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Perceptions of mothers and hospital staff of paediatric care in 13 public hospitals in northern Tanzania
Transactions of the Royal Society of Tropical Medicine and Hygiene (2008) 102, 805—810
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/trst
Perceptions of mothers and hospital staff of paediatric care in 13 public hospitals in northern Tanzania Rose Mwangi a,b,∗, Clare Chandler a,b, Fortunata Nasuwa a,c, Hilda Mbakilwa a,c, Anja Poulsen a,d, Ib Christian Bygbjerg d, Hugh Reyburn a,c a
Joint Malaria Programme, P.O. Box 2228, KCMC, Moshi, Tanzania London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK c Kilimanjaro Christian Medical Centre, P.O. Box 3010, KCMC, Moshi, Tanzania d Department of International Health, P.O. Box 2099, University of Copenhagen, ´ 5 Øster Farimagsgade Building 16, DK-1014 Copenhagen K, Denmark b
Received 9 November 2007; received in revised form 23 April 2008; accepted 23 April 2008 Available online 3 June 2008
KEYWORDS Paediatrics; Hospitals; Resource-poor setting; Health personnel attitude; Health knowledge, attitudes, practice; Tanzania
Summary User and provider perceptions of quality of care are likely to affect both use and provision of services. However, little is known about how health workers and mothers perceive the delivery of care in hospital paediatric wards in Africa. Paediatric staff and mothers of paediatric inpatients were interviewed to explore their opinions and experience of the admission process and conditions on the ward. Overcrowding, unsanitary conditions and lack of food were major concerns for mothers on the ward, who were deterred from seeking treatment earlier due to fears that hospital admission posed a significant risk of exposure to infection. While most staff were seen as being sympathetic and supportive to mothers, a minority were reported to be judgemental and authoritarian. Health workers identified lack of trained staff, overwork and low pay as major concerns. Staff shortages, lack of effective training and equipment are established problems but our findings also highlight a need for wards to become more parentfriendly, particularly with regard to food, hygiene and space. Training programmes focused on professional conduct and awareness of the problems that mothers face in seeking and receiving care may result in a more supportive and cooperative attitude between staff and mothers. Crown Copyright © 2008 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved.
1. Introduction ∗
Corresponding author. Tel.: +255 27 2750691; fax: +255 27 2753982. E-mail address: [email protected] (R. Mwangi).
Several studies have documented significant problems with the quality of delivery of inpatient paediatric care in Africa (English et al., 2004a; Nolan et al., 2001). In Tanzania, as in many African countries, the Ministry of Health (MOH)
0035-9203/$ — see front matter. Crown Copyright © 2008 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. doi:10.1016/j.trstmh.2008.04.033
806 is striving to improve the quality of care but most of this initiative is understandably focused on quantitative measures, such as availability of trained staff and essential drugs and supplies (Ministry of Health, 2003a). However, the quality of care is also dependent on how staff and especially patients perceive its delivery. In Tanzania, MOH has introduced a ‘Client Service Charter’ that outlines the approach that providers should take towards the provision of care (Ministry of Health, 2003b) and has suggested that quality indicators should include periodic reviews of client satisfaction. However, there is little awareness of these initiatives or evidence of how users of inpatient paediatric care perceive the service that is provided and in what areas they feel it falls short. In this study we aimed to compare and contrast the experience and perceptions of paediatric inpatient care among mothers (since mothers formed more than 90% of those interviewed, we have used this term to encompass all categories of caregiver) with those of staff caring for children on the ward. The study was conducted as part of a larger study to assess the quality of care in public hospitals in northeast Tanzania which took place during January—August 2006, the quantitative findings of which are reported elsewhere (Reyburn et al., 2008).
2. Methods The study was conducted as part of a 5-day assessment of paediatric care in 13 district hospitals in Kilimanjaro and Tanga regions of north-east Tanzania. Six were government district hospitals, five were government-supported mission district hospitals and two were government regional hospitals. The combined population of the two regions is 3.4 million. Malaria ecology varies widely and subsistence agriculture supported by plantations of sisal and coffee are the dominant economic activities. Childhood mortality in 2002 was estimated at 67/1000 and 162/1000 in Kilimanjaro and Tanga regions respectively, a difference that appears to follow the known trends in malaria transmission intensity and socio-economic status in the two regions (Tanzanian National Bureau of Statistics, 2002). Health workers directly involved in the delivery of paediatric care in each hospital were identified from the staff roster and invited for an interview in a private area of the ward. Eligible staff grades were doctors (MD), assistant medical officers (AMO) and clinical officers (CO) (non-physician clinicians with 4 and 3 years of training, respectively), nurses (with 3 years of training) and nurse auxiliaries (with 6 months of basic training). Along with demographic and work history data, staff were asked for opinions of the quality of care delivered, pay, working conditions and the quality of interactions between mothers and hospital staff. Mothers were invited for interview on their child’s day of discharge or after their child had spent 5 days on the ward. On obtaining informed consent, trained field workers conducted semi-structured interviews, recording social and economic details and their opinions of the care that had been provided. Interviews with mothers and health workers took place in a private area near or on the ward and lasted approximately 20 min each.
