Changing health care provider performance through measurement.

Can the quality of care be improved by repeated measurement? We show that measuring protocol adherence repeatedly over ten weeks leads to significant improvements in quality immediately and up to 18 months later without any additional training, equipment, supplies or material incentives. 96 clinicians took part in a study which included information, encouragement, scrutiny and repeated contact with the research team measuring quality. We examine protocol adherence over the course of the study and for 45 of the original clinicians 18 months after the conclusion of the project. Health workers change their behavior significantly over the course of the study, and even eighteen months later demonstrate a five percentage point improvement in quality. The dynamics of clinicians' reactions to this intervention suggest that quality can be improved by the repeated measurement by external peers in a way that provides reminders of expectations.

Perceptions of AIDS risk and condom use among out-of-school adolescents in Moshi rural district, northern Tanzania.

OBJECTIVE: To determine the magnitude of perceived AIDS risk among out-of-school adolescents in Moshi rural district of Kilimanjaro region, northern Tanzania. METHODS: A cross-sectional study involving face-to-face interviews with out-of-school adolescents in eleven rural villages in Moshi district, northern Tanzania. RESULTS: We found that of the 668 adolescents (10-19 years of age) surveyed, 45.4% were sexually active and significantly more men than women reported being sexually active (55.85 versus 23.0%, OR = 0.24, 95% CI = 0.16 to 0.34). Adolescents who had travelled to Moshi town or out of Tanzania were significantly more likely to be sexually active compared with those who have never travelled. Despite perception of AIDS risk, a large majority (70.5%) of sexually active adolescents reported having multiple sexual partners. Adolescents who perceived being at AIDS risk were less likely to report having multiple sexual partners and were more likely to report having used a condom at the last sexual intercourse. CONCLUSION: These findings indicate that adolescents in this rural population are still practising high risk sexual behaviours suggesting the need for youth-targeted intervention programmes in rural Tanzania.

Prevalence of and predictors of substance use among adolescents in rural villages of Moshi district, Tanzania.

PURPOSE: To determine the prevalence of substance use among primary school pupils and out-of-school adolescents in Moshi rural district, northern Tanzania. METHODS: A school-based cross-sectional study focusing on primary school adolescents in standards 6 and 7 in Kahe rural community. We also conducted a population-based cross-sectional study among out-of-school adolescents in the same rural villages. A self-administered questionnaire was used to collect data from the school-based survey while for the out-of-school survey the questionnaire was administered in the households using trained interviewers. RESULTS: A total of 545 in-school and 668 out-of-school adolescents participated in the study. Of the 545 school adolescents, 45.4% were males and 56.6% females while for the out-of-school adolescents, 68.1% were males and 31.9% females. Of the school adolescents, more males than females reported being alcohol drinkers (16.7% versus 9.2%; odds ratio (OR) = 1.9, 95% CI, 1.17 - 3.29). The prevalence proportions of cigarette smoking were 26.2% for men and 15.5% for women while prevalence proportions of marijuana smoking were 4.1% for men and 3.0% for women. As for the out-of-school adolescents, the prevalence proportions of alcohol use were 26.2% for men and 15.5% for women. The prevalence proportions of cigarette smoking were 14.3% for men and 1.9% for women while the prevalence proportions of marijuana smoking were 1.5% for men and 1.4% for women. CONCLUSIONS: Substance use among adolescents is very high suggesting the need for interventions in this rural population of Tanzania.

Professionalism and the know-do gap: exploring intrinsic motivation among health workers in Tanzania.

Professionalism can be defined generally as adhering to the accepted standards of a profession and placing the interests of the public above the individual professional's immediate interests. In the field of medicine, professionalism should lead at least some practitioners in developing countries to effectively care for their patients despite the absence of extrinsic incentives to do so. In this study we examine the behavior of 80 practitioners from the Arusha region of Tanzania for evidence of professionalism. We show that about 20% of these practitioners behave professionally, and almost half of those who do so practice in the public sector. These professional health care workers provide high quality care even when they work in an environment that does not reward this effort, a finding that has important implications for the use of performance-based incentives.

Sexual practices among unmarried adolescents in Tanzania.

BACKGROUND: Sexual activities are increasingly changing from the cultural point of view what they used to be. Knowledge of these practices among adolescents may be a basis to create awareness among adolescents on practices that involve risks. This study aims to assess sexual practices among unmarried adolescents in Tanzania. METHODS: A cross-sectional survey was conducted among in-school and out-of-school but unmarried adolescents aged 10 to 19 in five locations in Tanzania. A questionnaire was used to collect information and to characterize sexual practices among these adolescents. RESULTS: About 32% of adolescents reported being sexually active; a higher proportion being males than females. The only inquired and reported sexual practices include vaginal sex, masturbation, oral and anal sex. About 15% of sexually active adolescents reported having multiple sexual partners. Significantly more males reported having multiple partners than females. Nearly 42% of sexually active adolescents reported having used a condom during most recent sexual act. Females reported older partners at first sexual act. CONCLUSION: Adolescents experience several sexual practices that include penetrative and non-penetrative. More males reported being sexually active than females. Despite adolescents reporting having multiple sexual partners, reported condom use during the most recent sexual act was low. We advocate for a more enhanced approach of reproductive health education that includes safer sex to adolescents without forgetting those in-schools.

