The findings are presented by categories, themes, and essences to examine the processes and implementation of the MMs program in the Nigeria DoD. Ultimately, describing essences was employed in this descriptive study in an effort to provide a true essence (meaning) of the descriptive responses shared by some of the program stakeholders  These categories which emerged through asking some of the program stakeholders what the processes are that guide the implementation of the Mentor-Mothers program in the Nigeria DoD include Foundational Factors; Leadership; Skill acquisition; and Service Characteristics. The reviewed relevant literature provides insights into the processes and implementation of the MMs program and the resources and skills needed to deal with the challenges in order to lead effective organizations. For this study, this led to the discovery of four (4) categories that encompass the processes guiding the implementation of the Mentor-Mothers program in the Nigeria DoD.
This category emerged through asking some of the stakeholders if there was any document(s) guiding the implementation of the MMs program. Here, the relevant literature suggested that the National Strategic Framework 2017-2021, and the WHO Global Plan which aims at ending HIV/AIDS play a major role in the implementation of the MMs program in the Nigerian DoD towards achieving Zero new infections, zero AIDS related deaths and stigma  . Unlike the United Kingdom and some countries in Sub-Saharan Africa (Such as South Africa, Kenya, Lesotho, Malawi, Swaziland, Uganda, and Zambia) where the MM program is well established by law, there are no direct policies or Acts establishing the mothers2mothers (Mentor Mothers) program in Nigeria. While the Mentor Mothers model has been standardized and implemented for PMTCT care in these countries and other countries in the globe , the Nigeria’s National Health Act (No 8 of 2014) sections 42 (a-f) empower the minister of health to create new categories of health care providers to be trained or educated in conjunction with appropriate authority to meet the requirements of the national health system . Though the MMs program is not officially incorporated in the Nigerian National Health Strategic Plan, the Ministry of Health guidelines are an important part of the DoD’ strategy to reduce mother to child transmission of HIV through some mainstreams’ frameworks together with the National Health Act. These further support the findings recorded in the Kenya MM Program (KMMP) – suggesting that through the National Health Strategic Plan, aligned with the national Elimination of Mother-to-child Transmission (eMTCT) Framework, and the Kenya National AIDS Strategic Plan – the Kenya Mentor Mother Program was developed . Thus, as a participant in the Global Plan on eMTCT, the Government of Kenya supports the facilitation and implementation of the MMs program in the country . In addition, the Kenya Government also recognizes that women living with HIV must be at the centre of the response to the epidemic by critically playing a role in task-shifting to promote health service quality improvement as well as uptake, retention in and adherence to care .
The Foundational Factors revealed three (3) themes which are crucial to the facilitation and implementation of the MMs program in the Nigeria DoD. They include guiding principles/models; PEPFAR and State funding; and partnership with the national health system.
The findings from this study support the arguments reported in the Literature Review Chapter. For example, even though the MMs program is not legally supported by policy in the country, the Mentor-Mothers initiatives exists in Nigeria since 2007, currently guided by the  and operates in line with the WHO global plan (with some success), at different levels of training and structure in some states of the federation [15, 24]. All the stakeholders noted that the Nigerian DoD MMs program is modelled by mainstream guidelines/model, such as the WHO guidelines, the ICAP model, National Health Policy, and the Nigerian DoD policy.
