A process evaluation of the scale up of a youth-friendly health services initiative in northern Tanzania

BACKGROUND: While there are a number of examples of successful small-scale, youth-friendly services interventions aimed at improving reproductive health service provision for young people, these projects are often short term and have low coverage. In order to have a significant, long-term impact, these initiatives must be implemented over a sustained period and on a large scale. We conducted a process evaluation of the 10-fold scale up of an evaluated youth-friendly services intervention in Mwanza Region, Tanzania, in order to identify key facilitating and inhibitory factors from both user and provider perspectives. METHODS: The intervention was scaled up in two training rounds lasting six and 10 months. This process was evaluated through the triangulation of multiple methods: (i) a simulated patient study; (ii) focus group discussions and semi-structured interviews with health workers and trainers; (iii) training observations; and (iv) pre- and post-training questionnaires. These methods were used to compare pre- and post-intervention groups and assess differences between the two training rounds. RESULTS: Between 2004 and 2007, local government officials trained 429 health workers. The training was well implemented and over time, trainers' confidence and ability to lead sessions improved. The district-led training significantly improved knowledge relating to HIV/AIDS and puberty (RR ranged from 1.06 to 2.0), attitudes towards condoms, confidentiality and young people's right to treatment (RR range: 1.23-1.36). Intervention health units scored higher in the family planning and condom request simulated patient scenarios, but lower in the sexually transmitted infection scenario than the control health units. The scale up faced challenges in the selection and retention of trained health workers and was limited by various contextual factors and structural constraints. CONCLUSIONS: Youth-friendly services interventions can remain well delivered, even after expansion through existing systems. The scaling-up process did affect some aspects of intervention quality, and our research supports others in emphasizing the need to train more staff (both clinical and non-clinical) per facility in order to ensure youth-friendly services delivery. Further research is needed to identify effective strategies to address structural constraints and broader social norms that hampered the scale up

Developing Methods to Study Parent-Child Relationships in Rural Sub-Saharan Africa: An Exploratory Project in Mwanza, Northern Tanzania

To further develop methods for researching parent-child relationships, a small exploratory study was conducted over six weeks in a fishing village in northern Tanzania. The aims were to: a) assess the feasibility of different forms of participant observation, observation and informal interviews; b) assess the amount and kind of data collected by each method; and c) inform the development of questionnaire items. The study showed that it is feasible to collect rich data on household activities and parent-child relationships through informal interviews and observations in households by a professional researcher. Starting observations with focused informal interviews was probably unhelpful in establishing rapport. The data collected by the graduate researcher proved far more useful than that collected by local field assistants. The disadvantages of working with locally recruited field assistants (distorting sampling; overlooking important interactions; inhibited from acting as researchers) outweighed the benefits (familiarity with the local community, working outwith conventional hours, cheap to employ). Observations generally yielded more information than informal conversations, but their value depended on time of day and presence of children. Spending at least 24 consecutive hours in a household yielded a large amount of data of high validity. Even after three days living in a household, the graduate researcher was still unclear as to how much her presence influenced the host’s behaviour. The findings suggest there will be strong social desirability biases in questionnaires with parents about their relationships with their children. The relative validity of parent and child reports needs to be verified through observation. The five dimensions of positive parenting identified in the WHO review (WHO, 2007) can be observed in rural Mwanza. However, the dimensions are probably most usefully understood as each representing a continuum running from positive to negative interactions

Barriers to spectacle use in Tanzanian secondary school students.

PURPOSE: Screening school students for refractive errors is a component of many primary eye care programs. In 2004 a trial of two approaches of spectacle-delivery to Tanzanian secondary school students found that only one third of students were using their spectacles at three months. Barriers to spectacle use were investigated using questionnaires and focus group discussions. METHODS: At the three months follow-up survey a questionnaire explored satisfaction with spectacles and the attitudes of trial participants (median age 15 years). Attitudes and reactions of friends, teachers and families were also explored. Students also discussed their experience with spectacle use and reasons for non-use in 8 focus groups divided by intervention, sex and spectacle use. RESULTS: In general, students seemed happy with the appearance of their spectacles and the beneficial impact on their vision. Peer pressure and parental concerns about safety of spectacle use, cost of purchasing spectacles and difficulties in accessing good local optical services were identified as the main barriers. Students criticized prescribing practices of local opticians and favored alternative and traditional treatments for visual impairment. CONCLUSION: To increase the effectiveness of school vision screening in Tanzania, barriers such as peer pressure or concerns about safety need to be addressed, in addition to provision of affordable, good quality spectacles. Barriers to spectacle use in children are likely to exist in all populations, but may vary in their nature and importance and therefore should be investigated in existing and new screening programs

Dusty discos and dangerous desires: community perceptions of adolescent sexual and reproductive health risks and vulnerability and the potential role of parents in rural Mwanza, Tanzania.

This paper presents villagers' assessments of young people's sexual and reproductive health vulnerability and of community-based interventions that may reduce both vulnerability and risk in rural Mwanza, Tanzania. The primary methods used were 28 group discussions and 18 in-depth interviews with representatives of various social groups in four villages. The majority of participants attributed young people's sexual and reproductive health risks to a combination of modernisation (and its impact on family and community life), socioeconomic conditions, social norms in rural/lakeshore communities and the difficulties parents and other adults face in raising adolescents in contemporary Tanzania. Community life has limited opportunities for positive development but contains many risky situations. Young and old agreed that parents have a strong influence on young people's health but are failing in their parental responsibility. Parents acknowledged the multiple influences on sexual risk behaviour. They expressed a need for knowledge and skills related to parenting so that they can address these influences both through family- and community-based strategies