Addressing sexual health concerns in Tanzania: perceived barriers among healthcare professionals and students in the "training for health professionals" study

Little is known about the factors that may prevent healthcare professionals as key stakeholders from exploring sexual health issues in Tanzania. This study examined healthcare professionals' perspectives on the barriers to addressing sexual health concerns in practice. In June 2019, we conducted an exploratory qualitative study involving 18 focus group discussions among healthcare professionals (n = 60) and students (n = 61) in the health professions (midwifery, nursing, medicine) in Dar es Salaam, Tanzania. Study participants and design were purposively selected and stratified. We used a focus group discussion guide in Kiswahili. Data were transcribed in Kiswahili and translated into English. A thematic analysis approach was used for data analysis. Two themes were developed: (1) differences between health care professional and patient socio-demographic characteristics; (2) health care system and patients' backgrounds, such as communication barriers, lack of confidentiality and privacy within health facilities, type of clinical presentation and complaint, patient behaviours, and their clinical background. Several key barriers prevented sexual health communication between healthcare professionals and patients, affecting the quality of sexual health service delivery. Additional sexual health clinical training is warranted for health professions students and professionals to optimise sexual health care delivery in a culturally conservative country like Tanzania.

Evaluating the History-Taking Process of Sexual Reproductive Health Problems in Tanzania: Lessons from a Study of Health Students and Practitioners

Building trust and therapeutic relationships between healthcare providers and patients are crucial for delivering high-quality, comprehensive sexual and reproductive health (SRH) services. Yet, while patients face substantial SRH disparities in Tanzania, little is known about health care professionals' [HCPs] SRH history-taking practices and experiences. This paper describes HCPs' interdisciplinary practices, experience in conducting SRH taking, and the critical lessons learned to optimize quality SRH care. We conducted 18 focus group discussions in June 2019 in Dar es Salaam, Tanzania, with 60 healthcare practitioners and 61 students in midwifery, nursing, and medicine. We implemented a purposive, stratified sampling design to explore the experiences and perspectives of HCPs regarding providing sexual health services. We employed a grounded theory approach to perform the analysis. We provided seven scenarios to participants to discuss how they would manage SRH health problems. The scenarios helped us evaluate the practice and experience of SRH in Tanzania. Four broad themes and sub-themes emerged during the discussion; 1) SRH history-taking practices and experiences in the health care facilities; 2) the perceived benefit of effective SRH history-taking; 3) Factors hindering the SRH history-taking process; 4) The power of confidence. These findings have implications for strengthening a sexual health curriculum for medical students and continuing education programs for practicing health professionals designed to address the observed health disparities in Tanzania. These findings affirm that proper SRH history-taking requires a conducive environment, knowledge of relevant SRH-related laws and regulations; application of evidence-based techniques; and giving patients autonomy to make decisions for their health while making recommendations regarding standard care. Comprehensive SRH history-taking identifies critical data for illness diagnosis, provides foundational information for risk-reduction behavioural change counselling, and reduces medical costs. Therefore, the primary goal is to optimize health professional training on SRH issues and history-taking skills within the medical interview.

Perceptions of Sexual Healthcare Provision in Tanzania: a Key Informant Qualitative Study

INTRODUCTION

Sexual health care services must be standard and unbiased, guided by a structured health care system. There is a scarcity of data on how sexual health care is delivered in Tanzania.

METHODS

To address this gap, in July 2019 we interviewed eleven key informants: cultural and public health experts, and political, religious, and community leaders, selected from different organizations in Dar es Salaam, Tanzania. Participants were asked for their opinions about clinical practices of health care professionals when providing care to patients, with an emphasis on sexual health.

RESULTS

Participants' responses were classified into three subcategories: strengths, barriers, and gaps in sexual health care. Availability of services, service delivery to adults, and code of conduct were among the strengths observed in clinical care services. Barriers included the health care provider's attitudes, moral values, and inadequacy in health policies and treatment guidelines. Vulnerable populations including youth were frequently reported to face most challenges when seeking sexual health care services. In terms of gaps, informants emphasized gender equity in sexual health services provision within care settings.

CONCLUSION AND IMPLICATION

Data indicate that lack of training in sexual health and guidelines for dealing with sexual issues are a barrier to comprehensive health care. These findings can inform the main areas for curriculum developers to focus on, when developing an Afro-centric sexual health curriculum suitable for students in health care professional courses. Moreover, these findings can be useful when developing treatment guidelines and policies that are beneficial to the sexual health wellbeing of individuals.

Tailoring a sexual health curriculum to the sexual health challenges seen by midwifery, nursing and medical providers and students in Tanzania

BACKGROUND

 Tanzania is a country experiencing multiple sexual health challenges, but providers receive no formal training in sexual health.

AIM

 This study aimed to assess (1) what sexual health challenges are commonly seen in clinics in Tanzania, (2) which are raised by patients, (3) which are not addressed and (4) which topics to prioritise for a sexual health curriculum.

SETTING

 Healthcare settings in Tanzania.

METHODS

 Participants were 60 experienced and 61 student doctors, nurses and midwives working in Dar es Salaam. The authors conducted 18 focus groups stratified by profession (midwifery, nursing or medicine) and experience (practitioners vs. students).