If we are to talk about documents, that was what came up from the World Health Organization. Based on that, we are leveraged on that. As they do that, with other implementing partners, we adopt it. That is what is guiding us, in regard to that. We are more of leveraging on the international mentor mother model to be able to fashion out or carve out what we practice in the DoD and it is the same checklist used in accessing the progress, that is more of what we do here. Which means positively it has been able to help us adopt what they have and as well as use that to make sure that we are getting it right.(Bogo)
Partnership with the national health systems. The other participant having compared program activities with stakeholders from the east African region notes the difference in the recruitment criteria for mentor mothers:
I must be frank with you. Being the person anchoring the programs I have had very little interactions with the Mentor Mother Programmes elsewhere apart from the pages of theories of books and the little experience I came with from ICAP. But again, I think I have not been able to look at that clearly, except one of the review meetings we had with other countries from the east African sub region in Tanzania where experiences were shared and I saw that our operation was little bit far. Because the criteria we set for recruitment, our standard is high. At least we need a minimum of secondary school level. But in their region a lay person that has just little knowledge of how to write well were recruited. So I think that is just the difference I saw compared to the program elsewhere… from the experiences I came with from ICAP I proposed to the office and they gave me the go ahead to implement the Mentor Mother Program. …ICAP like CIHP is one of the international NGOs, it is the University of Columbia that supported the HIV program.(Sesa).
Working with governments, local partners, and communities played a pivotal role in the formation, facilitation, and implementation of the mothers2mothers’ MM model to effectively decrease HIV infections in children, reduce child and maternal mortality, improve the health of (women, adolescents, and families), reduce stigmatization and discrimination, and support the livelihood, development of women, families and communities . Furthermore, findings from this study also support the National Guidelines for the KMMP for PMTCT of HIV programs.
PEPFAR and State funding
The findings of this study further suggest that the MMs program is funded by PEPFAR and State funds as corroborated by the participants.
The program is funded by counterpart funding. The DoD brings some part which they administer themselves and the Federal Government of Nigeria makes available some parts. Unfortunately, things have not been rosy, from time to time it goes up and down.(Bogo).
We have been funded through PEPFAR and we are in collaboration with the Nigerian Minister of Defense. So, funding has been through the Nigerian government and the American government through PEPFAR(Sesa).
In addition, when asked of specific challenges facing the facilitation and implementation of the MMs program, these stakeholders also indicated that there has been a funding challenge facing the progressive implementation of the program. This is an indication that funding the program in the Nigeria DoD has been very unstable over the years. Thus, expanding the MMs program to other military sites in the country is limited by the amount of funds injected into the program over the years. This threatens the expansion and sustainability of the program.
They feel the program has been worthwhile, met its goals. The only challenge is that they look at the funding that has crashed, you know PEPFAR funding has been dwindling over the years. Otherwise I know they would have said ‘well go ahead and expand to all the other sites’. I think they see it that the program has worked and has impacted, and they are happy with what I am doing. …But again, funding has been a challenge; I could not expand that far.(Sesa)
Funding, funding, funding because when there is fund we are able to get personnel, we are able to get equipment, we are able to get all the logistics required to keep the program running.(Bogo)
Leadership was also noted by the participants as one of the key performance indicators that influenced the facilitation and implementation of the MMs program in the Nigeria DoD. This was determined by asking the stakeholders to specifically describe what has enabled the successful implementation of the program in the DoD.
I think the leadership has been there whenever I make a request. I seek approval to do some things and they allow me to do that. So, I think they have been supportive either through guided, quicker reviews of my proposals and my requests. They have been very supportive. … The leadership support, team support and the facility being there and the ownership i am seeing over time with facilities because i know by the time the little incentives we are giving to the sites stop which we do not pray for, i am sure the level of commitment i have seen from the leadership of those facilities would be able to take this on, so that the program would not just crash.(Sesa).
Thus, this category was associated with themes such as management team support, the military factor, and team player/spirit. The essences behind these three (3) themes speak more on the management team, the wisdoms and solutions that the management team brings into the program (management of the program), and the team spirit of the sites’ managements. These were deemed to be effective factors influencing the implementation of the program to improve the health of mothers through improving reproductive, maternal, newborn and child health outcomes. Through the DoD’s MMs program, the DoD leadership factor propagates working with governments, local partners, and communities. Hence, the findings from this study support the mothers2mothers’ Mentor Mother Model, which empowers mothers living with HIV – through education and employment – to promote access to essential services and medical care to other women . Just like the National Guidelines for the KMMP were established through the participatory and consultative processes drawn from expert opinions from public health institutions, academic intuitions, NGOs, and development partners , the findings from this study are an evidential conclusion that leadership support such as government support, experts support, institutional support (such as health, academic, private, and development intuitions), local partners, and communities play a pivotal role towards the formation, facilitation, and the implementation of the MMs programs in the DoD. Although findings from this study and other studies [15, 24] suggest that MMs program is not nationally implemented in Nigeria, the development and implementation of the program in Kenya incorporates best practice approaches from PMTCT implementers across the country for the development of the Kenya Mentor Mother Model .
