Human resources for emergency obstetric care in northern Tanzania: distribution of quantity or quality?

Background: Health care agencies report that the major limiting factor for implementing effective health policies and reforms worldwide is a lack of qualified human resources. Although many agencies have adopted policy development and clinical practice guidelines; the human resources necessary to carry out these policies towards actual reform are not yet in place. Objectives: The goal of this article is to evaluate the current status of human resources quality; availability and distribution in Northern Tanzania in order to provide emergency obstetric care services to specific districts in this area. The article also discusses the usefulness of distribution indicators for describing equity in the decision-making process.Methods: We conducted a quantitative facility survey in six districts of Northern Tanzania. We collected data from all 129 facilities that provide delivery services in the study area. The data includes information on the emergency obstetric care indicators; as described by the WHO/UNICEF/UFPA guidelines for monitoring the provision of obstetric care. The inventory also includes information on the numbers of qualified health personnel at the basic and comprehensive emergency obstetric care level. We analysed the distribution and workload of the available human resources in a wider policy context with a particular focus on equity; use and quality; by means of descriptive statistics and the Spearman's correlation test. Results: We determined that there are adequate human resources allocated for health care provision in Tanzania; according to national standards. Compared to similar countries however; Tanzania has a very low availability of health care staff. Most qualified staff are concentrated in a few centralized locations; while those remaining are inequitably and inefficiently distributed in rural areas and lower-level services. Rural districts have restricted access to government-run health care; because these facilities are understaffed. In fact; voluntary agency facilities in these districts have more staff than the government facilities. There is a statistical correlation between availability of qualified human resources and use of services; but the availability of qualified human resources does not automatically translate into higher availability of qualified emergency obstetric care services. Conclusion: National guidelines for human resources for health care in Tanzania require focused revisions in order to reflect the quality indicators more adequately when monitoring and setting criteria for HR distribution. Availability of qualified personnel as well as institutional management and capacity determine the quality of emergency obstetric care services and personnel. The current wide distribution of staff of inadequate quality should be reconsidered. The use of distribution indicators alone is not useful to properly monitor equity. This article suggests increasing access to high-quality health care instead of distributing low-quality services widely

Complicated deliveries, critical care and quality in emergency obstetric care in Northern Tanzania.

Our objective was to determine the availability and quality of obstetric care to improve resource allocation in northern Tanzania. We surveyed all facilities providing delivery services (n=129) in six districts in northern Tanzania using the UN Guidelines for monitoring emergency obstetric care (EmOC). The three last questions in this audit outline are examined: Are the right women (those with obstetric complications) using emergency obstetric care facilities (Met Need)? Are sufficient quantities of critical services being provided (cesarean section rate (CSR))? Is the quality of the services adequate (case fatality rate (CFR))? Complications are calculated using Plan 3 of the UN Guidelines to assess the value of routine data for EmOC indicator monitoring. Nearly 60% of the expected complicated deliveries in the study population were conducted at EmOC qualified health facilities. 81.2% of the expected complicated deliveries are conducted in any facility (including facilities not qualifying as EmOC facilities). There is an inadequate level of critical services provided (CSR 4.6). Voluntary agencies provide most of these services in rural settings. All indicators show large variations with the setting (urban/rural location, level and ownership of facilities). Finally, there is large variation in the CFR with only one facility meeting the minimum accepted level. Utilization and quality of critical obstetric services at lower levels and in rural districts must be improved. The potential for improving the resource allocation within lower levels of the health care system is discussed. Given the small number of qualified facilities yet relatively high Met Need, we argue that it is neither the mothers' ignorance nor their lack of ability to get to a facility that is the main barrier to receiving quality care when needed, but rather the lack of quality care at the facility. Little can be concluded using the CFR to describe the quality of services provided.

AIDS education in Tanzania: promoting risk reduction among primary school children.

