Leveraging AI and Machine Learning to Develop and Evaluate a Contextualized User-Friendly Cough Audio Classifier for Detecting Respiratory Diseases: Protocol for a Diagnostic Study in Rural Tanzania.

BACKGROUND: Respiratory diseases, including active tuberculosis (TB), asthma, and chronic obstructive pulmonary disease (COPD), constitute substantial global health challenges, necessitating timely and accurate diagnosis for effective treatment and management. OBJECTIVE: This research seeks to develop and evaluate a noninvasive user-friendly artificial intelligence (AI)-powered cough audio classifier for detecting these respiratory conditions in rural Tanzania. METHODS: This is a nonexperimental cross-sectional research with the primary objective of collection and analysis of cough sounds from patients with active TB, asthma, and COPD in outpatient clinics to generate and evaluate a noninvasive cough audio classifier. Specialized cough sound recording devices, designed to be nonintrusive and user-friendly, will facilitate the collection of diverse cough sound samples from patients attending outpatient clinics in 20 health care facilities in the Shinyanga region. The collected cough sound data will undergo rigorous analysis, using advanced AI signal processing and machine learning techniques. By comparing acoustic features and patterns associated with TB, asthma, and COPD, a robust algorithm capable of automated disease discrimination will be generated facilitating the development of a smartphone-based cough sound classifier. The classifier will be evaluated against the calculated reference standards including clinical assessments, sputum smear, GeneXpert, chest x-ray, culture and sensitivity, spirometry and peak expiratory flow, and sensitivity and predictive values. RESULTS: This research represents a vital step toward enhancing the diagnostic capabilities available in outpatient clinics, with the potential to revolutionize the field of respiratory disease diagnosis. Findings from the 4 phases of the study will be presented as descriptions supported by relevant images, tables, and figures. The anticipated outcome of this research is the creation of a reliable, noninvasive diagnostic cough classifier that empowers health care professionals and patients themselves to identify and differentiate these respiratory diseases based on cough sound patterns. CONCLUSIONS: Cough sound classifiers use advanced technology for early detection and management of respiratory conditions, offering a less invasive and more efficient alternative to traditional diagnostics. This technology promises to ease public health burdens, improve patient outcomes, and enhance health care access in under-resourced areas, potentially transforming respiratory disease management globally. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/54388.

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 designing effective and impactful solutions for addressing many challenges facing the health sector beyond interpersonal relationships. This is because co-designing is regarded as innovative, simple, and friendly, bringing together parties and end-users impacted by the problem to generate feasible and acceptable interventions that contribute to enhanced satisfaction. Furthermore, co-designing was described as facilitating the co-learning of new skills and knowledge among participants. Additionally, co-designing was regarded as a tool for behavior change and personal commitment, influencing changes in participants' own behaviors and cementing a commitment to change their practices even before the implementation of the generated solutions. CONCLUSION: End-users' perspectives after engagement in the co-design process suggest it provides a novel entry point for strengthening provider-client relationships and addressing other health sector challenges. Researchers and interventionists should consider embracing co-design and the HCD approach in general to address health service delivery challenges.

The perceived benefits and effectiveness of patient feedback systems in strengthening patient-provider relationships in Rural Tanzania.

INTRODUCTION: Patient feedback system (PFS) forms an important entry point for the medical personnel and healthcare administrators to identify healthcare service delivery gaps and develop responsive interventions. This may foster patient trust consequently increasing healthcare-seeking, engagement in decision, continuity, and satisfaction. However, research on the PFS in rural primary healthcare settings appears limited. OBJECTIVE: The paper examines the perceived role and effectiveness of PFS in improving therapeutic relationships building on the recent research on patient-provider relationships in rural Tanzania. METHODS: The paper examines the findings of qualitative descriptive research conducted in the Shinyanga Region which employed a human-centred design (HCD) approach to co-create an intervention package for improving nurse-client relationships between January and September 2022. The study used semi-structured interviews in Swahili to first explore drivers of poor provider-patient relationships with purposefully selected providers, patients, and administrators. The findings guided the co-designing of an intervention package in subsequent HCD steps. Interviews were concurrently translated and transcribed, then systematically coded to facilitate the development of themes using a deductive thematic analysis approach. RESULTS: PFS emerged as one of the key themes in the deductive analysis when examining factors shaping provider-client relationships. The PFS theme was characterized by three major subthemes, which included perceived benefits, availability and accessibility, and perceived effectiveness. The perceived benefits of PFS cited by most participants included: reducing patients' confusion around the complaints process, promoting patients' positivity towards providers and hospitals, and reducing tensions between patients and providers. Suggestion boxes (SBs) were the most frequently cited PFS, but there were widespread concerns and disagreements among participants about their accessibility and effectiveness. Despite the providers (nurses) and administrators describing SBs as widely available, they stated that they had not received feedback or complaints from patients for a very long time. In contrast, most patients stated that SBs were either unavailable or ineffective in many facilities, with concerns about non-user friendliness and lack of responsiveness as the main issues when discussing effectiveness. CONCLUSION: Despite the many benefits of PFS in improving healthcare service quality, their availability, user-friendliness, and responsiveness still pose challenges. A call is made to providers, health administrators and researchers to prioritize the PFS as both a useful entry point to reducing tensions in therapeutic relationships and, a tool for improving patient service uptake, continuity of care and satisfaction.

