Nurses’ and clients’ perspectives after engagement in the co-designing of solutions to improve provider-client relationships in maternal and child healthcare: a human-centered design study in rural Tanzania

Background There has been a persistent increase in clients’ dissatisfaction with providers’ competencies in maternal and child healthcare (MCH). Existing interventions have failed to address the complexity of provider-client relationships. Therefore, targeted, contextualized innovative solutions that place providers and clients at the forefront as agents of change in optimizing intervention design and implementation are needed. The study team adopted a co-design strategy as part of Human- Centered Design (HCD) approach, where MCH nurses, clients, and stakeholders partnered to design an intervention package to improve provider-client relationships in rural Tanzania. Objective This paper explored nurses’, clients’, and MCH stakeholders’ perspectives following participation in a co-design stage of the HCD study to generate interventions to strengthen nurse-client relationships in Shinyanga Region. Methods A qualitative descriptive design was used. Thirty semi-structured key informant interviews were conducted in the Swahili language with purposefully selected nurses, clients, and MCH stakeholders. The inclusion criterion was participation in consultative workshops to co-design an intervention package to strengthen nurse-client relationships. Data were transcribed and translated simultaneously, managed using NVivo, and analyzed thematically. Results Three main themes were developed from the analysis, encompassing key learnings from engagement in the co-design process, the potential benefits of co-designing interventions, and co-designing as a tool for behavior change and personal commitment. The key learnings from participation in the co-design process included the acknowledgment that both nurses and clients contributed to tensions within their relationships. Additionally, it was recognized that the benefits of a good nurse-client relationship extend beyond nurses and clients to the health sector. Furthermore, it was learned that improving nurse-client relationships requires interventions targeting nurses, clients, and the health sector. Co-designing was considered beneficial as it offers a promising strategy for designin

Experiences of informal women caregivers in caring for people living with HIV and AIDS in Dar es Salaam, Tanzania

Aim of the study: The aim of this study was to explore and describe the experiences of informal women caregivers of people living with HIV and AIDS at home in Dar es Salaam, Tanzania. The study took place in Temeke district in the Dar es Salaam region through the auspices of Pastoral Activities and Services for people with AIDS, Dar es Salaam Archdiocese (PASADA), a non-governmental organization that provides home-based care services. Research design and method: The research design was a qualitative, descriptive and exploratory study based on the interpretive paradigm. The study population was informal women caregivers looking after spouses or relatives at home who were living with HIV and AIDS (staged at World Health Organization clinical stages III and IV), some on antiretroviral therapy and others not. Purposive sampling was used to select participants who were attending PASADA's community centre. Data were collected using semi-structured· interviews which were audio-recorded. Eight participants were interviewed in order to explore their individual experiences of caring for people living with HIV and AIDS. Data collection continued until data saturation was achieved. The recorded data were transcribed verbatim and analysed using thematic analysis. Anonymity and confidentiality of the study participants was maintained throughout. Findings: Themes which emerged from the data were as follows: social and economic situation; HIV-related stigma and discrimination; stress and burn-out: treatment and support system; care burden and the challenges. Financial problems made an impact on food security, and the caregivers also had to cope with multiple illnesses in the people under their care. The lack of support for the caregivers increases their vulnerability to stress and burn-out

Disrespect and abuse in maternity care in a low-resource setting in Tanzania: Provider’s perspectives of practice

Background Globally, women experience disrespectful and abusive care from maternity healthcare providers at health facilities, committed intentionally or unintentionally, particularly during labor and delivery. Disrespectful care affects women’s childbirth experience and birth outcomes. Methods This study used a descriptive qualitative design to obtain thick and rich data on disrespect and abuse in maternity care in a low-resource setting in Tanzania. Three days workshop was conducted at the Aga Khan University comprising maternity healthcare providers from diverse settings. The workshop was designed based on the existing evidence and anecdotal data and inspired by the authors’ experiences of disrespectful and abusive care (stereotyping clients, not listening to client’s/relatives’ concerns, unconsented care) as a client, relative, or observant of colleagues. The targeted audience was maternity healthcare providers from public and private health facilities in the Dar es Salaam region. Data collection encompassed individual responses (reflection of practice) obtained by individuals, anonymously written reflections of practice, and compiled notes from group discussions. Data were analysed thematically guided by six steps described by Braun and Clerk. Results A total of 80 maternity healthcare providers participated in the workshop from various health facilities, including dispensaries (n = 25), health centres (n = 2), and hospitals (n = 3) located in semi-urban Dar es Salaam. Four main themes were identified from the data: Physical and verbal abuse; Lack of professional ethics and integrity; Vulnerable working environment; Abuse and disrespect to care providers. In addition, several sub-themes were identified within these themes: Harsh and abusive language; Beating/slapping/pinching of the mother in labor; notably, Junior midwives also disrespected and abused women; Lack of privacy and confidentiality; Poor communication; No consent for maternity healthcare procedures; Lack of courtesy and poor interpersonal skills; and, negligence of care and woman’s needs. Conclusion The actions of disrespect and abuse are alarming in practice and are associated with ignorance of fundamental human rights by both providers and recipients of services. Conducting workshops seems a useful approach to revealing disrespect and abuse deep-rooted in practice and provides an opportunity to rectify the problem with providers. A more extensive interventional study will be crucial to address the widespread actions of disrespect and abus

Capacity building among nursing and midwifery professional associations in East Africa

Background: Despite improvements in educational opportunities, policy changes, and pay raises in the nursing and midwifery professions in East Africa, poor working conditions, few professional development opportunities, and a general lack of respect for these professions predominate. These issues contribute to a low quality of care among a population with a high burden of communicable diseases. Health professional associations may help to address these challenges by providing a voice for nurses and midwives. Objective: This study evaluated the impact of a 5-year programme focused on strengthening nurses’ and midwives’ professional associations in East Africa. Methods: This study used a mixed methods design. Quantitative, cross-sectional descriptive data were captured via surveys (n = 1,266) distributed to association members. In-depth interviews (n = 65) were used to obtain qualitative data and complement the survey responses. Quantitative and qualitative data collection occurred concurrently. The results were compared to assess the impact of the programme across Uganda, Kenya, and Tanzania. Results: The programme successfully built capacity in four of five organisational capacity areas: resource mobilisation, financial management, strategy, and monitoring and evaluation. Marketing and communications, the fifth targeted area, did not show improvement. Capacity in both research and service delivery was also improved, despite the programme not providing training in these areas. In addition, collaboration among associations and their members was improved. Conclusion: These results support existing evidence on the impact of capacity building among professional nursing associations and coincide with the World Health Organization’s objectives for nursing. Future capacity building programmes should consider replicating the successful activities from this programme and investigate ways to reach more rural branches and provide tailored content. This study contributes to a small but growing body of knowl- edge that supports capacity building among the African health workforce

Introduction of an Advanced Practice Nurse Program in Kenya: A New Era in Nursing Education

Purpose: The purpose of this presentation is to share the intra and interprofessional collaborative process of developing an Advanced Practice Nursing (APN) program to be offered in 2020 in Kenya, a low middle-income country. Methods: Engagement with stakeholders (students, clinicians, regulators and educators) affirmed the need for an APN program. Faculty from Schools of Nursing and Midwifery in three East African countries developed an APN curriculum with input from local and international agencies such as the Nursing Council of Kenya with linkages to the ICN, the Nursing Now Team and partner universities in the UK and USA. The curriculum was reviewed for relevance and cultural sensitivity. Christmals and Crous (2019) noted the importance of contextualizing the APN role to the specific country and healthcare systems. The development of collaborative frameworks between nursing and midwifery, and higher educational councils is important (Muraraneza, Mtshali, and Mukamana, 2017), therefore, feedback from the Council for Higher Education was sought and incorporated. The final document will be sent to external reviewers from partner universities prior to implementation in 2020. Limited resources and opposition from the medical profession have been reported as challenges to APN programs in Sub Saharan Africa (Christmals and Armstrong, 2019). To address these problems, the Liverpool John Moore University, UK, will host a six weeks’ capacity building program for East African faculty who will teach in this program. The program will be also offered in partnership with Family Medicine physicians and pharmacists and this will enhance interprofessional competencies (Monahan, Sparbel, Heinschel, Rugen, and Rosenberger, 2018). A workshop will be held in 2020 to share a common understanding of the program with all collaborative partners. The APN role is evolving globally and there is no consensus on the core competencies and its definition (Heale and Buckley, 2016). Kenya has no scope of practice for APN (East, Arudo, Loefler and Evans, 2014) and one will be developed. Results: An APN curriculum has been developed and is in the final stages of review prior to implementation in 2020. Anticipated challenges have been identified such as lack of resources among others, and strategies have been put in place to mitigate them. Conclusion: An APN program is pivotal to the realization of the Universal Health Coverage (UHC) as graduates of this program will be deployed in primary health care settings. The intra and interprofessional collaboration will strengthen both the program and partnerships (local and global) with mutual benefits for all involved

Religious beliefs, social pressure, and stigma: Rural women’s perceptions and beliefs about vasectomy in Pwani, Tanzania

Despite being a reliable and cost effective family planning method, vasectomy remains underutilized in many low resource settings such as East Africa. We explored rural women’s perceptions and beliefs regarding barriers to vasectomy use in the low resource setting of Pwani, Tanzania. The qualitative study used in-depth semi-structured interviews to obtain data. Purposive sampling was used to recruit 20 married/cohabiting women with two or more children. Thematic analysis guided the data analysis, with qualitative data reporting informed by COREQ guidelines. Most participants were Muslim and had between two and six children. Most had completed primary-level education and were engaged in small-scale farming. We extracted three main themes with associated sub-themes:1) lack of education, which included men’s education levels and inadequate knowledge and misinformation 2) religious beliefs, social pressure and stigma, which included community stigma and the belief that vasectomy was not good for men with multiple wives; and 3) promoting men’s involvement in family planning which included educating men and the women’s perceived role in promoting vasectomy. Participating women perceived vasectomy uptake to be affected by a lack of low knowledge (among men, women, and the community), misinformation, and various sociocultural barriers. Efforts to promote vasectomy and male involvement in reproductive health services should be directed to addressing deeply-rooted sociocultural barriers. Women may have an essential role in encouraging their partners’ vasectomy uptake. In addition, engaging couples in family planning education is critical to enhance knowledge. Ideally, such community based education should be conducted in partnership with communities and healthcare providers

My husband will love me more if I give birth to more children: Rural women’s perceptions and beliefs on family planning services utilization in a low resource setting

Introduction: Responsibility for family planning in low resource settings is almost solely delegated to women, with very low male involvement. This study investigated rural Tanzanian women’s perceptions and cultural beliefs of the barriers to family planning services utilization. Methods: This study used a qualitative descriptive approach drawing on four group discussions with 20 purposively selected married women with two or more children. The study followed COREQ guidelines for reporting qualitative studies. Data were collected from participants at four health facilities in Bagamoyo and Kisarawe districts in Pwani, Tanzania. Results: Participants’ occupations included housewives, small-scale farmers, and entrepreneurs. Most women were Muslim and had a primary school education. Five main themes were identified: use of modern and traditional family planning methods; my husband will love me more if I give birth to more children; men’s expected roles in family planning; provide education to dispel myths; and religious barriers. Associated sub-themes covered use of strings, snares and pigis; calendars; breastfeeding linked to family planning; men as heroes for having many children; men not having time to attend clinic; and conflicting sources of health information. Conclusion: Lack of adequate family planning information; beliefs on and use of traditional/unconventional methods; gender roles expectations that influence decision making and limit women’s choices of family planning methods and; socio-cultural and religious beliefs were main perceived barriers for family planning utilization in this study. Mitigation of these barriers depends on the sustained engagement of key stakeholders including religious and community leaders. Health education must be designed to adapt socio-cultural and religious doctrines with benefits of family planning and health outcomes. Health delivery services must also address women’s’ prevailing perceptions and beliefs with emphasize on the partner communication and their encouragement of men’s’ involvement in reproductive health services utilization

Open and Distance Learning Programs for Nursing and Midwifery Education in East Africa: Protocol for a Scoping Review

Background: In the face of growing modernity and the coronavirus disease 2019 (COVID-19) pandemic, open and distance learning (ODL) is considered to play an important role in increasing access to education worldwide. There is a robust evidence base demonstrating its cost effectiveness in comparison with conventional class-based teaching; however, the transition to this new paradigm of learning for nursing and midwifery courses has been difficult in low-income countries. While there are notable efforts to increase internet and education access to health care professionals, not much is known about ODL for nurses and midwives in East African countries. Objective: The objective of this scoping review is to understand whether ODL programs for nursing and midwifery education exist, the drivers of their adoption, their implementation, the topics/courses covered, their acceptability, and their impacts in East African countries. Methods: The scoping review methodology employs the framework developed by Arksey and O’Malley. Using an exploratory approach, a two-stage screening process consisting of a title and abstract scan and a full-text review will be used to determine the eligibility of articles. To be included, articles must report on an existing ODL initiative for nurses and midwives in Uganda, Tanzania, and Kenya. All articles will be independently assessed for eligibility by pairs of reviewers, and all eligible articles will be abstracted and charted in duplicate using a standardized form. Results: Details of ODL for nursing and midwifery education initiatives and study outcomes will be summarized in a table. The extracted data will undergo exploratory descriptive analysis, and the results will be classified into learner and clinical outcomes. Conclusions: Evidence on ODL for nursing and midwifery education will inform the ongoing development and restructuring of health care professional education in East Africa amidst the COVID-19 pandemic

Improved postpartum care after a participatory facilitation intervention in Dar es Salaam, Tanzania: a mixed method evaluation

Background: In order to improve the health and survival of mothers/newborns, the quality and attendance rates of postpartum care (PPC) must be increased, particularly in low-resource settings. Objective: To describe outcomes of a collegial facilitation intervention to improve PPC in government-owned health institutions in a low-resource suburb in Dar es Salaam, Tanzania. Methods: A before-and-after evaluation of an intervention and comparison group was conducted using mixed methods (focus group discussions, questionnaires, observations, interviews, and field-notes) at health institutions. Maternal and child health aiders, enrolled nurse midwives, registered nurse midwives, and medical and clinical officers participated. A collegial facilitation intervention was conducted and healthcare providers were organized in teams to improve PPC at their workplaces. Facilitators defined areas of improvement with colleagues and met regularly with a supervisor for support. Results: The number of mothers visiting the institution for PPC increased in the intervention group. Some care actions were noted in more than 80% of the observations and mothers reported high satisfaction with care. In the comparison group, PPC continued to be next to non-existent. The healthcare providers’ knowledge increased in both groups but was higher in the intervention group. The t-test showed a significant difference in knowledge between the intervention and comparison groups and between before and after the intervention in both groups. The difference of differences for knowledge was 1.3. The providers perceived the intervention outcomes to include growing professional confidence/knowledge, improved PPC quality, and mothers’ positive response. The quality grading was based on the national guidelines and involved nine experts and showed that none of the providers reached the level of good quality of care. Conclusions: The participatory facilitation intervention contributed to improved quality of PPC, healthcare providers’ knowledge and professional confidence, awareness of PPC among mothers, and increased PPC attendance

Perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital in Tanzania

Background: Surgical Site Infections are a major cause of morbidity and mortality among operated patients. In spite of the accessibility of universal and national guidelines for surgical prophylaxis, recent studies surveying the present routine of prophylaxis have demonstrated overutilization of a wide range antibacterial medication for a single patient. Few studies have shown qualitatively factors influencing this and perceptions of surgeons on surgical antibiotic prophylaxis use. Unfortunately, none of these studies have been done in Tanzania. Objective: To describe the perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital. Methods: A qualitative study involving in-depth interviews with surgeons was conducted in English by the primary investigator. The interviews were audio-recorded and transcribed verbatim. Systematic text condensation by Malterud was used for data analysis. Findings: Fourteen surgeons and obstetrics and gynaecologists participated. Their perceptions were summarized into three main categories: Inadequate data to support practice; one who sees the patient decides the antibiotic prophylaxis; prolonged antibiotic use for fear of unknown. The participants perceived that choice of antibiotic should be based on local hospital data for bacterial resistance pattern, however the hospital guidelines and data for surgical site infection rates are unknown. Fear of getting infection and anticipating complications led to prolonged antibiotics use. Conclusion: The study provides an understanding of surgical antibiotic prophylaxis use and its implementation challenges. This was partly expressed by unavailability of local data and guidelines to enhance practice. To improve this, there is a need of guidelines that incorporates local resistance surveillance data and enhanced antibiotic stewardship programmes. A strong consideration should be placed into ways to combat the fears of surgeons for complications, as these significantly affect the current practise with use of surgical antibiotic prophylaxis