OBJECTIVES: The purpose of this study was to test the effects of an education program in Tanzania designed to reduce children's risk of human immunodeficiency virus (HIV) infection and to improve their tolerance of and care for people with acquired immunodeficiency syndrome (AIDS). METHODS: A randomized controlled community trial including baseline and 12-month follow-up surveys was employed. Public primary schools in the Arusha and Kilimanjaro regions of Tanzania were stratified according to location and randomly assigned to intervention (n = 6) or comparison (n = 12) conditions. Of the 1063 sixth-grade students (average age: 13.6 years) who participated at baseline, 814 participated in the follow-up survey. RESULTS: At follow-up, statistically significant effects favoring the intervention group were observed for exposure to AIDS information and communication, AIDS knowledge, attitudes toward people with AIDS, and subjective norms and behavioral intentions toward having sexual intercourse. A consistent positive but nonsignificant trend was seen for attitudes toward having sexual intercourse and for initiation of sexual intercourse during the previous year (7% vs 17%). CONCLUSIONS: It is feasible and effective to train local teachers and health workers to provide HIV/AIDS education to Tanzanian primary school children.

Predictors of intention to be sexually active among Tanzanian school children.

This paper presents the results from a study of human immunodeficiency virus/AIDS risk behaviour conducted among primary school children in the Kilimanjaro and Arusha regions of northern Tanzania. The study was guided by the theory of reasoned action, and the decision to have or abstain from sexual intercourse was studied. All sixth and seventh grade pupils at eighteen schools were invited to participate. A total of 2,026 pupils (mean age 14.0 years) participated (participation rate of 85%), representing a wide variety of ethnic, socio-economic and urban-rural groups. Sixty-three percent of the boys and 24% of the girls reported having had their sexual debut. Attitudes, subjective norms and self-efficacy were all predictors of intention to have sexual intercourse within the next three months, but prior behaviour emerged as the strongest predictor of intention. Primary schools appear to be an important arena for HIV/AIDS education in Tanzania and it is recommended that such education be directed toward young adolescents.

Doctors' continuing education in Tanzania: distance learning.

A distance learning programme for medical officers and their assistants at the district level has produced some valuable lessons for future activities in continuing education. Besides correspondence and study materials, face-to-face contact between students and their tutors is a particularly important ingredient, as it provides the guidance, flexibility and motivation that are essential for an effective programme.

Scale reliability and construct validity: a pilot study among primary school children in Northern Tanzania.

Based on the World Health Organization's standardized survey inventories assessing AIDS-related knowledge, attitudes, beliefs, and practices (KABP) for adolescents, a written questionnaire was developed and pilot tested among primary school children in Northern Tanzania. Subjects included 472 fifth and sixth graders at four schools in Arusha and Kilimanjaro regions. Results indicated that the large majority of the students understood the questions and were able and willing to complete the survey. Non-response patterns did not seem to be related to the sensitivity of included questions. AIDS-related knowledge and attitudes toward engaging in sexual behavior had acceptable reliability and construct validity when compared with similar surveys in Western countries, while perceived social norms and self-efficacy need further development. KABP questionnaires may serve as a useful method in AIDS-related surveys and evaluation studies among school children in Tanzania if survey instruments are adapted to reflect the local social and cultural context.

AIDS education for primary school children in Tanzania: an evaluation study.

OBJECTIVE: To test the effects of an HIV/AIDS education program. DESIGN: A quasi-experimental, nested cross-sectional design including baseline and 6-month follow-up surveys. Schools, stratified according to location, were randomly assigned to intervention (n = 6) or comparison conditions (n = 12). SETTING: Public primary schools in Arusha and Kilimanjaro regions, Tanzania. PARTICIPANTS: A total of 2026 sixth and seventh grade pupils (average age, 14.0 years) participated at baseline (85%) and 1785 at follow-up. INTERVENTION: The program was designed to reduce children's risk of HIV infection and to improve their tolerance of and care for people with AIDS. Local teachers and health workers attended a 1-week training workshop before implementing the program over a 2-3-month period (averaging 20 school hours per class). MAIN OUTCOME MEASURES: Self-reported exposure to AIDS information, communication regarding AIDS; AIDS knowledge, attitudes towards people with AIDS, attitudes towards having sexual intercourse, subjective norms regarding sexual intercourse, and intention to engage in sexual intercourse. RESULTS: Following this program, intervention pupils reported significantly higher scores for the following outcome measures than pupils attending the comparison schools: AIDS information (13.1 versus 10.5; P = 0.0001), AIDS communication (10.9 versus 7.8; P = 0.0001) AIDS knowledge (14.5 versus 11.5; P = 0.0001), attitudes towards people with AIDS (9.0 versus 6.7; P = 0.0008), subjective norms (45.5 versus 43.9; P = 0.011), and intention (1.3 versus 1.4; P = 0.020). No program effect was seen for attitudes towards sexual intercourse (47.0 versus 46.3, P = 0.44). CONCLUSIONS: These results indicate that it is feasible and effective to provide AIDS education for Tanzanian primary school children.