R. Mwangi et al. Responses were manually recorded verbatim in Swahili and were later translated by a research assistant fluent in both Swahili and English. Data were analysed through thematic analysis; transcripts were initially read through and emerging views and opinions were manually coded. The codes were grouped together into themes that were checked by three different social scientists (RM, CC, FN), systematically generating the themes presented in this paper. Verbal consent for interviews was obtained and names were not recorded. Bereaved mothers were not interviewed.
3. Results 3.1. Mothers Two hundred and sixty-five mothers were interviewed and four refused to participate; 126 (48%) were interviewed on the day of discharge and 135 (51%) had stayed in the ward for 5 days. Table 1 shows the relationship of the respondent to the child (93% mothers, 99% female) and selected socioeconomic characteristics. Almost all the mothers (249, 95%) spent more than 75% of their time on the ward while their child was in hospital and 261 (98%) slept on the ward. Ninety (34%) mothers reported sharing a bed with another child and his/her mother at some time during their admission. 3.1.1. The admission process and physical conditions on the ward Many caregivers (80, 31%) were surprised that their child was admitted and although 198 (76%) felt that the reason for admission had been explained, 193 (74%) still wanted more information on their child’s illness. Most mothers felt that the medical care and politeness of staff prior to admission were as expected or better but over 30% found waiting times were longer than they had expected.
Table 1
Socio-economic characteristics of mothers n = 261 (%)
Relationship to child Mother Grandmother Other, female Other, male
242 (93) 10 (4) 7 (3) 2 (1)
Education None
16 (6) 29 (11) 191 (73) 27 (10)
Present in the home Flush toilet Electricity Mobile phone Bicycle Non-mud floor Radio
32 (12) 66 (25) 88 (34) 134 (51) 147 (56) 203 (78)
Perceptions of paediatric hospital care in Tanzania Several mothers reported concerns on admission that they would be unavailable to care for other children at home, unable to meet out-of-pocket costs in hospital, especially for food, and be exposed to risk of infection from other children. Few of the hospitals provided food for mothers, the poorer of whom reported surviving on maize porridge (ugali). Food storage and cooking facilities were basic or absent and women reported having to store food in bedside lockers or plastic bags on the floor. Poor toilet facilities and contamination with faeces of other children were frequently mentioned. ‘‘We share the cabinets; the four of us are forced to keep the children’s food on the floor or on the shared beds and it is not hygienic especially because the wards are dirty.’’ (Mother, Hosp. 3) ‘‘There should be food for mothers and children because some of us are staying far and we do not have money to buy food, so we are forced to demand to be discharged even if children are not cured because they cannot get treatment only without food. The child may improve but then die because of drugs being too strong on an empty stomach.’’ (Mother, Hosp. 6) ‘‘The toilets do not have a door, there is not enough water for flushing, therefore many people leave the toilets without flushing them.’’ (Mother, Hosp. 3) ‘‘I do not like it when some of the women take their children to go to the toilet on the grass. . . sometimes one wants to rest outside and you find faeces all round the grasses.’’ (Mother, Hosp. 9) ‘‘The beds are small and four children are meant to sleep in one which causes the children to fall out and you will find that we are sleeping on the floor and it is not easy to see the child falling out, you only notice it when it is already down.’’ (Mother, Hosp. 12) 3.1.2. Technical standards of care While technical standards of care were often not in line with best practice (Reyburn et al., 2008) most mothers were satisfied with this aspect of care. For example, 212 (81%) thought that the medical checks on progress and reexamination were satisfactory and many were pleased with their treatment. ‘‘I am satisfied because they have never talked to me rudely. For example when I came here the child started to use tablets and I saw its condition had not yet improved and continued to get worse. When I told them they came to take medical examination again and they changed the dose to an injection and the child is progressing well.’’ (Mother, Hosp. 11) Dissatisfaction was most often expressed when poor care occurred in conjunction with perceived rudeness or indifference by staff, more frequently involving nurses than other cadres. ‘‘The nurse injected the child on the day before yesterday and she did not record in the file. I reminded her to record on the following day and she told me that that was not my work. What made me tell her is because
807 Table 2 Qualifications and duration of service of interviewed health workers in 13 Tanzanian hospitals Qualification
n (%)
Mean (median) years in current post
Auxiliary nurse Nurse Clinical officer (CO) Asst. medical officer (AMO) Medical doctor (MD)
19 (23) 13.7 (10) 45 (56) 11.4 (11) 9 (11) 6.9 (5) 3 (4) 2.0 (2) 5 (6) 4.0 (4)
Total
81 (100) 11.2 (10)