Interventions co-designed by healthcare providers and clients for improving therapeutic relationships in maternal and child healthcare: a pilot study using human centered design in rural Tanzania.

BACKGROUND: Research shows that poor provider-client interactions in maternity and child health (MCH) continue to affect health outcomes, service uptake, continuity of care, and trust in formal healthcare systems. OBJECTIVE: The study's objective was to jointly create a prototype intervention package for enhancing nurse-client relationships using human centered design (HCD) approach. METHODS: A five-step HCD methodology was used: (1) Community-driven discovery through qualitative descriptive research methods using 9 focus groups with nurses and clients and 12 key informant interviews with MCH administrators; (2) consultative ideation and co-creation meetings with 10 nurses, 10 clients, and 10 administrators to co-design a rough prototype model; (3) rough prototype validation through qualitative insight gathering using 6 FGDs with nurses and clients; (4) refinement and adaptation meetings with 14 nurses, 14 clients and 12 administrators; and (5) documentation and sharing of lessons learnt. RESULTS: According to the community-driven research, poor service, a lack of concern, poor communication, a bad attitude, and unhappiness at work are the nurse factors that affect the relationships between nurses and their patients. Non-compliance with procedures, unfavorable attitudes, poor communication, low education, poverty, and faith in conventional healers were among the client-related factors. Inadequate funding, bad management techniques, improper policy execution, and a lack of an independent institution for handling complaints are the health system factors that affect nurse-client relationships. In response, three ideation and co-creating meetings resulted in 24 interventions. Seven (7) of these were rated as more acceptable and feasible in the local context and formed a rough prototype. During validation, there were some disagreements on the feasibility of curriculum and resource-related interventions. Refinement meetings resulted in a final prototype including four interventions: (i) promotion of patient-centred care; (ii) awards and recognition for nurses; (iii) strengthening complaints mechanisms and (iv) disciplinary measures for abusive nurses and clients. The lessons learnt have been shared through publications and institutional research meetings. CONCLUSIONS: HCD approach provides a novel entry point for providers and clients to examine the problems and design interventions for strengthening their therapeutic relationships in MCH care. Researchers, practitioners, and policy developers are welcome to consider the emerging prototype as it was deemed acceptable and potentially feasible in rural African contexts.

The role of nurse-client relationships in maternal and child healthcare: a qualitative study in rural Tanzania.

Background: The literature suggests that poor provider-client relationships in maternal and child healthcare (MCH) continue to impact healthcare service uptake, continuity of care, and MCH outcomes. However, there is a paucity of literature on the benefits of the nurse-client relationship for clients, nurses, and the health system, particularly in rural African contexts. Objective: This study examined the perceived benefits and disadvantages of good and poor nurse-client relationships in rural Tanzania respectively. We present the findings of a community-driven inquiry that was the first step of a broader study that sought to co-design an intervention package for strengthening nurse-client relationships in MCH in rural contexts using a human-centred design approach. Methods: This study used a qualitative descriptive design. Nine focus group discussions and 12 key informant interviews were conducted using semi-structured interview guides. Participants were purposefully selected nurses/midwives and clients attending MCH services, and MCH administrators. Data were managed using NVivo and analysed thematically. Results: A range of perceived benefits of good nurse-client relationships and disadvantages of poor relationships emerged. Perceived benefits of good nurse-client relationships included: (i) benefits to clients (increased healthcare-seeking behaviours, disclosure, adherence, return to care, positive health outcomes, and referral tendencies); (ii) benefits to nurses (increased confidence, efficiency, productivity, job satisfaction, trust, and community reputation and support); and (iii) benefits to healthcare facilities/systems (increased client load and consequently income, fewer complaints and legal disputes, increased trust and facility delivery, and reduced maternal and child deaths). The disadvantages of poor nurse-client relationships were basically the opposite of their benefits. Conclusion: The benefits of good nurse-client relationships and the disadvantages of poor relationships extend beyond patients and nurses to the healthcare system/facility level. Therefore, identifying and implementing feasible and acceptable interventions for nurses and clients could pave the way for good nurse-client relationships, leading to improved MCH outcomes and performance indicators.