RESULTS

 Providers identified six common sexual health concerns: (1) Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) and sexually transmissible infection (STI) (especially syphilis and gonorrhoea), (2) sexual violence (including intimate partner violence and female genital mutilation), (3) early and unwanted pregnancy (including early sexual debut and complications from abortion), (4) sexual dysfunctions, (5) key population concerns (e.g. lesbian, gay, bisexual, transgender (LGBT); sex work) and (6) non-procreative sexual behaviour (including pornography and masturbation in males and oral and anal sex practices in heterosexual couples). Across professions, few differences were observed. Homosexuality, sex work, masturbation and pornography were identified as taboo topics rarely discussed. Most participants (81%) wanted one comprehensive sexual health curriculum delivered across disciplines.

CONCLUSION

 A sexual health curriculum for health students in Tanzania needs to address the most common sexual health concerns of patients. In addition to teaching sexual science and clinical care, skills training in how to address taboo topics is recommended. Students endorsed almost all sexual health topics, which suggests that a comprehensive curriculum is appropriate.

The management of childhood sexual abuse by midwifery, nursing and medical providers in Tanzania

BACKGROUND

Child sexual abuse (CSA) is a significant public health problem affecting one billion children aged 2 to 17 globally. The prevalence of CSA in Tanzania is one of the highest; however, how health care providers manage CSA cases has not been studied.

OBJECTIVES

This study investigated how medical, nursing, and midwifery professionals in Tanzania handle cases of CSA and identified the factors that facilitate or impede the provision of quality care to CSA victims.

METHODS

Participants were 60 experienced healthcare professionals and 61 health students working in Dar es Salaam, Tanzania. We conducted 18 focus groups stratified by profession (midwifery, nursing, or medicine) and experience (practitioners versus students).

RESULTS

Three main themes emerged. First, child abuse management involved using a multi-disciplinary approach, including proper history taking, physical assessment, treatment, and referral. Second, factors that enhanced disclosure of CSA included building rapport, privacy, and confidentiality. Third, factors that impeded care included fear of harm to the child if the abuse was reported, abuse reporting being perceived as a "waste of time" for providers, loss of evidence from the victim, family resistance, poverty, corruption and cultural dynamics.

CONCLUSIONS

Midwives, nurses and doctors were all experienced in and reported similar challenges in addressing CSA. At a structural level, the ratio of providers to patients in health facilities inhibits quality care. These findings have implications for strengthening CSA policy/guidelines and clinical practice in Tanzania. Mandated CSA training is necessary for midwifery, nursing, and medical students as well as in continuing education courses for more experienced providers.

Clinical Care of Victims of Interpersonal Violence and Rape in Tanzania: A Qualitative Investigation

Introduction

Africa has high rates of interpersonal violence and rape, although little is known about how these cases are handled in the clinical setting.

Methods

We enrolled 121 health care professionals and students in Tanzania from the fields of midwifery, nursing and medicine, and conducted 18 focus group discussions stratified by both professional and clinical experience. Two clinical scenarios were presented across all groups and participants were asked to give their opinions on how the hospital they worked in would manage the cases. Case 1 focused on how to address a case of an injured woman beaten by her husband (and whether the perpetrator would be reported to the police). Case 2 focused on how to handle a rape victim who is brought to the hospital by the police.

Results

Participants considered both cases as emergencies. There was a similarity in the clinical care procedures across both scenarios. This included building rapport with the patient, prioritization of the medical care, history taking, and referring to other specialties for follow-up. Participants differed in how they would handle the legal aspects of both cases, including whether and how to best follow mandated reporting policies. Providers wondered if they should report the husband in case study 1, the criteria for reporting, and where to report. Providers displayed a lack of knowledge about resources needed for sexual violence victim and the availability of resources.

Conclusion

These findings indicate that cases of intimate partner violence and rape are likely to be under-reported within hospitals and clinics in Tanzania. Health care providers lack training in their required obligations and procedures that need to be followed to ensure victim’s safety. The findings confirm that there is a need for health care students in Tanzania (and possibly Africa) to receive comprehensive training in how to handle such cases.

Mental health in Somali youth in the United States: the role of protective factors in preventing depressive symptoms, suicidality, and self-injury

Objectives: Community, school, family, and individual factors protect against mental illness in general samples of adolescents. How these assets apply to Somali youth resettled to the United States (U.S.), a group with significant trauma exposure, remains unclear. We aimed to quantify which protective factors are associated with lower prevalence of depressive symptoms, suicidality, and self-injury among Somali youth in the U.S. compared with their non-Hispanic white peers.Design: Participants consisted of 8th, 9th, and 11th grade respondents to the 2016 Minnesota Student Survey, an anonymous school-administered statewide survey with 85.5% school district participation, who identified as Somali ethnicity (n = 1552) or as non-Hispanic white (n = 80,583). Multivariable logistic regression assessed odds of depressive symptoms, suicidal ideation and attempts, and self-harm, using eight protective factors (i.e. internal developmental assets, school engagement, empowerment, and family and teacher connectedness, caring adults and after-school activity frequency and quality) as independent variables. Models were run separately for Somali and white youth.Results: Somali youth reported similar rates of depressive symptoms, but lower levels of suicidal ideation or attempts and self-harm behaviors than their white peers (p < 0.001). All eight protective factors were associated with outcomes in the expected direction for white youth. For Somali youth, internal developmental assets (aOR 0.79, 95% CI: 0.65-0.97), empowerment (aOR 0.58, 95% CI: 0.45-0.73), family connectedness (aOR 0.60, 95% CI: 0.51-0.71), perception of caring adults in the community (aOR: 0.84, 95% CI: 0.76-0.92), and quality of after-school activities (aOR: 0.72, 95% CI: 0.61-0.86) were protective against depressive symptoms, with similar patterns for other outcomes. Other school factors protected Somali youth less consistently.Conclusions: Previously established protective factors against mental illness, particularly school factors, do not universally apply to Somali youth. Interventions that strengthen individual, family, or community factors, or that increase the relevance of school factors, should be explored for these youth.

Cultural and clinical challenges in sexual health care provision to men who have sex with men in Tanzania: a qualitative study of health professionals' experiences and health students' perspectives

BACKGROUND

Health care providers across sub-Saharan Africa continue to face challenges while delivering sexual health care services. We explored the experiences, views and challenges of health care professionals and health students across different disciplines in Tanzania, towards delivery of sexual health services to men who have sex with men.

METHODS

Utilizing a qualitative approach, we recruited 121 health care professionals (providers) and students from the fields of midwifery, nursing and medicine in Dar es Salaam, Tanzania. We conducted 18 focus groups discussions, stratified by profession and experience, to investigate clinical management and challenges while addressing a case of an adult male presenting with rectal gonorrhea.

RESULTS

Findings indicated this case as extremely sensitive, clinical management involved establishing rapport and consent, medical care from history taking to treatment, and referral to other specialties. However, the illegal status of homosexuality in Tanzania was a primary concern to participants, this triggered the clinical care of this case scenario as challenging. There were uncertainties whether or not that such a case should be reported to the authorities.

CONCLUSION

Findings from this study revealed a need for training health students in Tanzania to address sexual health issues including accurate information on homosexuality, reporting requirements and clinical management in the legal and socio-cultural context of the African continent.

The Use of Spanish Language Educational Materials by American Cleft Palate–Craniofacial Association Teams

Objective

The goals of this study were to assess U.S.-based American Cleft Palate–Craniofacial Association (ACPA) teams’ use and perceived need for Spanish-language educational materials and to evaluate trends in number of Spanish-speaking patients treated.

Methods

A facsimile survey was sent to U.S.-based teams listed in the ACPA 1999 to 2000 and 2001 to 2002 Team Directories. Questions addressed demographics for Spanish-speaking patients/families and use of Spanish-language educational materials. Teams with a recent increase in Spanish speakers, 25% or more Spanish speakers, or both received a more in-depth follow-up survey.

Results

Response rate to the initial survey was 71%. Almost 16% of teams reported having greater than 25% primarily Spanish speakers. Forty-four percent of responders saw an increase in Spanish speakers over the past 5 years, and 41% of responders used Spanish-language materials of some type. Fifty-seven teams were sent a follow-up survey and 29 (51%) teams responded. Teams reported a need for more Spanish-language educational materials on specific craniofacial conditions, and many expressed frustration in communication and interaction with Spanish speakers.

Conclusions

Many U.S.-based ACPA teams reported an increase in primarily Spanish speakers and expressed a need for more Spanish-language educational materials in different formats. Consideration of the diverse dialectic, cultural, and literacy needs of U.S. Spanish speakers can contribute to more effective educational efforts and improved care of the increasing number of Latinos treated by ACPA teams.

Reaching Latinas with Our Bodies, Ourselves and the Guía de Capacitación para Promotoras de Salud: health education for social change

As the cultural and linguistic diversity of the United States continues to grow and population shifts transform the communities where we live and work, health care providers continue to face challenges to deliver health services in demographically redefined terrains. This report describes the development of a Spanish-language training guide for community health workers (Guía de Capacitación para Promotoras de Salud) based on the book Nuestros Cuerpos, Nuestras Vidas (NCNV), the Spanish-language translation and cultural adaptation of the classic women's health book Our Bodies, Ourselves. The guide aims to 1) provide a tool for addressing the health education needs of immigrant Latinas and 2) facilitate the use of the book NCNV as a health education tool in Latino communities. Thirty telephone interviews with individuals working in agencies and organizations serving Latinos and 2 focus groups with Latinas were conducted to select the topics included in the training guide, all of which were drawn directly from NCNV. The guide contains 11 modules organized into 6 workshops. The modules address 11 topics related to women's health, ranging from sexuality and pregnancy to domestic violence and mental health. An ecological framework is used to deliver the health information. The materials acknowledge the roles of history, environment, culture, economic conditions, migration history, and politics as key determinants of health and illness. The workshops are designed to train community health workers on the women's health topics contained in the guide and to equip them for the delivery of health education among immigrant Latinas.