Team spirit describes the feeling of loyalty, commitment, and pride that exists among members of a team that keeps them committed to the team’s success. This entails a lot of corporation among team members. This theme emerged as one of the key factors influencing the MM program implementation as volunteered by Bogo ;although that has not been without some challenges:
The team spirit, encouragement, training and the willingness to sacrifice. … on the positive side we have our site team commanders, especially site team commanders give us a lot of encouragement in making sure that the program flourishes. But on the negative side they are bound to be some challenges here and there. But in the communities where we operate, the military, the commanders, the nurses, every other person is very supportive. That is the spirit behind the success of this program as a whole in the military (Bogo).
While a portion of the program success story is attributed to the management team (including the program staff), the findings of this study further revealed that poor management also impacts negatively towards the facilitation of the program. Bogo states further:
My problem is the program staff and some of the challenges that they have. They are trained on logistics to be able to have about two months stock for them to make requisition using CRF (Cost Revolving Fund), but some people will just wait until everything is finished and they wake up one morning and then say there is no test kit and they start talking about emergency order and the rest. When you look at it, it is not that the program is out of these consumables, it is just the inertia on the part of people who are supervising the training. Occasionally I tell them, “in your house would you wait until the whole salt that you have in your house is finished”? You do not wait, because when you see it is halfway gone, you start looking for how to make them available… “in your houses do you wait until the whole box of matches is finished”? You have and keep a spare, that is why we are able to have some buffer supply in case there is need (Bogo).
As a category, skills acquisition was described as one of the focal points that plays a significant role for the facilitation and implementation of the Program in the DoD. Here, the findings suggested that the program staff acquire skills through three (3) main themes: personal experiences with HIV; training (trained through general training on HIV, PMTCT training, review meetings and skills update, workshops and seminars, and data literacy), and basic education qualification (a minimum Secondary School qualification). The essence of these themes is to measure providers’ preparedness, skills, and competency. In other words, the findings from this study revealed that to ensure the successful facilitation and implementation of the MMs program in the Nigeria DoD requires skills acquisition. This entails selected candidates undergoing several trainings. Here, the most important primary engagement criteria are personal experience (women who are living with HIV and had successfully undergone the PMTCT program) and have a minimum of a Secondary School certificate. Thereafter, they are trained in several specific aspects related to PMTCT to enable them deliver the right services needed as Mentor Mothers. Although not the same approaches are applied in different MMs Programs in other countries, these findings are similar to the findings recorded in most studies around the globe. For example, several studies venture on personal experiences (women who are living with HIV and had successfully passed through the PMTCT program) as their primary engagement criteria [26,22, 12, 15, 25, 27, 28, 11,29,30]. Concerning specific training, both the findings from this study and other studies agreed in most of the specific trainings that Mentor Mothers undergo to deliver quality services such as basic communication and counselling skills, HIV testing and counselling, PMTCT and paediatric care, training on adherence to HIV care and treatment, record keeping, training on confidentiality, infant feeding and child nutrition training and many more [22, 12, 15, 25, 27, 28, 11,29,30].
