? CHAPTER 1
Background of the Study
Zika virus infection was declared a public health emergency in 2016. Zika virus infections have been present in Africa and Asia since the 1940s and have since spread dramatically to mainly in the Americas and western Pacific countries. Series of studies were conducted because sudden increase rates of microcephaly in Zika infected places. Brazil reported the detection of Zika virus in amniotic fluid samples from pregnant women with ultrasound-confirmed microcephaly, culminating in the issuance of a national public health emergency. Zika virus reached the United States (US) in mid-2016 when the first local-transmission was documented in Miami then there had been over 143 symptomatic alerting the world to do something on this infection.
Since the first documented cases in the western hemisphere, the scientific community has made substantial progress in terms of understanding Zika virus transmission and outcomes. Findings on the study conducted by the WHO (2016) showed that an infected mother can pass the Zika virus vertically to her fetus during pregnancy as well as during the delivery of her infant. Furthermore, it can also be passed through sexual intercourse, even if the infected person is asymptomatic which makes it more dangerous.
In the Philippines, based on the report of DOH (2017) there are 57 confirmed cases of Zika virus infections including 7 cases on pregnant women. A cross-sectional study was also conducted by the said agency showed 19 out of 153 (12.4 %) human samples in Filipinos had elevated Zika antibodies interpreted as exposure to the said virus (ABS- CBN, 2017)
In Mindanao, that DOH (2017) has not specifically identified cases of Zika infection, but is suspecting there are unreported cases. The massive information drives on a preventive measure as launched and was included in the health education program of the agency to help people understand and promote safe practices towards protecting self against this infection (Mateo, 2017).
The danger it poses to pregnant mother and their unborn child is a major concern of every midwife and other health care providers who are advocates of safe pregnancy and delivery. Thus, the researchers are motivated to conduct an assessment on the preventive strategies implemented on preventing transmission of Zika virus in the unborn and newborn babies. The resulting study can be a good basis for developing better practices and action plan towards preventing its transmission.
Statement of the Problem
The study aims to determine the level of implementation of the strategies to avoid sexual transmission of Zika Virus to newborn.
Specifically; it will seek answers to the following research questions:
What is the profile of the respondents in terms of;
educational Attainment, and
What is the level of implementation strategies to avoid sexual transmission of Zika Virus in terms of;
Information dissemination, and
What is the level of disease prevention and newborn protection from Zika virus transmission?
Is there a significant relationship between the level of implementation of the strategies to prevent sexual transmission and the level of disease prevention and newborn protection of Zika virus?
What are the problems encountered in the implementation strategies to prevent transmission of Zica virus to infection to newborn?
The significance of the Study
The study holds the firms view that the findings of this study will benefit the following:
Department of Health. This study will serve them as the source of additional information on the progress of the implementation of strategies to prevent Zika virus transmission.
Midwives. This study will provide the knowledge on how to improve strategies in preventing transmission of Zika virus specifically to mother and newborn infant.
Community. These findings of the study are essential to them since information about preventive measures against Zika virus transmission will be provided to them,
Midwifery practice. This study can be a source of additional information of improving the strategies towards maternal and child care on infectious diseases that may cause complications during pregnancy.
Researchers. This study will enhance the ability of the researchers to find out the preventive measures against Zika Virus transmission.
Future researchers. This study will be used as a reference for the future researchers on reliable data in Zika virus transmission related researches.
Scope and Delimitation of the Study
The study will focus on the perceptions of the 25 midwives and 25 mothers on the implementation of the strategies to avoid Zika virus sexual transmission to the newborn. It will specifically focus on the information dissemination strategies and sources of support and resources available conducted in Saudi Arabia that can be adopted in the Philippine setting.
The study is limited to the government hospitals in King Saud Medical City in the Kingdom of Saudi Arabia. It will not include the programs implemented for other sexually transmitted diseases in other hospitals.
Definition of Terms
The following terms used will be operationally defined to easily understand the study.
Disease Prevention and Newborn Protection refer to the decrease in cases of transmission and negative cases of Zika infection in the King Saud Medical City.
Implementation Strategies refers to the information dissemination and support and resource to avoid Zika virus sexual transmission.
Information Dissemination refers to the tv and radio ads, posters and health education session to avoid Zika virus sexual transmission.
Newborn refers to the young individual who is born for the first 24 hours to 30 days.