she was telling me the child is left with two more injections while I knew only one injection was left. I felt bad because if that nurse was not around the child could get an overdose.’’ (Mother, Hosp. 3) ‘‘I do not have any problem with this child but last time her twin was very sick. I called the nurse and she kept telling me that she was coming and the child’s condition continued to worsen. When I saw she was not turning up, I decided to go and call the doctor who was there at that time. He answered me that someone like me should not call him but by the nurse who is the one supposed to address him [doctor]. I was forced to go back to the ward. When I went back to the ward, the child’s condition continued to worsen till it died. I was not happy with it at all because I know my child could have survived if only they had attended it on time. I see it as their ignorance and negligence.’’ (Mother, Hosp. 12)
3.2. Health workers A total of 81 health workers were interviewed, amongst whom clinical staff were slightly under-represented due to their lack of availability during the assessment. Most nurses had worked in the hospital for more than 10 years, while this period was much shorter for clinical staff (Table 2). 3.2.1. Problems with ward facilities and food Health workers were generally critical of the ward facilities, both for accommodation and clinical care; in almost all categories fewer than half of the staff thought these facilities were adequate or good (Figure 1). Staff rated the quality and availability of patient food, hygiene of the toilets and space for patients to sleep as particularly deficient. However, some health workers did not see food as integral to clinical care but more a personal responsibility of patients: ‘‘We don’t have anything to do with food, parents bring their own food for the children and it’s difficult to tell if they have enough or not. We concentrate more on saving the lives of the children.’’ (Clinical officer, Hosp. 10) 3.2.2. Staffing levels, training and motivation Staff reported serious staff shortages on paediatric wards; only four hospitals had a fully qualified doctor (MD) on site and only one of these was a paediatrician. The remaining paediatric wards were run by an assistant medical officer (AMO) and there were five unfilled paediatric medical posts.
808
Figure 1
R. Mwangi et al.
Proportion of respondents reporting ‘good or adequate’ facilities in the ward for both accommodation and clinical care.
Qualified staff were often reported not to be replaced when they were away and staff felt underpaid (nurses were commonly paid under US$100 per month at the time of the study), with inadequate fringe benefits. These deficiencies made them feel undervalued and demotivated. One clinical officer said: ‘‘If today I was given the retirement benefits I would quit the job without even saying goodbye’’. Although regular (generally weekly) staff meetings were held in all hospitals and 66% reported having attended an all-day training session in the previous year, many staff felt that in-service training was inadequate and provided limited career prospects. Not knowing how best to manage severely ill children was a particular problem expressed by nurses. In spite of these demotivating factors, staff felt that the nature of their work brought satisfaction and respect from the community and this was clearly important to all the staff interviewed. There was much evidence of human kindness and resulting friendships between mothers and staff. ‘‘A child came having tetanus, unconscious and with fits. Everybody was touched with child’s condition and we all volunteered to help. I felt good being able to follow up the medication. Also I was able to buy for it milk and fruits. Its condition is good and it can walk and eat by itself. I was happy to see it in that situation because I thought the child was going die.’’ (Nurse, Hosp. 7) ‘‘The child came having severe anaemia and its mother had given up. We introduce to it dose of quinine drip but its condition was still bad, so when it finished the dose it started to be fine. I was glad for being able to give the child food because the mother was poor so I volunteered to buy for her milk everyday. . . The mother was so happy and whenever she comes to the clinic she always comes to greet me.’’ (Nurse, Hosp. 3)
more distant and some mothers reported being able to turn to nurses for advice or help. Health worker opinions of mothers tended to label mothers as at fault for late presentation and described mothers as ignorant or incompetent: ‘‘there are many children who die because local medicines and the hospital ones are combined and this causes deaths’’ or ‘‘it would be good if mothers were educated’’ were common sentiments from the nurses. These attitudes sometimes resulted in confrontations with mothers. ‘‘The child had severe malaria and pneumonia when it was brought here, we did its [malaria] tests and we put it on a drip. The child’s mother decided to increase the quinine by opening up the drip to the end and the child’s condition worsened. We were forced to stop the drip for some time and to advise the woman. The next day we put the child on another drip, in the afternoon the relatives came with the local medicines and gave them to the child; the child’s condition worsened again. What caused the child’s death were the mother’s ignorance and the mixing of drugs.’’ (Clinical officer, Hosp. 8) In crowded wards nurses were often in the position of rationing attention or making judgements about the mothers’ competence and this was often resented by mothers if it was done in an uncaring way. Some mothers reported use of various coping strategies. ‘‘It is difficult for us to explain the child’s problem to the nurses, for example you can tell the nurse the child’s problem and she will answer, ‘you do not listen! Wait for the doctor and tell him’, this discourages us to ask anything.’’ (Mother, Hosp. 1)