Predictors of risky sexual behavior among adolescents in Tanzania.

Studies on sexual behavior among adolescents are fundamental in understanding and fighting against outcomes of unprotected sex that include unplanned/unwanted pregnancies and sexually transmitted diseases. This survey conducted among in- and out-of-schools adolescents measured prevalence of sexual behavior variables, including risky sexual behavior and associated factors. Risky sexual behavior was defined as having first sex before 16 years, inconsistent condom use and having multiple sexual partners. About 30% of adolescents reported being sexually active; a higher proportion being among males than females and 24.5% of sexually active adolescents reported having multiple sexual partners. More males (37%) reported having multiple sexual partners than females (26%). Nearly 48% of unmarried sexually active adolescents reported having used a condom during the most recent sexual intercourse. Predictors of risky sexual behavior were being male, young age (10-14 years) and being inschool. Preventive information and education should take into consideration these factors.

Status and visions for the school health service as reported by local health care workers in Northern Tanzania.

OBJECTIVE: The World Health Organization's (WHO) Global School Health Initiative provides a strategy to utilize schools to promote health and reduce the burden of diseases worldwide. The aim of this study was to investigate local school health work in Tanzania in relation to existing national guidelines and the WHO initiative. METHODS: We interviewed 30 health care workers employed at 15 health institutions throughout Arusha and Kilimanjaro regions. RESULTS: The results indicate a wide gap between the national and international guidelines for school health programs and the health workers' current practices. We found the main obstacles to providing adequate health care to be related to the burden of poverty that influences all levels of school health services, lack of clarity regarding the current official guidelines for school health services, and lack of appropriate offers for continuing education in the area of school health services. CONCLUSION: In order to successfully establish an integrated school health service, the working relationship between schools, health centres and the community clearly needs improvement.

Variations in the quality of care accessible to rural communities in Tanzania.

The government of Tanzania has made access to health care a priority. In particular, it has made great efforts to increase the number of facilities available to the rural population. By examining one such rural area, we find that although facilities exist and are staffed with competent clinicians, the quality of care received by patients visiting government facilities is subpar, especially that received by the poor in rural areas compared with urban areas. Importantly, nongovernmental organization (NGO) facilities provide better and more consistent care across the rural-urban divide. Access to high-quality care is inequitable, and this inequality is not inevitable.

Outpatient process quality evaluation and the Hawthorne Effect.

We examine the evidence that the behavior of clinicians is impacted by the fact that they are being observed by a research team. Data on the quality of care provided by clinicians in Arusha region of Tanzania show a marked fall in quality over time as new patients are consulted. By conducting detailed interviews with patients who consulted both before and after our research team arrived we are able to show strong evidence of the Hawthorne effect. Patient-reported quality is steady before we arrive, rises significantly (by 13 percentage points) at the moment we arrive and then falls steadily thereafter. We show that quality after we arrive begins to look similar to quality before we arrived between the 10th and 15th consultations. Implications for quality measurement and policy are discussed.

The use of direct clinician observation and vignettes for health services quality evaluation in developing countries.

This paper reports the results of a comparison between two different methods of examining quality in outpatient services in a developing country. Data from rural and urban Tanzania are used to compare the measures of quality collected by direct clinician observation (DCO) (where clinicians are observed in the course of their normal consultations) and vignettes (unblind case studies with an actor). The vignettes are shown to exhibit a strong connection between the inputs provided during consultation (rational history taking, physical examination and health education) and the ability of the clinician to properly diagnose the presented illness. However, the inputs provided in vignettes are not well correlated with the inputs provided in DCO, suggesting that the inputs provided in the vignette are not well correlated with the inputs that would be provided in an actual consultation. We conclude that since vignettes do not appear to be measuring what would be provided in an actual consultation they are not a good measure of quality. Instead, we suggest that vignettes and DCO be used simultaneously. We show how the scores obtained using vignettes in conjunction with DCO can be used to improve the reliability of DCO and therefore our estimates of actual clinician quality.

Frequency and perceived credibility of reported sources of reproductive health information among primary school adolescents in Arusha, Tanzania.

AIMS: To describe adolescents' sources of reproductive health information and perceived credibility of these sources. METHODS: A questionnaire survey was conducted among 1247 seventh grade pupils in Arusha district; enquiring their sources of reproductive health information and perceived credibility of these sources. Mean scores were computed for each type of information in relation to frequency of source and credibility, and scales for reproductive health information sources and credibility constructed. Analysis of covariance was used to compare mean scores by demographic and sexual behaviour variables. RESULTS: Mass media ranked first as sources of reproductive health information, followed by teachers and health workers. Health workers ranked first in credibility followed by parents, while credibility rating for media was low. Religious leaders and respondents' friends played a rather minor role as sources of reproductive health information, and their credibility ratings were also low. CONCLUSION: Mass media were the most frequent sources of reproductive health information for primary school adolescents, but parents and health workers were regarded as more credible sources. Programmes seeking to promote reproductive health of young people should take into account the diverse arenas through which young people currently obtain reproductive health information, and strive to tap into and strengthen the full range of these arenas. Increased involvement of parents and health workers in providing reproductive health information to young people seem indispensable.