Problem refers to the hindering factors in the implementation strategies to avoid sexual transmission of Zika virus.
Prevention practices refer to the hand washing, wearing of mask and eating of fruits and vitamin c rich food to increase resistance against viral diseases.
Zika Virus Sexual Transmission to Newborn refers to the transfer of Zika virus to a woman through sexual intercourse and infecting their newborn due to it.
Review of Related Literature and Studies
According to WHO (2016), Zika virus is an arbovirus in the Flavivirus genus and is mainly transmitted through the bite of infected Aedes mosquitoes which are also vectors for chikungunya, dengue, and yellow fever. It is also transmitted through sexual intercourse and blood-borne transmission. Some of its carriers are without symptoms while others manifest different symptoms.
In the study of Possas (2016), she mentioned the symptoms of Zika virus infection are mild, similar to those of dengue, including fever, rash, joint pain, muscle pain and/or conjunctivitis and in most cases hospitalization is not required. However, the virus, which had been confined for six decades to ecological niches in tropical and subtropical areas in Africa and Asia, has changed its behavior from causing mild illness in a limited number of human cases to causing severe neurological disorders in newborns (microcephaly) and adults (Guillain-Barre syndrome).
World Health Organization (2016) declared Zika to be a public health emergency of international concern on February 1, 2016. The Emergency Operations Center of the US Centers for Disease Control and Prevention (CDC)
was also activated, with a level 1 activation announced on February 8, 2016. A recent review study led by CDC investigators concluded that a causal relation can be inferred and the Zika virus can cause microcephaly if a woman is infected during pregnancy.
Since the first documented cases in the western hemisphere, the scientific community has made substantial progress in terms of understanding Zika virus transmission and outcomes. It is known that an infected mother can pass the Zika virus vertically to her fetus during pregnancy as well as during the delivery of her infant. The Zika virus can also be passed through sexual intercourse, even if the infected person is asymptomatic (Martine’s, et al., 2015).
Strategies to Avoid Zika Virus Transmission
According to Politer (2013), the prevention strategies to pregnant mothers on filterable virus such as Zika transmission is very vital in preventing complications during fetus development. The information dissemination provided to the mothers will help them be able to practice self-protection in preventing transmission of the disease.
Similarly, Marshall (2014) described in his book the following strategies to prevent transmission of communicable diseases to newborn. The use of personal protective equipment’s and practices such as hand washing, the wearing a mask will prevent transmission. It is very helpful also to eat balanced diets with high fruits content to increase resistance against viral infections
In the article of Health and Home (2017), it had mentioned about the prevention of Zika virus transmission through prevention measures such as cleaning the environment because the mosquitoes breed in stagnant waters. Using mosquito lotion repellents and nets helps in preventing transmission of the disease from the vectors. These safety practices are helpful in protecting people from this highly communicable disease.
The Control of Communicable Diseases Manual (2014) recommended hand washing and the standard precaution measures to be implemented in preventing communicable diseases to transfer from one person to another. It also emphasized proper monitoring and surveillance of cases can help in formulating better strategies towards prevention. It recommended proper information dissemination and tri-media ads to the public for better understanding and cooperation of the people towards it.
According to DOH (2016), previous interventions such as the use of insecticides have been proved to work well for preventing the spread of malaria and other mosquito-borne diseases. Unfortunately, these methods have not been successful for the Aedes Aegypti mosquito that causes Zika Virus. The fumigation made by airplanes and lorries has proven only to have a very limited effect on these mosquitoes because the fumes do not make their way into buildings where mosquitoes are often present. The government with the knowledge of the limited effectiveness of these fumigation programs often goes through with them anyway as “a visible symbol of government action”.
Apart from surveillance, WHO (2016) underlines that the complications of Zika Virus should be treated with psychological support. The healthcare provider has many opportunities to provide strategies to manage and prevent this disease through support, which consists of giving accurate information, providing basic psychosocial support, supportive communication and strengthening social support. Midwives may find it especially challenging to help support women who are pregnant or planning pregnancy since so little can be done except take the necessary steps to prevent it (Turienzo & Brown 2016).
Prevention through safe strategy practices is the most effective way to protect yourself from the Zika infection and unborn babies, and it is crucial that information that prevents further exposure to the mosquito is shared with all patients (Kadri, 2016).