‘‘There was a child who had burns around the stomach. We worked hard to see the child got better. The mother was very poor and did not have any clothes for her child so I brought clothes from home.’’ (Nurse, Hosp. 6) 3.2.3. Relations between mothers and staff While most mothers found staff to be friendly, there were a number of reports that some nursing staff were found to be too strict, uncaring or rude (Figure 2). Mothers were more likely to criticise nurses’ than doctors’ attitudes towards them. Nurses were more accessible, while medical staff
Figure 2 Opinions of caregivers on the attitude of staff during admission. CO: clinical officer; AMO: assistant medical officer.
Perceptions of paediatric hospital care in Tanzania ‘‘I try to be kind; for example there is a certain nurse who is so cruel and when I need her support I start with an apology because they like being flattered most of the time.’’ (Mother, Hosp. 10) ‘‘I was attending this child who had severe malaria and worked very hard every day to see the child improve, although initially I did not think he would survive. This particular day the child looked much better. When I went to give an injection, I saw the baby [nine months] at the edge of the bed almost falling down. When I looked for the mother, she was washing her hands on the sink and also chatting with another woman. But when I shouted to tell her to watch the baby, it almost fell but I was fast enough to catch it. I went to the mother and slapped her very hand I felt pain on my palm! I took the baby with me and gave him the injection and looked at him until my shift was over. It was pure negligence of the mother and had the baby fell on his head he would have died.’’ (Nurse, Hosp. 3)
4. Discussion Our study provides a snapshot of the human experience of the delivery of care for sick children where the burden of disease is high and resources very limited. While standards of technical care, both in these particular hospitals and in African hospitals generally, have been shown to be seriously deficient in a number of important areas mothers rarely reported this as a problem. It is possible that mothers of children who died (and were excluded for ethical reasons) may have had more to say but given that few mothers in our study had received more than primary education it is not surprising that mothers lacked awareness of what constitutes good standards of care and is consistent with a similar study in Kenya (English et al., 2004b). What concerned mothers most was ward hygiene, food and politeness of staff, while staff were most concerned with low pay, overwork and poor career prospects. Overcrowding and bed-sharing, blocked toilets and lack of food and cooking facilities were major concerns for mothers and these were likely to deter timely seeking of hospital care. Many of these concerns would require major investment to rectify but we also observed that minor repairs such as broken taps, non-functional sinks and blocked toilets remained unattended for extended periods. Although ward staff were aware of these, they did not report them with the same urgency as mothers or feel empowered to initiate action within the hospital system to correct them. We found a striking difference between health workers and mothers in accounting for delays in bringing sick children to hospital. Mothers avoided hospitals due to concerns around hygiene and food-related issues, while health workers consistently complained that children were brought too late due to the mothers’ ignorance and inappropriate use of medicines (either traditional or approved). Such assumptions of mothers’ ignorance are likely to restrict an understanding of the real and complex reasons for late presentation (Peterson et al., 2004) and tend to reinforce a hierarchy based on possession of technical knowledge. This undermines the personal agency of mothers and supports a