Nurses' preparedness for disaster response in rural and urban primary healthcare settings in Tanzania.

INTRODUCTION: Nurses are often on the frontline of disaster management, providing care to patients with emerging physical, mental, and emotional turbulence, and acting as educators for health promotion and disaster prevention in both rural and urban contexts. However, the literature suggests that nurses are inadequately prepared for disaster response. This study examined preparedness for disaster response among nurses in rural and urban primary healthcare settings in Tanzania. METHODS: This qualitative descriptive study involved purposefully selected qualified nurses and nurse administrators working in rural (n=20) and urban (n=11) primary healthcare facilities in Tanzania. Telephone-based interviews were conducted to gather data that were then analyzed thematically. RESULTS: Five themes emerged from the analysis: previous experiences, technical capacity, current strategies, challenges, and overall preparedness. Previous experiences included personally caring for victims, working in disaster response teams, working in administrative roles during disasters, and conducting community sensitization. Most nurses in rural contexts had not received training on disaster response and relied on past experience, knowledge from nursing school, observing peers, and knowledge from the internet and movies. Current strategies for disaster response included response teams (although these were considered 'weak'), ensuring the availability of equipment and supplies, and infrastructure for victim management. Challenges in disaster response included inadequate resources, understaffing, lack of expertise at primary healthcare facilities, nurses tasked with multiple responsibilities, inadequate technical capacity, fears of infection, poor interpersonal relationships, inadequate community knowledge, poor reporting systems, delayed healthcare seeking, long distances to facilities, and poor road infrastructure. These challenges were more pronounced in rural settings. Most nurses felt they were well prepared to respond to disasters, although this appeared to be rooted in a willingness to provide care rather than having adequate knowledge, skills, and resources for disaster response. Suggestions for better preparing nurses for disaster response included training, increasing essential equipment and medical supplies, increasing the nursing workforce, improving reporting systems, disseminating local guidelines, strengthening disaster response teams, and improving the nursing training curricula to cover disaster management. CONCLUSION: A range of institutional, individual, and community challenges affect nurses' preparedness for disaster response in rural and urban primary healthcare settings. Addressing these challenges requires multiple strategies that extend beyond the capacity building of nurses to strengthen health system disaster preparedness in general, prioritizing rural contexts.

Implementation of evidence-based multiple focus integrated intensified TB screening to end TB (EXIT-TB) package in East Africa: a qualitative study.

INTRODUCTION: Tuberculosis (TB) remains a major cause of morbidity and mortality, especially in sub-Saharan Africa. We qualitatively evaluated the implementation of an Evidence-Based Multiple Focus Integrated Intensified TB Screening package (EXIT-TB) in the East African region, aimed at increasing TB case detection and number of patients receiving care. OBJECTIVE: We present the accounts of participants from Tanzania, Kenya, Uganda, and Ethiopia regarding the implementation of EXIT-TB, and suggestions for scaling up. METHODS: A qualitative descriptive design was used to gather insights from purposefully selected healthcare workers, community health workers, and other stakeholders. A total of 27, 13, 14, and 19 in-depth interviews were conducted in Tanzania, Kenya, Uganda, and Ethiopia respectively. Data were transcribed and translated simultaneously and then thematically analysed. RESULTS: The EXIT-TB project was described to contribute to increased TB case detection, improved detection of Multidrug-resistant TB patients, reduced delays and waiting time for diagnosis, raised the index of TB suspicion, and improved decision-making among HCWs. The attributes of TB case detection were: (i) free X-ray screening services; (ii) integrating TB case-finding activities in other clinics such as Reproductive and Child Health clinics (RCH), and diabetic clinics; (iii), engagement of CHWs, policymakers, and ministry level program managers; (iv) enhanced community awareness and linkage of clients; (v) cooperation between HCWs and CHWs, (vi) improved screening infrastructure, (vii) the adoption of the new simplified screening criteria and (viii) training of implementers. The supply-side challenges encountered ranged from disorganized care, limited space, the COVID-19 pandemic, inadequate human resources, inadequate knowledge and expertise, stock out of supplies, delayed maintenance of equipment, to absence of X-ray and GeneXpert machines in some facilities. The demand side challenges ranged from delayed care seeking, inadequate awareness, negative beliefs, fears towards screening, to financial challenges. Suggestions for scaling up ranged from improving service delivery, access to diagnostic equipment and supplies, and infrastructure, to addressing client fears and stigma. CONCLUSION: The EXIT-TB package appears to have contributed towards increasing TB case detection and reducing delays in TB treatment in the study settings. Addressing the challenges identified is needed to maximize the impact of the EXIT-TB intervention.

Improving nursing education curriculum as a tool for strengthening the nurse-client relationships in maternal and child healthcare: Insights from a human-centered design study in rural Tanzania.

Background: There are growing evidence of poor nurse-client relationships in maternal and child health (MCH). The nursing curriculum forms an important entry point for strengthening such relationships, consequently improving client satisfaction with nurses' competencies, confidence in the formal healthcare system, healthcare-seeking practices, continuity with care, and MCH outcomes. Objective: MCH nurses and clients were invited to design an intervention package (prototype) to improve nurse-client relationships using a human-centered design (HCD) approach. Methods: A multi-step HCD approach was employed to first examine the contributors of poor nurse-client relationships using nine focus group discussions with nurses and clients and 12 key informant interviews with MCH administrators. Then, three meetings were held with 10 nurses, 10 clients, and 10 administrators to co-develop an intervention package to address the identified contributors. The solutions were validated by collecting qualitative information through six focus groups with nurses and MCH clients who were not involved in the initial HCD stages. Finally, refinement and adaptation meetings were held with 15 nurses, 15 clients, and 10 administrators. The data were managed with NVivo 12 software and analyzed thematically. Results: Nursing curriculum challenges contributing to poor nurse-client relationships in MCH care included inadequate content on nurse-client relationships specifically topics of customer care, communication skills, and patient-centered care; an inadequate practice on communication skills within nursing schools; and the absence of specific trainers on interpersonal relationships. Consequently, improving the nursing curriculum was one of the interventions proposed during the co-design and rated by participants as highly acceptable during validation and refinement meetings. Suggested improvements to the curriculum included increasing hours and credits on communication skills and patient-centered care, including customer care courses in the curriculum and creating a friendly learning environment for clinical practice on strengthening interpersonal relationships. Conclusion: Improving the nursing curriculum was considered by nurses and clients as one of the acceptable interventions to strengthen nurse-client relations in MCH care in rural Tanzania. Nursing education policy and curriculum developers need to ensure the curriculum facilitates the development of much-needed interpersonal skills among nursing graduates for them to have positive therapeutic interactions with their clients.

Implementation of distance learning IMCI training in rural districts of Tanzania.

BACKGROUND: The standard face-to-face training for the integrated management of childhood illness (IMCI) continues to be plagued by concerns of low coverage of trainees, the prolonged absence of trainees from the health facility to attend training and the high cost of training. Consequently, the distance learning IMCI training model is increasingly being promoted to address some of these challenges in resource-limited settings. This paper examines participants' accounts of the paper-based IMCI distance learning training programme in three district councils in Mbeya region, Tanzania. METHODS: A cross-sectional qualitative descriptive design was employed as part of an endline evaluation study of the management of possible serious bacterial infection in Busokelo, Kyela and Mbarali district councils of Mbeya Region in Tanzania. Key informant interviews were conducted with purposefully selected policymakers, partners, programme managers and healthcare workers, including beneficiaries and training facilitators. RESULTS: About 60 key informant interviews were conducted, of which 53% of participants were healthcare workers, including nurses, clinicians and pharmacists, and 22% were healthcare administrators, including district medical officers, reproductive and child health coordinators and programme officers. The findings indicate that the distance learning IMCI training model (DIMCI) was designed to address concerns about the standard IMCI model by enhancing efficiency, increasing outputs and reducing training costs. DIMCI included a mix of brief face-to-face orientation sessions, several weeks of self-directed learning, group discussions and brief face-to-face review sessions with facilitators. The DIMCI course covered topics related to management of sick newborns, referral decisions and reporting with nurses and clinicians as the main beneficiaries of the training. The problems with DIMCI included technological challenges related to limited access to proper learning technology (e.g., computers) and unfriendly learning materials. Personal challenges included work-study-family demands, and design and coordination challenges, including low financial incentives, which contributed to participants defaulting, and limited mentorship and follow-up due to limited funding and transport. CONCLUSION: DIMCI was implemented successfully in rural Tanzania. It facilitated the training of many healthcare workers at low cost and resulted in improved knowledge, competence and confidence among healthcare workers in managing sick newborns. However, technological, personal, and design and coordination challenges continue to face learners in rural areas; these will need to be addressed to maximize the success of DIMCI.

Factors shaping good and poor nurse-client relationships in maternal and child care: a qualitative study in rural Tanzania.

BACKGROUND: Evidence indicates that poor nurse-client relationships within maternal and child health (MCH) continues to impact trust in formal healthcare systems, service uptake, continuity with care and MCH outcomes. This necessitates contextualized innovative solutions that places both nurses and clients at the forefront as agents of change in optimizing intervention designs and implementation. This study explored nurses and clients' perspectives on the factors shaping nurse-client relationships in MCH care to generate evidence to guide subsequent steps of human centered design (HCD) that involve designing effective strategies for improving therapeutic relationships in Shinyanga, Tanzania. METHODS: Qualitative descriptive design was employed. About 9 Focus Group Discussions (FGDs) and 12 Key Informant Interviews (KIIs) with purposefully selected nurses and midwives, women attending MCH services and administrators were conducted using semi-structured interview guides in Swahili language. Data were transcribed and translated simultaneously, managed using Nvivo Software and analyzed thematically. RESULTS: Factors shaping nurse-client relationships were heuristically categorized into nurse, client and health system factors. Nurse contributors of poor relationship ranged from poor reception and hospitality, not expressing care and concern, poor communication and negative attitudes, poor quality of services, job dissatisfaction and unstable mental health. Client contributors of poor relationship include being 'much know', late attendance, non-adherence to procedures and instructions, negative attitudes, poor communication, inadequate education and awareness, poverty, dissatisfaction with care, faith in traditional healers and unstable mental health. Health system contributors were inadequate resources, poor management practices, inadequate policy implementation and absence of an independent department or agency for gathering and management of complaints. Suggestions for improving nurse-client relationship included awards and recognition of good nurses, improving complaints mechanisms, continued professional development, peer to peer learning and mentorship, education and sensitization to clients, improving service quality and working conditions, improving renumeration and incentives, strengthening nursing school's student screening and nursing curriculum and improving mental health for both nurses and clients. CONCLUSIONS: The factors shaping poor nurse- client relationships appear to extend beyond nurses to both clients and healthcare facilities and system. Implementation of effective interventions for addressing identified factors considering feasibility and acceptance to both nurses and clients using novel strategies such as HCD could pave the way for employing good nurse-client relationships as a tool for improving performance indicators and health outcomes within MCH care.

Strengthening Interpersonal Relationships in Maternal and Child Health Care in Rural Tanzania: Protocol for a Human-Centered Design Intervention.

BACKGROUND: Evidence indicates that clients' dissatisfaction with providers' competencies within maternal and child health (MCH) continues to impact trust in formal health care systems, service uptake, continuity with care, and MCH outcomes. A major problem with existing interventions is the failure to address all the complexities of provider-client relationships necessitating targeted, contextualized, innovative solutions that place providers and clients at the forefront as agents of change in optimizing intervention design and implementation. To improve the provider-client relationship, the Aga Khan University is piloting a human-centered design (HCD) intervention where MCH nurses and clients are invited to partner with researchers in the intervention design and evaluation process. OBJECTIVE: The objective of this research is to co-design an intervention package (prototype) for improving nurse-client relationships in the rural Shinyanga region of Tanzania using a series of iterative HCD steps, involving key stakeholders to tailor solutions for complex problems impacting provider-client interactions in MCH care. METHODS: The following 5-step HCD approach will be implemented: (1) community-driven discovery through qualitative descriptive research methods using focus group discussions and key informant interviews; (2) co-design of an intervention package through consultative ideation and cocreation meetings with nurses, clients, and other stakeholders; (3) prototype validation through qualitative insight gathering using focus group discussions; (4) refinement and adaptation meeting; and (5) documentation and sharing of lessons learned before the final prototype is tested and validated in a broader community. RESULTS: A prototype characterized by a package of interventions for improving nurse-client relationships in MCH care in rural contexts is expected to be developed from the co-design process. CONCLUSIONS: An HCD approach provides a novel entry point for strengthening provider-client relationships, where clients are invited to partner with providers in the design of acceptable and feasible interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37947.

The impact of training on self-reported performance in reproductive, maternal, and newborn health service delivery among healthcare workers in Tanzania: a baseline- and endline-survey.

BACKGROUND: Delivery of quality reproductive health services has been documented to depend on the availability of healthcare workers who are adequately supported with appropriate training. However, unmet training needs among healthcare workers in reproductive, maternal, and newborn health (RMNH) in low-income countries remain disproportionately high. This study investigated the effectiveness of training with onsite clinical mentorship towards self-reported performance in RMNH among healthcare workers in Mwanza Region, Tanzania. METHODS: The study used a quasi-experimental design with pre-and post-intervention evaluation strategy. The baseline was compared with two endline groups: those with intervention (training and onsite mentorship) and those without. The differences among the three groups in the sociodemographic characteristics were analyzed by using chi-square test for categorical variables, independent-sample t-test for continuous variables and Mann-Whitney U test for ordinal or skewed continuous data. The independent sample t-test was used to determine the effect of the intervention by comparing the computed self-reported performance on RMNH services between the intervention and control groups. The paired-samples t-test was used to measure the differences between before and after intervention groups. Significance was set at a 95% confidence interval with p ≤ 0.05. RESULTS: The study included a sample of 216 participants with before and after intervention groups comprising of 95 (44.0%) and 121 (56.0%) in the control group. The comparison between before and after intervention groups revealed a statistically significant difference (p ≤ 0.05) in all the dimensions of the self-reported performance scores. However, the comparison between intervention groups and controls indicated a statistical significant difference on intra-operative care (t = 3.10, df = 216, p = 0.002), leadership skills (t = 1.85, df = 216, p = 0.050), Comprehensive emergency obstetric and newborn care (CEMONC) (t = 34.35, df = 216, p ≤ 0.001), and overall self-reported performance in RMNH (t = 3.15, df = 216, p = 0.002). CONCLUSIONS: This study revealed that the training and onsite clinical mentorship to have significant positive changes in self-reported performance in a wide range of RMNH services especially on intra-operative care, leadership skills and CEMONC. However, further studies with rigorous designs are warranted to evaluate the long-term effect of such training programs on RMNH outcomes.

Reproductive maternal and newborn health (RMNH) in low- and middle-income countries continue to face critical challenges. Training healthcare workers especially using a combined approach (training followed by immediate clinical mentorship) in RMNH have been documented as an essential strategy to reduce maternal and neonatal mortality in low-and middle-income countries closer to those in high-income countries. This study investigated the effectiveness of a Continuous Professional Development (CPD) trainings on performance among healthcare workers in Mwanza Region. The study included a sample of 216 participants with before and after intervention groups comprising of 95 participants and control group comprising of 121 participants. The findings revealed that in comparison between before and after intervention groups all dimensions of the self-reported TNA questionnaire had a statistically significant difference. However, the comparison between intervention and controls groups indicated a statistical significant difference on leadership skills, intra-operative care, Comprehensive emergency obstetric and newborn care (CEMONC) and overall RMNH self-reported performance. In conclusion, the findings demonstrated that healthcare workers' self-identified and prioritized training needs that are supported with clinical mentorship results in significant positive changes in performance across a wide range of RMNH tasks. Therefore, conducting TNA that is followed by training and mentorship according to the identified needs among healthcare workers plays a significant role in improving performance on RMNH services among healthcare workers.

Healthcare Providers' Experiences With a Clinical Mentorship Intervention to Improve Reproductive, Maternal and Newborn Care in Mwanza, Tanzania.

Introduction: There is increasing evidence suggesting that clinical mentorship (CM) involving on-the-job training is one of the critical resources-friendly entry points for strengthening the knowledge and skills of healthcare providers (HCPs), which in turn facilitate the delivery of effective reproductive, maternal, and newborn health (RMNH) care. The article explores the experiences of HCPs following participation in the CM program for RMNH in eight districts of Mwanza Region in Tanzania. Materials and Methods: A qualitative descriptive design employing data from midterm project review meetings and Key Informant Interviews (KIIs) with purposefully selected HCPs (mentors and mentees) and District Medical Officers (DMOs) during endline evaluation were employed. Interview data were managed using Nvivo Software and analyzed thematically. Results: A total of 42 clinical mentors and master mentors responded to a questionnaire during the midterm review meeting. Then, a total of 17 KIIs were conducted with Mentees (8), Mentors (5), and DMOs (4) during endline evaluation. Five key themes emerged from participants' accounts: (i) the topics covered during CM visits; (ii) the benefits of CM; (iii) the challenges of CM; (iv) the drivers of CM sustainability; and (iv) suggestions for CM improvement. The topics of CM covered during visits included antenatal care, neonatal resuscitation, pregnancy monitoring, management of delivery complications, and infection control and prevention. The benefits of CM included increased knowledge, skills, confidence, and change in HCP's attitude and increased client service uptake, quality, and efficiency. The challenges of CM included inadequate equipment for learning and practice, the limited financial incentive to mentees, shortage of staff and time constraints, and weaker support from management. The drivers of CM sustainability included the willingness of mentees to continue with clinical practice, ongoing peer-to-peer mentorship, and integration of the mentorship program into district health plans. Finally, the suggestions for CM improvement included refresher training for mentors, engagement of more senior mentors, and extending mentorship beyond IMPACT catchment facilities. Conclusion: CM program appears to be a promising entry point to improving competence among HCPs and the quality and efficiency of RMNH services potentially contributing to the reduction of maternal and neonatal deaths. Addressing the challenges cited by participants, particularly the equipment for peer learning and practice, may increase the success of the CM program.

Translation and validation of Training Needs Analysis Questionnaire among reproductive, maternal and newborn health workers in Tanzania.

BACKGROUND: Continuous professional development (CPD) has been reported to enhance healthcare workers' knowledge and skills, improve retention and recruitment, improve the quality of patient care, and reduce patient mortality. Therefore, validated training needs assessment tools are important to facilitate the design of effective CPD programs. METHODS: A cross-sectional survey was conducted using self-administered questionnaires. Participants were healthcare workers in reproductive, maternal, and neonatal health (RMNH) from seven hospitals, 12 health centers, and 17 dispensaries in eight districts of Mwanza Region, Tanzania. The training needs analysis (TNA) tool that was used for data collection was adapted and translated into Kiswahili from English version of the Hennessy-Hicks' Training Need Analysis Questionnaire (TNAQ). RESULTS: In total, 153 healthcare workers participated in this study. Most participants were female 83 % (n = 127), and 76 % (n = 115) were nurses. The average age was 39 years, and the mean duration working in RMNH was 7.9 years. The reliability of the adapted TNAQ was 0.954. Assessment of construct validity indicated that the comparative fit index was equal to 1. CONCLUSIONS: The adapted TNAQ appears to be reliable and valid for identifying professional training needs among healthcare workers in RMNH settings in Mwanza Region, Tanzania. Further studies with larger sample sizes are needed to test the use of the TNAQ in broader healthcare systems and settings.

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. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/17765.

Birth preparedness and complication readiness among women of reproductive age in Kenya and Tanzania: a community-based cross-sectional survey.

BACKGROUND: Delayed health-seeking continues to contribute to preventable maternal and neonatal deaths in low resource countries. Some of the strategies to avoid the delay include early preparation for the birth and detection of danger signs. We aimed to assess the level of practice and factors associated with birth preparedness and complication readiness (BPCR) in Kenya and Tanzania. METHODS: We conducted community-based multi-stage cross-sectional surveys in Kilifi and Kisii counties in Kenya and Mwanza region in Tanzania and included women who delivered two years preceding the survey (2016-2017). A woman who mentioned at least three out of five BPCR components was considered well-prepared. Bivariate and multivariable proportional odds model were used to determine the factors associated with the BPCR. The STROBE guidelines for cross-sectional studies informed the design and reporting of this study. RESULTS: Only 11.4% (59/519) and 7.6% (31/409) of women were well-prepared for birth and its complications in Kenya and Tanzania, respectively, while 39.7 and 30.6% were unprepared, respectively. Level of education (primary: adjusted odds ratio (aOR): 1.59, 95% CI: 1.14-2.20, secondary: aOR: 2.24, 95% CI: 1.39-3.59), delivery within health facility (aOR: 1.63, 95% CI: 1.15-2.29), good knowledge of danger signs during pregnancy (aOR: 1.28, 95% CI: 0.80-2.04), labour and childbirth (aOR: 1.57, 95% CI: 0.93-2.67), postpartum (aOR: 2.69, 95% CI: 1.24-5.79), and antenatal care were associated with BPCR (aOR: 1.42, 95% CI: 1.13-1.78). CONCLUSION: Overall, most pregnant women were not prepared for birth and its complications in Kilifi, Kisii and Mwanza region. Improving level of education, creating awareness on danger signs during preconception, pregnancy, childbirth, and postpartum period, and encouraging antenatal care and skilled birth care among women and their male partners/families are recommended strategies to promote BPCR practices and contribute to improved pregnancy outcomes in women and newborns.

What factors shape doctors' trustworthiness? Patients' perspectives in the context of hypertension care in rural Tanzania.