Insecticide-treated bed nets, insect repellent and protecting your skin from exposure are all examples of good preventative measures. However, a particularly hard challenge is to find and destroy the water sources where mosquito larvae thrive, usually near houses (Blood-Siegfried et al 2015).The nurse’s role and health literacy according to the International Council of Nurses (2012) outline the four fundamentals of nursing as preventing illness, restoring health, alleviating suffering and promoting health. It also states that retrieving and distributing the right information at the right time is one of the key aspects of the nurse’s work. Zika can be battled by prevention, and prevention is essentially information that can be distributed. Just distributing information is however not enough, since it has become apparent that many people have a hard time translating the information they receive into good healthy choices for their lives. Thus the explanation about it is needed.
The importance of proper information dissemination needs to be to be strengthened by policies in the government to support is more efficient. Health threat information dissemination has two different components and both should be reflected upon in the context of Zika and other communicable disease management. Firstly, Individual health literacy is the capacity of a person to use and acquire information to make the decision and take appropriate actions about health and health care. Secondly, there is the health literacy environment which consists of infrastructure, policies, material, people, and relationships that make up the health system (Johnson 2015).
Tillman & Kristofferson (2017), added to facilitate good health literacy states that nurses need to organize, present and communicate information in an effective manner, both interpersonally and with the patients. One of the most common complaints about health care is communication failure, and health professionals need to communicate with patients to strengthen health literacy which in turn would improve health outcomes (ibid). In the context of Zika, a lack of health literacy could mean that very few preventative measures are taken to avoid the infection. Here lies one of the nurses’ biggest roles, namely to educate the patient. The patients have a right to receive an education that is individually tailored, to help them take responsibility regarding their own well-being and the treatment they are receiving. Often when nurses or midwives give out information, the patients need to practically apply the health information to their daily lives.
According to Fontes (2016), severe fetal birth defects such as microcephaly have been found in infants born to women infected with Zika virus, according to PAHO guidelines and National Surveillance Protocol in Brazil. The average number of reported cases of microcephaly in newborns in the years before the emergence of Zika virus in Brazil in May 2015 was 200. Recently, the number of cases has increased exponentially, and the incidence of microcephaly cases in 2015 has been reported to be 20 times higher than in previous years. In February 2016, the Brazilian Ministry of Health reported 5,640 cases of microcephaly, most of them Zika virus infection-related, with 4,107 cases under investigation. Of these cases, 538 were confirmed, with 120 deaths, most were concentrated in the economically disadvantaged northeast area of the country.
Additionally, several scientific studies have been conducted regarding Zika virus infection-related neurological disorders in newborns. In one study, the authors were able to determine the complete sequence of Zika virus from a microcephalic fetus that was aborted by a Slovenian mother who visited the northeast region of Brazil and showed symptoms of Zika virus infection, including fever and rash. At approximately the same time, researchers in Brazil and at the US CDC found Zika virus in the brains of two newborn babies who died shortly after birth (Mlakar, Korva, Tul, Popovi?, Poljšak-Prijateljand, Mraz, 2016).
In the study of Hadjra (2016), she mentioned Brazil reported the detection of Zika virus in amniotic fluid samples from pregnant women with ultrasound-confirmed microcephaly, culminating in the issuance of a national public health emergency. Zika virus reached the United States (US) in mid-2016 when the first local-transmission was documented in Miami on July 29, 2016. As of July 2017, there had been over 143 symptomatic Zika virus disease cases reported within the US and over 513 cases within US Territories.
According to ECDC (2016), Zika virus disease typically produces mild and self-limiting symptoms. The proportion of asymptomatic infections may be as high as 80%. This, paired with limitations in the diagnostic capacity, means that only a small fraction of Zika virus infections are likely to be laboratory confirmed. Monitoring of epidemic expansion and intensity of transmission
through laboratory reports is likely to be unreliable. The definition of microcephaly is not standardized and the distribution of occipital frontal circumferences (OFC) varies with ethnicity, sex, age, and gestational age. OFC alone, particularly its milder forms, is a poor predictor for intellectual deficits. Microcephaly should be evaluated in the context of a child’s other body measurements and the OFC of its parents.
In the study of Katler, Godiwala, Macri, Pineles, Simon, Chang, and Ahmadzia (2017), the conclusion revealed Zika virus is a new consideration in the field of congenitally acquired diseases. This study aimed to address the evolving knowledge, attitudes, and practice regarding the Zika virus during a tumultuous time of many unknowns for patients and providers alike. From this study, we can extrapolate that, as more information is gathered about the virus, more questions will be answered and there will be fewer fears regarding the virus. This data can be used to identify gaps in knowledge at this time about Zika virus and prepare medical providers to offer to counsel regarding safety and preventive practices.
In 2015, the prevalence of children born with microcephaly was amplified in Brazil. Many of the mothers reported rashes during their pregnancy, and they had not been exposed to any substances that are known to be harmful to fetuses. The incidence increased even more in 2016 because of this the WHO declared the Zika virus as an epidemic and as a public health emergency of global concern in February 2016. (Teixeira, Costa, de Oliveira, Nunez and Rodrigues, 2016). The Virus has gained much attention from media, perhaps mostly because of its connections with microcephaly. Microcephaly is an unusual multifactorial condition in which the most common symptoms are hearing impairment, severe mental retardation, developmental difficulties, cerebral palsy and seizure disorder. Neonatal deaths related to the conditions are also occurring. Microcephaly is characterized by an abnormally small head and it is a condition called Zika fetal syndrome because of its ties to the Zika virus.
There is no cure for microcephaly, but there’s a lot that can be done to cope with the different disabilities (Malone et al., 2016). Guillain-Barré syndrome (GBS) is a syndrome of various autoimmune etiologies. The syndrome will by unknown cause damage the peripheral nerves, which leads to acute flaccid paralysis. The symptoms are pain, numbness and feeling weak in the limbs (Charrel et al, 2016). The main characteristics are the two-sided symmetrical weakness of the limbs that quickly get worsened. The cranial and respiratory nerve-innervated muscles can also be affected. Both of these diagnoses linked to ZIKA have had a higher prevalence in the current epidemic regions and have also been retrospectively identified in the French Polynesia outbreak (ibid).
To date, health authorities have reported eight adverse pregnancy outcomes and/or other congenital Central Nervous System (CNS) malformations with laboratory confirmation of Zika virus in amniotic fluid, placenta or fetal tissues. In addition, information on six cases of Zika virus detection in newborns from the Paraiba State with partly severe congenital malformations has been recently published. All fourteen reported cases have the history of exposure in Brazil. After performing a retrospective analysis following the alert from Brazil, the health authorities of French Polynesia reported an increase from an average of one case annually to 17 cases of CNS malformations in fetuses and infants during 2014–2015, following a Zika virus outbreak in 2013–2014 (ECDC, 2016).
In summary, the evidence regarding a causal link between Zika virus infections during pregnancy and congenital CNS malformations is growing, although the available information is not yet sufficient to confirm it. The definitions of suspected cases applied in the epidemiological surveillance protocol for Brazil are broad and will capture many healthy children who are within the normal variation as well as children with medical conditions that are unrelatedto Zika virus infections. The cases identified with the surveillance protocol will need to be further investigated and assessed, and many will have to be followed over time. It is expected that many of the suspected cases will bereclassified and discarded. So far, no results have been made public from the epidemiological studies that reportedly are ongoing and may substantiate or disprove the association between intra-uterine Zika virus infections andcongenital lesions in CNS (ECDC, 2016).
The transmission of Zika virus through sexual intercourse is also getting higher interest because it was already confirmed that transmission of this infection through sexual intercourse has been positive and proven. The WHO (2016) confirmed that has the same effect on the fetus whatever the mode of transmission is. Thus, safe sex strategies were encouraged along with the campaign against AIDS and other sexually transmitted diseases. This has been part of the goals of all health agencies also.
According to Transco (2016), the people living in the countries affected by the Zika virus are dependent on the state to control the mosquitoes and the implemented prevention strategies. Tronosco continues to explain that these countries have seen a negative trend, the governments have a tendency to promise results they cannot accomplish. When fighting the spread of the Zika virus goal has been to implement countermeasures. Sadly, by the decision makers working in the public health sector and their failure to launch strategies in a long and medium long-term has worked in favor for the spread of the Aedes Aegypti causing problems in its prevention and control.
According to Kadri (2016) points out that social and environmental conditions must be improved to eradicate the mosquito breeding sites. This harmful breeding sites can be illuminated is proper guidelines from the government on cleaning habits should be implemented. However oftentimes people’s cooperation in this programs is not strong resulting in occurrence still of Zika infections.
In the study of Brasileira (2016), it was noted that despite the increase seen in the number of cases of newborns diagnosed with microcephaly, the total number of cases that are actually associated with Zika virus infection is not known. This failure to track down about the cases is another loophole and challenge to be overcome for proper management. Also, aspects of a cause and effect relation between Zika virus infection and microcephaly, diagnosis, treatment, knowledge of the viremic period, and factors related to increased risk to the fetus, including recognition of the gestation period that is more susceptible to the virus and monitoring of the newborn, are not clarified.
According to Mateo of DOH (2016), studies in the Philippines revealed there are existing chances that Zika virus transmission is also occurring in the other places in the Philippines; however, there are only a few reported cases. There were many cases in the Philippines wherein the manifestation is often correlated with a common cough and colds, thus people do not concern themselves about it so much.
The study of Baquial (2017), shows the facilities’ and resources of the health facilities’ in the Philippines usually is not sufficient and adequate to the needs of the people. These result in the problem in the implementation of many programs effectively.
Synthesis of Related Literature and Studies
The support and commitment of the Department of Health, personnel, and their partner will help build a robust knowledge framework of the occurrence of this infection among pregnant women and its effect on the fetus, this can be a means to improve awareness and cooperation of the people. The need for prospective studies with adequate follow-up is needed. In view of the aspects explained above, the development of clinical guidelines regarding the knowledge acquired to date on an association between infection with Zika virus and its effects on pregnancy and childbirth is imperative in order to delimit and advise on panoramas related to preconception counseling, prenatal, labor, postpartum and newborn care.
This research is within the discipline of “caring sciences”. Since transmission of disease through safe practices are essential in protecting the mother and child from transmission of contagious and deadly disease.
The study will be anchored in the Social Cognitive Theory (SCT) which explains that self-efficacy or a person’s confidence in his or her ability to take action and to persist in that action despite obstacles or challenges is especially important for influencing health behavior change efforts.
The social cognitive theory explains that if the person is aware of the consequences of actions and things towards their health, they are more likely to adopt and do it. Thus, it is the most effective theory in formulating plans towards helping a person improve one’s health practices.
In Social Cognitive Theory the intervention strategies targeting the individual level include goal setting, behavioral contracting, and tailored health communication as a means to improve the practices of the people. It explains human behavior in terms of a three-way, dynamic, reciprocal model in which personal factors, environmental influences, and behavior continually interact. Key constructs of the social cognitive theory that are relevant to behavior change interventions include observational learning, reinforcement, self-control, and self-efficacy to do it.
The theory further emphasizes that if awareness is obtained in certain advocacy the cooperation of the people is stronger because they realized it will
Have good benefits for them. Health professionals or public health educators can make deliberate efforts to increase clients’ self-efficacy using three types of strategies such as: setting small, incremental and achievable goals; using formalized behavioral contracting to establish goals and specify rewards; and monitoring and reinforcement, including client self-monitoring by keeping records.
Conceptual Framework of the Study
The first box presented in Figure 1 describes the implementation of the strategies to avoid sexual transmission of Zika virus explored in terms of the profile of the respondents, implementation of strategies to prevent sexual transmission of Zica virus, the level of prevention of Zica virus and the problems encountered, as the input. The second box contains the design and tools used in the analysis of the implementation of the strategies in the prevention of Zica virus transmission, as the process. The third box shows the effective implementation of strategies and the prevention and protection of the newborn from Zica virus and the formulation of the action plan to improve the implementation strategies, as the output of the study.
This chapter presents the methods utilized in data gathering. Descriptions of research design, locale, respondents, measures and procedures used are included in this chapter.
The study utilized the descriptive – correlational design. The descriptive design is appropriate since it will gather data through a survey on the level of implementation strategies to avoid sexual transmission of Zika virus, level of disease transmission and newborn protection, and problems encountered. The correlational aspect will describe the significant relationship between the two variables.
Locale of the Study
The locale of the study will be in the government hospitals in King Saud Medical City. The biggest and oldest hospital in the Kingdom of Saudi Arabia was named Riyadh Medical Complex, King Saud Medical City is a tertiary health care facility consist of 1,500-bed capacity.
The respondents of the study were the selected 25 personnel, and 25 mothers from King Saud Medical City, Riyadh Kingdom of Saudi Arabia a total of 50 respondents will be selected to participate in the study.
The study made use of the random sampling using Gray’s method for identifying the total number of the sample size. It is done through fishbowl method computing the 20 percent of the total population.
Simple random sampling is a probability sampling technique which refers to the use of any randomized method in selecting the sample. It is considered unbiased estimates, easy data analysis. It is done through which the whole population has an equal chance; selection is done in one process. The most primitive type is fishbowl or lottery, nowadays; researchers rely on machines and/or computers.
Gray’s method, on the other hand, is the strategy in computing for the sample size. It is usually selected for descriptive Research wherein the researcher will get the 20% for population below 500 and 10% for the population as large as 1,000 or above. In the thesis study since the population of the mothers is more than 1,000, thus it was the sample size will be multiplied to 10%.
A researcher made questionnaire will be used as the tools during the data gathering. The research instrument is made up of five parts.
Part 1includedstatements about the profile of the respondents. Part 2 are statements about the level of prevention practices. Part three are statements about the implementation strategies to avoid Zika virus sexual transmission. Part 4 is about the level of disease prevention and child protection. Part 5 will be statements about the problems encountered.
The instrument used the 4- point Likert scale presented as follows:
4-Very Much Available -Very High Implementation
3-Available -Average Implementation
2-Moderately Available-Moderate Implementation
1-Not Available-Not Implemented
4-Excellent-Very High Improvement
3-Satisfactory -Average Improvement
1-Poor -Not Improvement
Data Gathering Procedure
The research process undergoes several steps in data gathering. The first step to being undertaken by the researchers will be the determination of the validity and reliability of the questionnaire. The panel of experts coming from this institution and two midwives from RHU will evaluate the instrument for content validity. The reliability will be done by the Cornbrash Alpha method to 5 respondents who will be not be included in the final conduct of the study.
It will be followed by the distribution of the permission to conduct the study, the researcher will personally distribute the letters for approval to conduct the study signed by the dean of the Midwifery College to the hospital administrator in charge in the government hospital for proper coordination and permission to conduct the survey.
The actual survey will be conducted personally by the researchers. Informed consent and permission will be asked from the respondents with an assurance on the privacy of their identity.
After the survey and retrieval of data, it will be tabulated and analyzed with the help of the statistician.
Statistical Treatment of Data
Based on the data gathered the percentage and frequency distribution will be used in an analysis of the profile. The mean will be used in interpreting the implementation strategies, level of disease prevention and infant protection and problems encountered. The Pearson correlation will be used in describing the significant relationship between the implementation strategies and disease prevention.
For the purpose of the study, the five points rating scale was used by the researchers with the following weight and range implementation strategies and disease prevention Zika Virus.
Formula for Percentage
P=fnx 100WM= ?fiXinP= percentage
N= number of responders
WM= weighted mean
N= number of respondents
Part I. Profile of the Respondents:
Name (optional): ____________________
Educational Attainment: __________
Part II. Implementation Strategies to Avoid Zika Virus Sexual Transmission
Direction: Below is a checklist of the implementation of the strategies to prevent Zika transmission you are providing for your clients. Please rate them according
to your experience using the given scale below:
4-Very Much Available -Very High Implementation
3-Available – Average Implementation
2-Moderately Available-Moderate Implementation
1-Not Available-Not Implemented
Part III. Prevention Practices
Direction: Below is a checklist of prevention practices done to prevent transmission of Zika virus. Please rate them according to your experience using the given scale below:
4-Very Much Practiced-Very High Implementation
2-Moderately Practiced-Moderate Implementation
1-Least Practiced-Not Implemented
Part IV. Disease Prevention and Newborn Protection
Direction: Below is a checklist for the level of disease prevention and infant protection against Zika Virus. Please rate them according to your experience using the given scale below:
4-Excellent-Very High Improvement
3-Satisfactory -Average Improvement
1-Poor -Not ImprovementPart V Problems Encountered
Direction: Below is a checklist for the degree of problems encountered in the implementation of strategies of Zica prevention program. Please rate them according to your experience using the given scale below:
4-Very Big ProblemVery Poorly Available
3-Moderate Problem Moderately Available
2-Less ProblemSeldom Available
1-Least Problem Not Available