When asked about the criteria for engagement as a Mentor Mother in the DoD, the specific training they require for the performance of their duties, the contents and nature of their training, and the efficacy of the training – in response to skills acquisition the participants provided these responses:
Basically the person must be able to read and write, so a minimum of a secondary school certificate suffices. Although we have some that are Bsc holders. Then the person must have a fair knowledge of HIV services, must be a positive woman living with HIV and would have gone through the PMTCT program in the sites. … Ja even though, first and foremost as a Mentor Mother the issue of stigma should not be in the way. That is one of the criteria. It should be a woman that can come in front of other mothers and say “I am a positive mother”. But again, we also tell them that HIV issues surround confidentiality, stigma to ensure that a high level of confidentiality is needed from them. As much as possible clients’ information should not be divulged to people who should not know and I think they have been doing well on that, compliant to that.(Sesa).
What plays out most of the time is-those people who probably have the same status challenge, those are the ones we make use of because they are veterans in that field and they have done very well. Based on that we could use them to mentor other people (Bogo).
Having been employed, the MMs undergo training to enable them carry out their duties:
They receive basic training about prevention of mother to child transmission, HIV testing, disclosure of results to mothers, we teach them how to track, we also give them some elements of EID services, that is early infant diagnosis services. And basically, those are them; and how they can track lost clients. Those are the basic things that are captured in the curriculum we currently operate for them now (Sesa).
The mentor mothers occasionally are brought along with the HEADS of Nursing Services in the different health facilities and they are just given a general training on HIV, at least a basic foundational training on HIV for about two days. Some of them come in here for about three days and from time to time they are still invited and updated on the current knowledge (Bogo).
Training contents and nature of the training
In Ethiopia, the Mentor Mothers Training curriculum encompasses 14 modules, encompassing 52 individual sessions,  carefully developed to cover the objectives of PMTCT including male involvement in PMTCT/ANC/MNCH and reduction in gender-based violence. Asked what the content of the training curriculum for MMs in the DoD entail, the participants related thus:
It is both didactic and practical hands-on training especially when it requires EID services. We put them through that even though some facilities would not ask them to do it physically but again, we give them that knowledge so they know how those services are done. It is both didactic and also hands-on training (Sesa).
It is more of foundational training, more of telling them about HIV incidence, how it is acquired, how it is transmitted, what we can do to avoid getting infected, and the need for breastfeeding because of some of the challenges we have with people who mix feed and the rest of them. These are the contents of what we mentor them on and the need to tell them about adherence on their drugs, how to follow the mothers up especially those ‘lost-to-follow up’. Apart from the general tracking, they still do their own tracking. … from time to time, there are other central trainings…(Bogo).
Their narratives reveal an absence of a structured curriculum for training of the MMs as it obtains in South Africa. The MM program in the DoD being borne out of the initiative of one of the directors could be one of the reasons for the absence of a definitive policy establishing its implementation and subsequently, lack of a definitive career structure for the MMs.
To effectively build human resource capacity for health particularly in HIV care requires implementing HIV care and treatment programs for health care providers. The PI sought further clarification on the effectiveness of the training programs for the healthcare providers which included the MMs, and Sesa responded as follows:
Sometimes whenever we call them for the review meeting, we also flash on those trainings to remind them especially if there are new things introduced into the program. So, I think on the effectiveness I will say it is good because that has improved our indicators for lost- to follow up… it has come down because mothers have been tracked now actively. Positive mothers not just pregnant positive mothers(Sesa).
Facility and service characteristics predict access to ART, retention in care and PMTT outcomes. Four (4) key performance indicators that promote the facilitation and implementation of the MMs program in the DoD emerged from this study. They aim at promoting healthy living (through tracking patients’ progress, free and inclusive services, EID services and HIV testing, and promoting zero discrimination). These are: Staffing and wages, social, financial and service quality, socioeconomic and psychological support, and service satisfaction. The essences in this category include: Personnel, Services and Products, and Service quality. In summary, this study findings concur with the argument that the utilization of mentor mothers in PMTCT, especially in high-burden-low-resource centers, improves rates of retention in care with positive outcomes . In agreement with  findings, the results of this study revealed that Scale-up of ART and PMTCT has been some of the great successes of the MMs program in the DoD since its inception. Therefore as part of its strategic interventions, the MM program fosters an enabling environment for HIV positive pregnant and breastfeeding mothers and HIV-exposed infants to access antiretroviral drugs.