INTRODUCTION: There is increasing evidence that improving patient trust in doctors can improve patients' use of healthcare services, compliance and continuing engagement with care -particularly for chronic diseases. Consequently, much of the current literature on trust in therapeutic relationships focuses on factors shaping doctors' trustworthiness. However, few studies on this issue have been conducted among rural populations in low-income Africa, where health service delivery, cultural norms and patient expectations differ from those in high-income countries. This study examined patients' perspectives of factors that shape doctors' trustworthiness in rural Tanzania in the context of hypertension care. METHODS: A qualitative inquiry using in-depth interviews was conducted between 2015 and 2016 in two characteristically rural districts of Tanzania. Data were analysed thematically. RESULTS: The accounts of 34 patients from a Western-based care setting were examined. There was broad consensus about factors shaping doctors' trustworthiness along the care trajectory (before, during and after a therapeutic encounter). Two major themes emerged: doctors' interpersonal behaviours and doctors' technical competence. Good interpersonal behaviour and technical skills in healthcare settings were factors that constructed a positive reputation in the community and shaped patients' initial trust before a physical encounter. Doctors' interpersonal behaviours that portrayed good customer care, understanding and sympathy shaped trustworthiness during a physical encounter. Finally, doctors' technical competence shaped trustworthiness during and after an encounter. Participants used these factors to differentiate a trustworthy ('good') doctor from an untrustworthy ('bad') doctor. CONCLUSION: Good interpersonal behaviours and good technical skills are important in shaping patients' judgements of doctors' trustworthiness in rural Tanzania. The present findings provide useful insights for designing interventions to improve patient trust in doctors to address challenges associated with non-communicable diseases in rural low-income Africa.

Maternal healthcare services use in Mwanza Region, Tanzania: a cross-sectional baseline survey.

BACKGROUND: Improving maternal health by reducing maternal mortality/morbidity relates to Goal 3 of the Sustainable Development Goals. Achieving this goal is supported by antenatal care (ANC), health facility delivery, and postpartum care. This study aimed to understand levels of use and correlates of uptake of maternal healthcare services among women of reproductive age (15-49 years) in Mwanza Region, Tanzania. METHODS: A cross-sectional multi-stage sampling household survey was conducted to obtain data from 1476 households in six districts of Mwanza Region. Data for the 409 women who delivered in the 2 years before the survey were analyzed for three outcomes: four or more ANC visits (ANC4+), health facility delivery, and postpartum visits. Factors associated with the three outcomes were determined using generalized estimating equations to account for clustering at the district level while adjusting for all variables. RESULTS: Of the 409 eligible women, 58.2% attended ANC4+, 76.8% delivered in a health facility, and 43.5% attended a postpartum clinic. Women from peri-urban, island, and rural regions were less likely to have completed ANC4+ or health facility delivery compared with urban women. Education and early first antenatal visit were associated with ANC4+ and health facility delivery. Mothers from peri-urban areas and those who with health facility delivery were more likely to attend postpartum check-ups. CONCLUSION: Use of ANC services in early pregnancy influences the number of ANC visits, leading to higher uptake of ANC4+ and health facility delivery. Postpartum check-ups for mothers and newborns are associated with health facility delivery. Encouraging early initiation of ANC visits may increase the uptake of maternal healthcare services.

Structured on-the-job training to improve retention of newborn resuscitation skills: a national cohort Helping Babies Breathe study in Tanzania.

BACKGROUND: Newborn resuscitation is a life-saving intervention for birth asphyxia, a leading cause of neonatal mortality. Improving provider newborn resuscitation skills is critical for delivering quality care, but the retention of these skills has been a challenge. Tanzania implemented a national newborn resuscitation using the Helping Babies Breathe (HBB) training program to help address this problem. Our objective was to evaluate the effectiveness of two training approaches to newborn resuscitation skills retention implemented across 16 regions of Tanzania. METHODS: An initial training approach implemented included verbal instructions for participating providers to replicate the training back at their service delivery site to others who were not trained. After a noted drop in skills, the program developed structured on-the-job training guidance and included this in the training. The approaches were implemented sequentially in 8 regions each with nurses/ midwives, other clinicians and medical attendants who had not received HBB training before. Newborn resuscitation skills were assessed immediately after training and 4-6 weeks after training using a validated objective structured clinical examination, and retention, measured through degree of skills drop, was compared between the two training approaches. RESULTS: Eight thousand, three hundred and ninety-one providers were trained and assessed: 3592 underwent the initial training approach and 4799 underwent the modified approach. Immediately post-training, average skills scores were similar between initial and modified training groups: 80.5 and 81.3%, respectively (p-value 0.07). Both groups experienced statistically significant drops in newborn resuscitation skills over time. However, the modified training approach was associated with significantly higher skills scores 4-6 weeks post training: 77.6% among the modified training approach versus 70.7% among the initial training approach (p-value < 0.0001). Medical attendant cadre showed the greatest skills retention. CONCLUSIONS: A modified training approach consisting of structured OJT, guidance and tools improved newborn resuscitation skills retention among health care providers. The study results give evidence for including on-site training as part of efforts to improve provider performance and strengthen quality of care.