/non-desire and ability/inability to practice Zika prevention behaviors and to understand the perspectives of facility-based staff on which aspects of the intervention facilitated the providers’ ability to effectively counsel women on Zika prevention during ANC visits.

Methodology: Two complementary analyses were conducted: a quantitative analysis of existing data from four ASSIST-supported countries (Dominican Republic, Guatemala, Nicaragua, and Paraguay), and a qualitative case study specifically assessing ASSIST-supported Zika activities in Guatemala. The quantitative analysis utilized a mixed effects regression to explore the association between intervention duration (in months) and Zika counseling comprehensiveness on knowledge of Zika prevention among pregnant women exiting ANC services in supported facilities in the four countries. The model also controlled for the facilities’ country and region. To understand the implementation of the ASSIST intervention and how it influenced the provision of Zika counseling as part of ANC and the perceptions of the clients of ANC related to Zika prevention knowledge and behaviors, the methods for the qualitative case study included in-depth interviews in ten health centers (centros de atención permanente or permanent health centers) with women who attended antenatal care visits and with health providers in both ASSIST-supported  and non-ASSIST-supported facilities. A total of 80 interviews were conducted: 46 pregnant women, 18 health providers in ASSIST-supported facilities, 12 health providers in non-ASSIST-supported facilities, and four ASSIST technical staff.

Findings: The findings from both analyses converged to suggest that provider capacity development and effective counseling were associated with improved knowledge and potential for enacting prevention practices. For the quantitative analysis, the mixed effects regression model revealed that time and comprehensiveness of Zika counseling in ANC were significantly associated with women’s knowledge of Zika prevention behaviors (p value< 0.01).The model predicted that, on average, holding all else constant, one additional month of the ASSIST intervention was associated with a marginal increase in knowledge of one percentage point, and an increase of one additional percentage point on a facility’s Zika counseling comprehensiveness score was associated with nearly a 0.6 percentage point increase in knowledge.

In the Guatemalan context, the intervention reinforced the importance of standardized preparation processes and training of a range of health and support staff. Implementation barriers included a lack of human resources in the health facilities, high staff turnover, and the limited participation of doctors at the beginning of the program resulting from slower physician buy-in, unlike the nursing staff, whose support was stronger from the start. Given challenges related to time, infrastructure, supplies, and client volume, health facility staff adopted different processes to maximize quality of care and ensure they took advantage of opportunities to provide Zika counseling during ANC visits. Interviews with women attending ANC suggest that these women benefited from the Zika counseling and had at least some knowledge and understanding about Zika and the prevention measures. On average, the women and the ASSIST-supported providers and staff rated the majority of the priority prevention practices as “easy” to enact, which was contrary to what the non-supported providers perceived. Participants reported that reasons that impeded the realization of the recommended behavior varied across the priority practices. 

Conclusions and Way Forward: Findings suggest the importance of continuing to increase knowledge, but also of promoting sufficient understanding of risks and prevention measures to enable behavior change.  For example, exit interview data to monitor Zika knowledge among ANC clients did not capture whether women understood the severity of the potential risk to the baby, but rather only whether they understood Zika can be transmitted sexually and that condoms are a primary method for prevention of sexual transmission. However, the qualitative data indicated that the threat of microcephaly to the baby sometimes served as a “tipping point” in convincing partners to use a condom during pregnancy. Routine monitoring and evaluation going forward should include whether this key risk to the baby is understood.  Messaging must be strategic, take into account other similar diseases, and be nuanced enough to assist in the proper execution of the priority practices. The study participants’ recommendation to engage the community is a good one, as provider reinforcement of practices during intermittent ANC visits at the facility level is likely insufficient. Finally, while the acute threat of Zika has passed and priorities have shifted to other competing and pressing health issues, the hope is that the processes, training materials, lessons learned, and expertise will remain sufficiently embedded in the health system to support action during the next phase of the Zika epidemic in the future.

Report Author(s): 
Samantha Ski, Emily Peca, Lilian Carolina Ramírez, Luisa María Mazariegos, Maria Rene Ortiz, Astou Coly
ASSIST publication: 
ASSIST publication
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