Study setting: The study was conducted in Mekelle zone, Tigray of Northern Ethiopia, 802km from Addis Ababa, the capital city of Ethiopia. It is among the top three high HIV prevalent and prioritized areas in Tigray. According to the 2007 national census, the projected total population of Mekelle town is 320,000. Zonal health tier system composed of 12 health facilities [17]. Of which, three of them are hospitals and nine health center respectively. All health facilities were providing OptionB+PMTCT under MNCH continuum of care [18].
Study design, period and sample size: A study was facility based cross-sectional involving both quantitative and a qualitative. It was conducted from October 2016 to February 2017 in Mekelle. Nine health facilities were included in the study. Twelve health care providers (one from each) working in MNCH unit were subjected for interview. Similarly, exit interview and record review were conducted among 60 clients (five from each) enrolled under follow-up in chronic HIV care in MNCH clinic.
Data collection and classification: A total of eight nurses with college degree having at least five year clinical experience and two supervisors were recruited for data collection. Data collection was conducted using Donabedian three quality components such as input quality component (materials, equipments, and human resources), process quality components (service compliance with national standards), and output quality components such as clinical service utilization and mothers satisfactions [7, 19].
Data collection tools used to gather data were facility audit checklist to assess the availability of essential resources such as equipments, drugs, human resources, and supplies to address the input quality component of Option B+PMTCT. A mother’s exit interview questionnaire is used to gather information from 60 clients attending the service. Of which, 5 sessions were taken from each study health facilities to examine the process of Option B+ service delivery and their satisfaction level about the service. A one year record (2016) review from maternity register also conducted to gather information about the utilization of OptionB+ one year prior to the study period. Similarly a semi-structured interview guide was used to conduct in-depth interview of health care providers about their experience during service provision. The questions were prepared in English and then translated in to a local language (Tigrigna) by language experts to assure their consistency.
Data were collected by six BSC nurses experienced on data collection and working in Regional Demographic Health Survey unit in Mekelle University and two health officers as supervisor form Ayder Specialized Referral Hospital in Mekelle who had experience in health and health related surveys in the region. Training was provided for data collectors and supervisors for two days. During data collection period there was strict follow up by appointed supervisors and principal investigators to ensure quality data. Qualitative data from key informant informants were gathered by principal investigators.
Input quality component: Input quality component was measured using 32 items which was developed from the national technical guide line.We gave equal weight to assess the items. Facilities were categorized as good input quality component if the weighted score was 100 % [7]. See the list of variables used in measuring input quality (Additional file 1).
Process quality component: Process quality component was measured using 42 items which was adopted from UNAIDS and Family Health International (FHI) and customized with the national technical guide line [19, 10]. All items had given equal weights and facilities were categorized as having good process quality component if the average weighted score was 95% or more [11]. See the list of variables used in measuring output quality (Additional file 1).
Output quality component: Output quality was assessed using 11 items adopted from the national technical guide line [10] based on mothers’ service utilization and satisfaction about Option B+PMTCT. All items had given equal weights. Facilities were categorized as having good process quality component if the average weighted score was 90% or more [7]. See the list of variables used in measuring output quality (Additional file 1).
Overall quality component: This was assessed by combining input, process and output quality delivery service at facility level. Facility was categorized as providing standardized quality care of Option B+ if it had the average weighted score was 90% or more in pre-determined three quality components. See list of each quality score for each facilities (Additional file 1).