809 socio-cultural order that disadvantages the most vulnerable (Waitzkin, 1984). Staff morale is a crucial factor in the quality of care. We found that staff were acutely aware of demotivating factors in their work (low pay, overwork etc) but this was offset by the respect and gratitude they experienced from mothers and the community at large and this was of the utmost importance to them, a finding supported by other studies (Kyaddondo and Whyte, 2003). While in many cases such respect seemed to be justified by supportive and kindly treatment of mothers, there was a tendency to devalue mothers’ knowledge and competence that inherently elevated health workers’ own status. This appeared to be tolerated but certainly not welcomed by mothers, who appeared very sensitive to the way they were treated and reported flattery or wariness towards certain nurses as coping strategies. Staff attitudes have been found to be important in the perception of both the quality of care (Gilson et al., 1994) and the willingness to pay (Hanson et al., 2005) in other studies in Africa but in our study mothers seemed to have limited options to express these. Patients in any healthcare setting have two primary options for expressing dissatisfaction with services: voice or exit (LeGrand, 2006). In settings such as Tanzania, alternatives to the district hospital for inpatient care are few or non-existent and we did not find any functioning patient complaint systems at the hospitals studied. Empowering patients to make their voices heard when dissatisfied and strengthening management systems within health facilities to enable them to listen and to act may be effective in improving the delivery of both interpersonal and technical aspects of care. In our study, nurses were generally reported to be more authoritarian than clinical staff, with one nurse reporting that she’d found occasion to physically strike a mother. The reasons for this apparent difference between staff grades are not clear but may reflect nurses’ own vulnerabilities; while clinicians could gain respect from their clinical knowledge and authority to prescribe, lower cadres may feel the need to assert their authority more directly. In addition, nurses are closer to the day-to-day operation of the ward and are often reliant on the cooperation of mothers for ward cleaning etc. Evans (1994) has suggested that in requiring mothers to conduct menial rather than caring tasks, nurses can reinforce their own power while creating resistance among mothers, thereby widening the social gap between mothers and health workers. Mothers’ reports of interactions between themselves and health workers suggest a need for a more deliberate approach to ensuring that hospital staff have a deeper understanding of the problems faced by mothers, an understanding of which has been shown to correlate with indicators of quality of care and patient satisfaction (Cleary and McNeil, 1988; Christakis et al., 2002). In conclusion, our findings highlight how mothers and health workers experience the strains of caring for severely ill children in these settings. The problems of providing basic care with few resources can be exacerbated by dysfunctional and authoritarian attitudes towards mothers and there is a need for health planners and providers to become more aware of mothers’ experiences, particularly in relation to food, basic hygiene and the need to be treated with consideration and respect. While much remains to be done to
810 improve care in African hospitals, some of the problems perceived as most pressing by mothers can be tackled with modest additional resources and a greater awareness of their importance. Authors’ contributions: RM and HR conceived the study; RM, HR, CC, AP and IB designed the study; RM and HR supervised data collection; FN and HM collected the data; RM, HR, CC, AP, IB, FN and HM analysed the data; RM, HR, AP and IB interpreted the data; RM, HR and CC drafted the manuscript; AP, IB, FN and HM critically revised the paper. All authors read and approved the final manuscript. RM and HR are guarantors of the paper. Acknowledgements: The authors are grateful to the caregivers and their children who participated and to the research assistants of the Joint Malaria Program. We thank the Regional Medical Officer, District Medical Officers, and the hospital staff in the two regions and 13 districts for providing support and cooperation. Chris Whitty provided critical comments on the manuscript. Funding: The study was funded by a grant from the European Union SANTE/2004/078-607. Conflicts of interest: None declared. Ethical approval: The study was approved by the ethical review board of the National Institute for Medical Research in Tanzania (Approval No. NIMR: NIMR/HQ/R.8a IX/498).
References Christakis, D.A., Wright, J.A., Zimmerman, F.J., Bassett, A.L., Connell, F.A., 2002. Continuity of care is associated with high-quality care by parental report. Pediatrics 109, e54. Cleary, P.D., McNeil, B.J., 1988. Patient satisfaction as an indicator of quality care. Inquiry 25, 25—36. English, M., Esamai, F., Wasunna, A., Were, F., Ogutu, B., Wamae, A., Snow, R.W., Peshu, N., 2004a. Assessment of inpatient paedi-
R. Mwangi et al. atric care in first referral level hospitals in 13 districts in Kenya. Lancet 363, 1948—1953. English, M., Esamai, F., Wasunna, A., Were, F., Ogutu, B., Wamae, A., Snow, R.W., Peshu, N., 2004b. Delivery of paediatric care at the first-referral level in Kenya. Lancet 364, 1622—1629. Evans, M.A., 1994. An investigation into the feasibility of parental participation in the nursing care of their children. J. Adv. Nurs. 20, 477—482. Gilson, L., Alilio, M., Heggenhougen, K., 1994. Community satisfaction with primary health care services: an evaluation undertaken in the Morogoro region of Tanzania. Soc. Sci. Med. 39, 767—780. Hanson, K., McPake, B., