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.

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.

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.

Cost analysis of large-scale implementation of the 'Helping Babies Breathe' newborn resuscitation-training program in Tanzania.

BACKGROUND: Helping Babies Breathe (HBB) has become the gold standard globally for training birth-attendants in neonatal resuscitation in low-resource settings in efforts to reduce early newborn asphyxia and mortality. The purpose of this study was to do a first-ever activity-based cost-analysis of at-scale HBB program implementation and initial follow-up in a large region of Tanzania and evaluate costs of national scale-up as one component of a multi-method external evaluation of the implementation of HBB at scale in Tanzania. METHODS: We used activity-based costing to examine budget expense data during the two-month implementation and follow-up of HBB in one of the target regions. Activity-cost centers included administrative, initial training (including resuscitation equipment), and follow-up training expenses. Sensitivity analysis was utilized to project cost scenarios incurred to achieve countrywide expansion of the program across all mainland regions of Tanzania and to model costs of program maintenance over one and five years following initiation. RESULTS: Total costs for the Mbeya Region were $202,240, with the highest proportion due to initial training and equipment (45.2%), followed by central program administration (37.2%), and follow-up visits (17.6%). Within Mbeya, 49 training sessions were undertaken, involving the training of 1,341 health providers from 336 health facilities in eight districts. To similarly expand the HBB program across the 25 regions of mainland Tanzania, the total economic cost is projected to be around $4,000,000 (around $600 per facility). Following sensitivity analyses, the estimated total for all Tanzania initial rollout lies between $2,934,793 to $4,309,595. In order to maintain the program nationally under the current model, it is estimated it would cost $2,019,115 for a further one year and $5,640,794 for a further five years of ongoing program support. CONCLUSION: HBB implementation is a relatively low-cost intervention with potential for high impact on perinatal mortality in resource-poor settings. It is shown here that nationwide expansion of this program across the range of health provision levels and regions of Tanzania would be feasible. This study provides policymakers and investors with the relevant cost-estimation for national rollout of this potentially neonatal life-saving intervention.

Implementation of "Helping Babies Breathe": A 3-Year Experience in Tanzania.

OBJECTIVES: This first-ever country-level study assesses the implementation of the Helping Babies Breathe (HBB) program in 15 of Tanzania's mainland regions by measuring coverage, adoption and retention of provider skills, acceptability among providers, and barriers and challenges to at-scale implementation. METHODS: Longitudinal facility-level follow-up visits assessed provider resuscitation knowledge and skills in using objective structured clinical examinations and readiness of facilities to resuscitate newborns, in terms of birth attendants trained and essential equipment available and functional. Focus group discussions were held with providers to determine the acceptability, challenges, and barriers to implementation of the HBB program. RESULTS: Immediately after HBB training, 87.1% of providers passed the objective structured clinical examination. This number dropped to 79.4% at 4 to 6 weeks and 55.8% at 4 to 6 months (P < .001). Noting this fall-off in skills, the program implemented structured on-the-job training and supportive supervisory visits, which were associated with an improvement in skill retention. At long-term follow-up, >90% of facilities had bag-mask devices available to all beds in the labor and delivery ward, and 96% were functional. Overall, providers were highly satisfied with the HBB program but thought that the 1-day training used in Tanzania was too short, so they would welcome additional training and follow-up visits to reinforce skills. CONCLUSIONS: The HBB program in Tanzania has gained acceptability and shown success in equipping providers with neonatal resuscitation knowledge, skills, and supplies. However, assessing the program's impact on neonatal mortality has proven challenging.

Validation of a novel tool for assessing newborn resuscitation skills among birth attendants trained by the Helping Babies Breathe program.

OBJECTIVE: To validate a simplified objective structured clinical examination (OSCE) tool for evaluating the competency of birth attendants in low-resource countries who have been trained in neonatal resuscitation by the Helping Babies Breathe (HBB) program. METHODS: A prospective cross-sectional study of the OSCE tool was conducted among trained birth attendants working at dispensaries, health centers, or hospitals in five regions of Tanzania between October 1, 2013, and May 1, 2014. A 13-item checklist was used to assess clinical competency in a simulated newborn resuscitation scenario. The OSCE tool was simultaneously administered by HBB trainers and experienced external evaluators. Paired results were compared using the Cohen κ value to measure inter-rater reliability. Participant performance was rated by health cadre, region, and facility type. RESULTS: Inter-rater reliability was moderate (κ = 0.41-0.60) or substantial (κ = 0.61-0.80) for eight of the OSCE items; agreement was fair (κ = 0.21-0.41) for the remaining five items. The best OSCE performances were recorded among nurses and providers from facilities with high annual birth volumes. CONCLUSION: The simplified OSCE tool could facilitate efficient implementation of national-level HBB programs. Limitations in inter-rater reliability might be improved through additional training.