Staffing and wages
Areas worst hit by the HIV epidemic require an ideal number of health workers, who are suitably distributed across different occupations and geographical regions, to ensure population coverage of health interventions. Health worker shortages in HIV care provision are high in Nigeria which is listed among countries with acute health worker shortages and by extension the DoD. This has been seen to impact on the progress towards reducing the rate of new infections in the country. Asked to describe what guides facility decisions regarding the implementation of the MM Program in the DOD, the participants responded thus:
Data shows that many women that are positive are not remaining faithful on their drugs. Sometimes they will initiate it, before they leave, we hardly see them, So, we felt getting an effective tracker using the Mentor Mothers who are by themselves positive mothers who have delivered in our sites… getting them on board so they will be able to come in and also track the sites, that is how we got them on board. … There are nineteen of them at the moment, one per site.(Sesa).
We could say we have about 30 mentor mothers because they are attached to each site, comprehensive sites based on what I have said.(Bogo).
The participants also gave reasons for the current state of the MMs wages based on the complaints by the MMs:
Ja, I remember in a few of the sites they have made this thing known to me. But again, that even informed why we increased the stipend we are giving them. I know we started with about N20 000 and when I presented their issues to the office, office said I can ensure an increment over that which they now gave close to about 100% increment. So, they are now paid a maximum of N40 000. But what we did not do was to look at the various sites based on the standard of living there. We just did it as a program so as to have a unified structure for them.(Sesa).
We give the mentor mothers some stipends to encourage them at least for their transport, for making their time to be able to follow up on these other mothers who are challenged. … Looking at the financial status of the country; and these are mentor mothers. Some of them get as much as N40 000, whereas graduates are not even getting up to twenty thousand. So, it is really big, really and for some of them who have lost their husbands, this has been a source of income…they are very happy as far as I am concerned.(Bogo).
It would appear that definitely, the MMs exist in the DoD to fill a gap based on an existing need. Therefore when asked about their employment status, Bogo described it as ad hoc (not permanently employed):
We can say that they are not permanently employed; they are more of ad hoc, contract ad hoc staff. As far as the program lasts and there is funding, they will continue to exist (Bogo).
An interaction with one of the MMs confirmed the narrative above:
As a MM you are not employed, and because you are not employed you have not tendered any certificate to say this is what they are employing you based on. The qualification that they need is if you could read and write, and you are “positive”. Some with primary school certificate could read and write so they came in as volunteers. Some with secondary school certificate, some with BSc and some with Masters. So if at least they can look out for…ok people with this qualification maybe will be paid a certain amount because you have this qualification, you can be paid this other amount , I think it would go a long way.
Much as complaints such as this had attracted an increment to their stipends, the narrative of Bogo reemphasized the status of their employment:
Being a mentor mother is a privilege and not a right.. it is not a regular job. . And there is no work, no employment for now and they are not coerced, it is offered to them. Some people who are out there are struggling to see how they can come into the program. But I know that for some other people even if they are placed on N200 000, they will still say ‘how we wished they could make it N250’.(Bogo).
The above narratives underscore the lack of permanency of the MM’s employment which perhaps MMs view as a lack of support and subsequently could impact on service delivery. However, Sesa paints a clearer picture of the MMs engagement for service delivery:
Services and Products
Basically, we are exposing them to also look at more of tracking among people on treatment, that is, mothers that are on HIV treatment, not necessarily mothers who are pregnant now. So, we are using them on that and also exposing them to data recording around EID services (Sesa).
Clearly, from this participant’s narrative, tracking is a focal aspect upon engagement as an MM. Interestingly, they are also trained on data recording which is a more engaging aspect of the MM system, which not only affords research capacity building but also for the MM’s to witness how their involvement contributes more comprehensively to the programme.
The DoD management also avails patients and other healthcare consumers with social support services to further build capacity towards sustaining the program:
There are other social services beside HIV services and we’ve always encouraged patients to go to the right place to seek those services. Those rights to treat, patients’ rights also spell out some of those things in sites where those services are available. So, they go in and seek those additional services. …(Sesa).
Bogo further justifies the existence of the MM program and services:
The mentor mothers program has come to be simply because we want to use them to encourage other people who have these HIV challenges so that they can encourage them to adhere to their treatment and other processes that are supposed to keep them and their families healthy. …we counsel them one on one on pre-counselling, post-counselling and other necessary things. It is done in such a way that they are away from where people can hear what they are discussing, where them only can see one on one so that there will not be any need for anybody to know who they are talking to, or who is volunteering information. … Occasionally we make available little things, there is this OVC site where we have an OVC program that takes care of about 250 OVCs and those ones who are out of school. We send them for skills acquisition. Just last week Tuesday we had four of them who passed out from OVC skill acquisition and they were given start up packs. … there is some social support and financial benefits. These are the things that are the motivating factors behind the progress so far made. … we are sponsoring about 250 pupils, I mean students now. And we have some people for out of school program and we’ve spent almost up to eight to ten million Naira in the OVC program. I think it is fairly encouraging (Bogo).
When asked about how accessible the services within the program are, the participants responded that their services are:
Very accessible and that is why even most of our clients are even civilians. About 85/90% of our clients are civilians. That is just to tell you our services are very accessible. …we provide them with mamma packs, we make sure antenatal investigations are free, and that when they deliver the delivery fees are made very cheap and attractive. And in some of our facilities, from the time of registration to the time of delivery they do not pay anything (Bogo).
All our services are at no costs. PEPFAR supports everything. … They are very accessible, except because of the insurgency, some restriction to the barracks has been enforced, where we see some sites still having to profile clients coming in to seek ANC services. But again, with our engagement with the commanders, women who are pregnant are not being profiled because that women first is seen as a pregnant person who is going to access services in the ANC. So, access I think we don’t have any issue with that (Sesa).
Quality determines the extent to which a product complies with a set standard. The core of the MM program is access to anti-retroviral therapy with positive outcomes for both mother and baby. To achieve this, trained MMs within peer group settings provide individual support for HIV-positive pregnant women and postpartum mothers to help them address unmet needs for understanding HIV, psychosocial support and acceptance, self-care, infant care, and over the longer term, economic needs .
On how the recipients of the program would describe the services they receive, the participants had this to say:
I think the mothers are happy for it because on two occasions on a site visit, I engaged with them, they would tell me this mentor mother is a superb woman around, she is so welcoming, she is so supportive of their actions, of the services. The mothers see it as a welcome service and these services have actually improved, improved on their engagement with the facility. So, they see it more as a beneficiary service, rather than being a burden. So, I think the recipients are happy, and they will never want this program to die so soon (Sesa).
He went further to highlight the gains of the program:
I think the goals have been well met and that is why we’ve sustained that action. As I said we’ve seen improvement especially in our PMTCT final outcome where most babies are coming soon after eighteen months negative. To me it has been well met. With the engagement of Mentor Mothers, with advocacy, with the kind of improvement they are seeing with those that are attending services there. So many are now seeing the need to have facility delivery. … In summary as I said, we are having better outcome for our babies now. We are having increase in facility deliveries. And the issue of stigma that has been a major issue in the program has actually crashed down. People are now ready to come and disclose their status, because they feel that for the Mentor Mother in the first place to come out publicly and tell them well, “I am positive and I am looking healthy and I have given birth to so so number of children who are negative”. So those are the good effects of the entire program (Sesa).
This view was corroborated by Bogo:
From my own assessment I will say to a reasonable extent they will give it a pass mark. … they see the services of the mentor mothers as encouraging, because when I say encouraging, I am saying it from the perspective that those who would not have followed both treatments, care and the other supports have now been able to be retained in the program by virtue of the activities of the mentor mothers. … The significant difference that I have found is that we have more people being retained in our care now compared to what it used to be (Bogo).