Caregivers' perspectives of community acceptance before and after surgical treatment for their child's disability.

In Tanzania, about 600 000 youth between 5 and 24 years old have a disability. Individuals with disabilities face numerous obstacles due to social stigma. The aim of this formative evaluation is to assess how caregivers of children with correctable disabilities (e.g., cleft lip/palate, club foot, and burn scar contractures) in Tanzania perceive their community's acceptance of their child before and after surgical treatment. Semi-structured interviews were conducted with 80 caregivers of children with disabilities treated at Kafika House in Arusha, Tanzania. The constant comparative method identified themes regarding the caregivers' feelings on their child's functional abilities and experiences of stigma in their community. Caregiver perceptions of stigma before and after surgical treatment were categorized and quantified as 'positive', 'neutral' and 'negative'. Thematic analysis of the 80 interviews resulted in five major themes: (1) stigma and acceptance (pre-treatment) and (2) post-treatment; (3) functional abilities (pre-treatment) and (4) post-treatment; and (5) emotional impact (pre- and post-treatment). These themes indicate caregivers and their children experience a range of emotional impacts before and after treatment, more severe stigma before treatment, and overall better social, emotional and functional status after treatment. Frequency analysis of caregiver experiences indicated that stigma experienced by children and their families decreased from 75% before surgical treatment to 2.5% after surgery. Surgical intervention and rehabilitation of physical disabilities mitigated experiences of social stigma for both children and their caregivers. Findings support the need for expanded treatment of correctable disabilities, larger investments in community-based rehabilitation programmes and further interventions to support stigmatized parents and their children.

From Housing Instability to a Home: The Effects of Furniture and Household Goods on Well-being.

The quality of housing, the neighborhood in which one lives, and community social structures all affect one's physical and mental health. We conducted a qualitative evaluation of one non-profit organization's mission to provide furniture and household goods to low-income families. Based on semi-structured interviews with 20 clients and 15 caseworkers, we assessed how furniture and household goods contributed to individuals' sense of home and overall well-being. Results of our thematic analysis revealed four themes: (1) respect; (2) creating a home; (3) physical comfort; and (4) emotional well-being. Participants described how the absence of furniture, dishes, and other goods affected their self-esteem, mental health, and physical health. This study suggests the need to include the presence or absence of furniture in housing quality assessments. Social support services that provide access to low-cost, quality furniture to low-income families should exist in parallel with housing support programs.

Physician assistant burnout, job satisfaction, and career flexibility in Minnesota.

OBJECTIVES: This study explores associations between job satisfaction, career flexibility, and burnout among physician assistants (PAs) in Minnesota. METHODS: A survey comprising the Maslach Burnout Inventory (a validated burnout tool) and original questions was emailed to PAs practicing in Minnesota. Spearman rank correlation coefficients were used to assess associations between variables and burnout. RESULTS: PAs (response rate = 31.4%, N = 312) reported moderate levels of burnout. Working in primary care and being female were independently associated with higher rates of burnout. Satisfaction with one's career and one's current position were both high (95.9% and 87.8%, respectively) and independently associated with lower rates of burnout. CONCLUSIONS: Despite high levels of career and job satisfaction, PAs in Minnesota report moderate levels of burnout, particularly women in primary care. Further research should examine a broader population and the effect of burnout on patient care.

Cancer Training for Frontline Healthcare Providers in Tanzania.

Cervical and breast cancer are responsible for the highest cancer-related mortality in Tanzania, although both are preventable or curable if diagnosed at an early stage. Limited knowledge of cervical cancer by clinic and dispensary level healthcare providers in Tanzania is a barrier for prevention and control strategies. The purpose of the study was to provide basic oncology training to frontline healthcare workers with a focus on cervical and breast cancer in order to increase knowledge. A 1-day cancer training symposium was conducted in Arusha, Tanzania, with 43 clinicians. Pre- and post-intervention surveys assessed cancer knowledge and confidence of clinicians in risk assessment. Sixty-nine percent of the participants reported never receiving any cervical cancer training in the past. A significant difference was found between the pre- and post-test in a majority of knowledge questions and in reported confidence recognizing signs and symptoms of breast and cervical cancer (p < 0.05). The 1-day community oncology training symposium was effective in delivering and increasing basic knowledge about cervical and breast cancers to these healthcare providers. The low level of baseline cancer knowledge among frontline medical providers in Tanzania illustrates the need for increased training around the country.

American Sign Language Interpreters Perceptions of Barriers to Healthcare Communication in Deaf and Hard of Hearing Patients.

Communication barriers between healthcare providers and patients contribute to health disparities and the effectiveness of health promotion messages. This is especially true regarding communication between providers and deaf and hard of hearing (HOH) patients due to lack of understanding of cultural and linguistic differences, ineffectiveness of various means of communication and level of health literacy within that population. This research aimed to identify American Sign Language (ASL) interpreters' perceptions of barriers to effective communication between deaf and HOH patients and healthcare providers. We conducted a survey of ASL interpreters attending the 2015 National Symposium on Healthcare Interpreting with an overall response rate of 25%. Results indicated a significant difference (p < 0.05) in all areas of preferred communication between providers and deaf/HOH patients as perceived by interpreters. ASL interpreters observed that patients did not understand provider instructions in nearly half of appointments. Eighty-one percent of interpreters said that providers "hardly ever" use "teach-back" methods with patients to ensure understanding. A focus on improving health care and health promotion efforts in the deaf/HOH community depends on improving communication, health literacy, and patient empowerment and involves holding health care organizations accountable for assuring adequate staffing of ASL interpreters and communication resources in order to reduce health disparities in this population.

Community Gardens for Refugee and Immigrant Communities as a Means of Health Promotion.

Refugees and new immigrants arriving in the United States (U.S.) often encounter a multitude of stressors adjusting to a new country and potentially coping with past traumas. Community gardens have been celebrated for their role in improving physical and emotional health, and in the Twin Cities of Minnesota, have been offered as a resource to immigrants and refugees. The purpose of this study is to present a mixed method evaluation of a refugee gardening project hosted by area churches serving primarily Karen and Bhutanese populations. Quantitative data were obtained from early and late season surveys (44 and 45 % response rates, respectively), and seven focus groups conducted at the end of the season provided qualitative data. Although few gardeners (4 %) identified food insecurity as a problem, 86 % indicated that they received some food subsidy, and 78 % reported vegetable intake increased between the early and late season surveys. Twelve percent of gardeners indicated possible depression using the PHQ-2 scale; in focus groups numerous respondents identified the gardens as a healing space for their depression or anxiety. Refugee gardeners expressed receiving physical and emotional benefits from gardening, including a sense of identity with their former selves. Gardens may serve as a meaningful health promotion intervention for refugees and immigrants adjusting to the complexity of their new lives in the U.S. and coping with past traumas.

Ethnicity and child health in northern Tanzania: Maasai pastoralists are disadvantaged compared to neighbouring ethnic groups.

The Maasai of northern Tanzania, a semi-nomadic ethnic group predominantly reliant on pastoralism, face a number of challenges anticipated to have negative impacts on child health, including marginalisation, vulnerabilities to drought, substandard service provision and on-going land grabbing conflicts. Yet, stemming from a lack of appropriate national survey data, no large-scale comparative study of Maasai child health has been conducted. Savannas Forever Tanzania surveyed the health of over 3500 children from 56 villages in northern Tanzania between 2009 and 2011. The major ethnic groups sampled were the Maasai, Sukuma, Rangi, and the Meru. Using multilevel regression we compare each ethnic group on the basis of (i) measurements of child health, including anthropometric indicators of nutritional status and self-reported incidence of disease; and (ii) important proximate determinants of child health, including food insecurity, diet, breastfeeding behaviour and vaccination coverage. We then (iii) contrast households among the Maasai by the extent to which subsistence is reliant on livestock herding. Measures of both child nutritional status and disease confirm that the Maasai are substantially disadvantaged compared to neighbouring ethnic groups, Meru are relatively advantaged, and Rangi and Sukuma intermediate in most comparisons. However, Maasai children were less likely to report malaria and worm infections. Food insecurity was high throughout the study site, but particularly severe for the Maasai, and reflected in lower dietary intake of carbohydrate-rich staple foods, and fruits and vegetables. Breastfeeding was extended in the Maasai, despite higher reported consumption of cow's milk, a potential weaning food. Vaccination coverage was lowest in Maasai and Sukuma. Maasai who rely primarily on livestock herding showed signs of further disadvantage compared to Maasai relying primarily on agriculture. We discuss the potential ecological, socioeconomic, demographic and cultural factors responsible for these differences and the implications for population health research and policy.

Where there is no morphine: the challenge and hope of palliative care delivery in Tanzania.

BACKGROUND: In Tanzania, a country of 42 million, access to oral morphine is rare. AIM: To demonstrate the effectiveness of palliative care teams in reducing patients' pain and in increasing other positive life qualities in the absence of morphine; and to document the psychological burden experienced by their clinical providers, trained in morphine delivery, as they observed their patients suffering and in extreme pain. SETTING: One hundred and forty-fie cancer patients were included from 13 rural hospitals spread across Tanzania. METHOD: A mixed method study beginning with a retrospective quantitative analysis of cancer patients who were administered the APCA African POS tool four times. Bivariate analyses of the scores at time one and four were compared across the domains. The qualitative arm included an analysis of interviews with six nurses, each with more than fie years' palliative care experience and no access to strong opioids. RESULTS: Patients and their family caregivers identifid statistically signifiant (p < 0.001) improvements in all of the domains. Thematic analysis of nurse interviews described the patient and family benefis from palliative care but also their great distress when 'bad cases' arose who would likely benefi only from oral morphine. CONCLUSION: People living with chronic cancer-related pain who receive palliative care experience profound physical, spiritual and emotional benefis even without oral morphine. These results demonstrate the need for continued advocacy to increase the availability of oral morphine in these settings in addition to palliative care services.

Sustainability of NGO capacity building in southern Africa: successes and opportunities.

Despite an increase in organizational capacity building efforts by external organizations in low and middle income countries, the documentation of these efforts and their effects on health programs and systems remains limited. This paper reviews key frameworks for considering sustainability of capacity building and applies these frameworks to an evaluation of the sustainability of an AIDS non-governmental organization (NGO) capacity building initiative. From 2004-2007 Bristol-Myers Squibb Foundation's Secure the Future(TM) initiative in southern Africa funded a five country program, the NGO Training Institute (NGOTI), to build capacity of NGOs working to address HIV/AIDS. Lessons learned from this project include issues of ownership, the importance of integrating planning for sustainability within capacity-building projects, and the value of identifying primary capacity-building objectives in order to select sustainability strategies that are focused on maintaining program benefits. Sustainability for capacity building projects can be developed by discussing key issues early in the planning process with all primary stakeholders.

Men's and women's experiences with HIV and stigma in Swaziland.

To explore how gender differentially affects the stigma experiences of people living with HIV (PLHIV) in Swaziland, the extent and dimensions of HIV-related felt and enacted stigma and social support were analyzed. Thirty-seven semistructured, face-to-face interviews were conducted with PLHIV in Swaziland between 2004 and 2006. Through the process of conceptual analysis, themes, including felt stigma, information management, enacted stigma, and social support, were explored, coded, and analyzed in the contexts of partner and familial relationships, and workplace and neighborhood settings. Findings revealed that there were high levels of felt stigma in all contexts, yet fewer than anticipated accounts of enacted stigma in family, work, and neighborhood contexts compared to their expressions of felt stigma. The amount and characteristics of felt and enacted stigma and social support differed based on gender, as women often experienced more felt and enacted stigma than men, and had less definite financial or emotional support.

Critical challenges ahead in bioterrorism preparedness training for clinicians.

PURPOSE: A survey was distributed to determine physicians' confidence levels in recognizing potential Category-A bioterrorism disease threats (e.g., smallpox, anthrax), preferred means of obtaining continuing medical education (CME) credits, and their knowledge of the Connecticut Department of Public Health's (DPH) disease reporting requirements. METHODS: Surveys were mailed to all physicians in the three-hospital Yale New Haven Health (YNHH) System (2,174) from January to March 2004; there were 820 respondents for a 37.7% response rate. RESULTS: A total of 71% of physicians indicated that they were "not confident" that they could recognize five of the infectious agents named; they had higher confidence rates for smallpox (48.8%). Infectious diseases and emergency medicine physicians had the highest rates of confidence. Seventy-eight percent of physicians indicated conferences and lectures as their preferred CME learning modality. Nearly 72% of physicians reported a low familiarity with the DPH reporting requirements. DISCUSSION: The results highlighted the breadth of perceived weaknesses among clinicians from disease recognition to reporting incidents, which signifies the need for greater training in these areas. As clinicians themselves emphasized their lack of skills and knowledge in this area, there should be a rapid development and dissemination of problem-based learning CME courses in bioterrorism preparedness.

Promoting healthy people 2010 through small grants.

The Department of Health and Human Services initiated a pilot "microgrant" or small grants program in 2001 to promote Healthy People 2010 (HP 2010) implemented by the Yale-Griffin Prevention Research Center. This article describes the 103 agencies funded under this initiative and 67 control group agencies. It evaluates the HP 2010 focus areas targeted and the effectiveness of promoting HP 2010 objectives through microgrants. Forty-four percent of the grant recipients and 79% of the control group agencies indicated low levels of familiarity with HP 2010 goals. Changes in knowledge of HP 2010 goals for the microgrant group increased significantly from 5.24 +/- 3.67 to 7.83 +/- 1.86 (p < .05). The results suggest that microgrants can be a useful mechanism to plant the seeds for developing community and organizational capacity to define local health priorities, practice and test new initiatives or expand existing programs and promote knowledge about HP 2010.

Care for the most vulnerable children in Tanzania: a faith-based model of care and support for children affected by HIV.

In the fight against HIV and AIDS in sub-Saharan Africa, the plight of orphaned and vulnerable children was long overlooked. The first United Nations report on orphans and vulnerable children did not emerge until 2002 after more than two generations of children and youth had struggled to survive with limited family, institutional, or government support. The major social determinants of health for infants and children with one or more parents dying or dead from HIV include pervasive poverty, weak community social support systems, lack of policy commitment by governments or foreign donors, lack of access to anti-retroviral drugs, limited access to schools, and gender. In this paper, we present a model of care and support to the most vulnerable children (MVC) affected by HIV that brings together faith-based institutions in partnership with the government and community volunteers in 13 rural districts of Tanzania. Although still being implemented, the project has a number of valuable lessons learned for program managers, donors, and researchers working with faith-based organizations in the development and delivery of services to the most vulnerable children in a resource-limited setting.

Hospital quality improvement in Ethiopia: a partnership-mentoring model.

BACKGROUND AND OBJECTIVE: Quality improvement efforts are increasingly common in the United States; however, their use in developing countries is limited. We sought to evaluate the impact of a large-scale intervention on several key management indicators through hospital quality improvement efforts. DESIGN: Pre-post-descriptive study of 14 hospitals in Ethiopia. SETTING: Six regions and two city administrations in Ethiopia. PARTICIPANTS: Hospital leaders and management mentors in participating hospitals. INTERVENTION: In collaboration with the Ministry of Health and the Clinton HIV/AIDS Initiative, we implemented a countrywide quality improvement initiative in which 24 mentors with hospital administration experience were placed for 1 year in Ethiopia to work side-by-side with hospital management teams. We also provided a professional development course to enhance quality improvement skills. MAIN OUTCOME MEASURE: s) Presence of 75 key management indicators; reported management skills of hospital leaders by the mentors. RESULTS: In pre-post analysis, we found improvement in 45 of the 75 (60%) key management indicators between August 2006 and May 2007. The changes reflected a total of 105 management indicators improved across the 14 hospitals, which equates to a per-hospital mean of 7.5 (standard deviation 5.9) improvements. Reported management skills of hospital leaders improved in several management domains, although their reported confidence in these skills remained largely unchanged. CONCLUSIONS: Our findings indicate that quality improvement efforts can be effective in improving hospital management in developing countries. Longer follow-up is required to assess the sustainability of the hospital improvements accomplished.

Building capacity for AIDS NGOs in southern Africa: evaluation of a pilot initiative.

In this paper, we present the evaluation results of an AIDS non-governmental organization (NGO) capacity building 20-month pilot initiative in five countries in southern Africa called the NGO Institute. A five-person international team conducted a 2 week evaluation of the pilot in 2004 to assess the strength of the model, designed and funded by Bristol-Myers Squibb Foundation. The NGO Institute functioned through a separate consortium in each country. Results of the pilot indicate variations in adaptation and implementation of the model in each of the five countries. Each consortium took considerable time to develop its own governance and management systems. There were examples of strengthened NGO capacity in each country although it was too soon to establish overall impact. The strengths and weaknesses of this NGO capacity building model are presented along with the implications for other funding agencies and NGOs.

Government-NGO collaboration and sustainability of orphans and vulnerable children projects in southern Africa.

Given current donor attention to orphans and children made vulnerable by HIV/AIDS, and the need for a new framework that recognizes the complementary roles of nations and non-governmental organizations (NGOs), this analysis reviews NGO-operated community-based orphans and vulnerable children (OVC) projects in Botswana, Lesotho, Namibia, South Africa, and Swaziland. There has been a lack of attention within the field of evaluation to inter-organizational relationships, specifically those with government agencies, as a factor in sustainability. We analyzed evaluations of nine OVC projects funded by the Bristol-Myers Squibb Foundation for the influence of government-NGO collaboration on project sustainability. For eight of the nine projects, evaluations provided evidence of the importance of the government partnership for sustainability. Government collaboration was important in projects designed to help families access government grants, initiate community-based solutions, and advocate for OVC rights through legislation. Government partnerships were also critical to the sustainability of two projects involved in placing children in foster care, but these showed signs of tension with government partners. In addition to the more common factors associated with sustainability, such as organizational characteristics, donors and NGOs should concentrate on developing strong partnerships with local and national government agencies for the sustainability of their projects.

Hospital management in the context of health sector reform: a planning model in Ethiopia.

Through health sector reform in developing countries, Ministries of Health have sought to enhance health care through greater community governance and improved management effectiveness in their public hospitals. In this paper, we present a partnership-mentoring model for enhancing management capacity that has been piloted in Ethiopia and may be useful in other developing countries. The model included needs assessment and baseline evaluation using a hospital management indicator checklist, deployment of 24 Fellows (US and international hospital administrators) for 1 year to work as mentors with hospital management teams in 14 Ethiopian hospitals, continuing didactic and practical training in quality improvement methods for hospital management teams, and 24 management improvement projects to be completed during the year with plans for replication more broadly as appropriate. Surveys of Fellows and Ethiopian managers within the first quarter of onsite activity found high levels of trust in one another's abilities and intent to implement changes. The partnership-mentoring model promotes sustainability and may provide other countries with approaches for improving the quality of hospital care through improved hospital management.

The value of microgrants for community-based health promotion: two models for practice and policy.

In 2001, the Office of Disease Prevention and Health Promotion in the US Department of Health and Human Services announced its intention to (1) identify innovative ways to increase public awareness and focus on Healthy People 2010 objectives and (2) broaden the participation of community-based organizations, including agencies new to public health. The mechanism selected, microfinancing, was modeled after small venture loans for economic stimulus in developing countries. The Office of Disease Prevention and Health Promotion selected one state health department and one academic research organization from 80 applicants to test models of awarding "microgrants" of 2,010 dollars to community agencies. This article describes the two models, the types of agencies that were funded, the primary Healthy People 2010 objectives targeted, examples of how the monies were used and leveraged by grantees, and the implications of microgrants for public health practice and policy.

AIDS and "shared sovereignty" in Tanzania from 1987 to 2000: a case study.

After more than 15 years of foreign assistance to support HIV/AIDS prevention in Sub-Saharan Africa, HIV rates in the sub-continent remain high with only a few examples of reduced HIV incidence. This case study used the frame of "shared sovereignty" between nation-states and official development assistance agencies to analyze 13 years of technical assistance for HIV/AIDS programs in Tanzania from 1987 to 2000. The study draws on 21 key informant interviews and a systematic review of key program documents from the National AIDS Control Programme (NACP) and 14 other international agencies. Applying Jamison et al.'s (Lancet 351 (1998) 514) shared sovereignty framework, the analysis focused on fulfilled shared functions in moving Tanzania's NACP from dependence to independence. The analysis revealed an uneven and inconsistent level of technical assistance to the NACP with a rotation of multilateral and bilateral donors over the period of study. The Tanzanian government was often ambivalent toward agencies providing assistance towards its HIV/AIDS programs and toward its own NACP. Results are discussed in terms of implications for future strategic planning to mitigate the effects of HIV/AIDS. Determining roles, shared accountability and responsibility in a shared sovereignty framework remain a challenge in the governance of HIV/AIDS programs in Tanzania.