PIP: In the adjacent regions of Arusha and Kilimanjaro in Tanzania, researchers conducted a quasi-experimental, nested cross-sectional design to evaluate the Ngao (shield) HIV/AIDS education program for public primary school children, a culturally specific program. The baseline survey and the 6-month follow-up survey included 2026 and 1785 6th-7th grade children, respectively. Teachers of the participating schools and health workers participated in a 1-week training workshop before they implemented the program over 2-3 months. Its intent was to reduce the pupils' risk of HIV infection and to improve their acceptance of and care for people with AIDS. At baseline, the pupils in intervention and comparison schools tended to be comparable. At follow-up, however, intervention pupils had been exposed to more AIDS information (scores, 13.1 vs. 10.5), had discussed AIDS more often (10.9 vs. 7.8), and had a higher increase in AIDS knowledge (14.5 vs. 11.5) than did the comparison pupils (p = .0001 for all the above). They also had significantly more positive attitudes towards people with AIDS than the comparison pupils (9 vs. 6.7; p = .0008). Pupils in the intervention had more restrictive subjective norms regarding sexual intercourse (45.5 vs. 43.8; p = .011) and less intention to engage in sexual intercourse over the next 3 months than at baseline. Yet, they were not significantly different from comparison pupils, because the comparison pupils also had a change in attitude. These findings show that teachers in primary schools and health educators can implement a workable and effective HIV/AIDS education program for school children.

Continuing education. The experience of Tanzania.

PIP: The continuing education program in Tanzania aims, as part of primary health care (PHC) training, to provide leadership in planning, implementing, and monitoring PHC training; and to implement PHC educational activities. The program was initiated in 1981 under the Ministry of Health with support from the African Medical and Research Foundation. Pilot projects were begun in the Arusha region until funding ceased in 1986. In 1988, the Danish International Development Authority funded the integration and decentralization of continuing education into the existing health system for all 6 zones. Career-based training for health workers was emphasized. Methods involved distance learning and institutional training. The Arusha Center for Educational Development in Health had developed teacher training, research and curriculum development, management training, and production of health learning materials. The Expanded Program on Immunization and Oral Health, as separately funded vertical programs, have been successfully integrated into the health system. Distance learning has been incorporated into the continuing education program, because it permits studying away from the institutions and is affordable for training all types of health workers. The technique has been effectively used after donor support has ended. Distance learning modules were developed for teaching about essential drugs, environmental sanitation and water, food quality control, and diarrheal diseases. Rural medical officers have been trained with distance learning and use of modules on obstructed labor, acute respiratory infections, and epidemiology, which were field tested and evaluated in a pilot project. District Action Research and Evaluation aims to strengthen management capabilities through long and short workshops. The skills emphasized include problem identification, analyzing causes of problems, identifying possible solutions, development of action plans, implementing action plans, and evaluation of activities. Clinical meetings aim to improve hospital-based staff. Lobby meetings inform medical staff and managers of current activities. Lack of funds, lack of qualified staff, inadequate support, and misdirected practices are limitations of continuing education.^ieng

Exposure to HIV/AIDS information, AIDS knowledge, perceived risk and attitudes toward people with AIDS among primary school-children in northern Tanzania.

An AIDS survey based on WHO's KABP survey instrument for adolescents was implemented with sixth and seventh grade students attending one of 18 randomly selected primary schools in the Arusha and Kilimanjaro regions of Northern Tanzania (n = 2,026). While students reported having been exposed to several sources of AIDS information, overall knowledge level was low, particularly with respect to risk associated with causal contact, and the fact that a person can be infected and show no signs of the disease. Students who reported frequent exposure to AIDS information or who frequently talked to others about AIDS, were more knowledgeable regarding AIDS than students who reported less frequent exposure to AIDS information or communication. Furthermore, students with high scores on AIDS knowledge were more likely to report AIDS as a very severe disease. Also, they perceived themselves as less susceptible to AIDS, and were more likely to have a positive attitude toward spending time with and taking care of people with AIDS than did less knowledgeable students. It is recommended that primary schools be utilized as an arena for AIDS education in Tanzania.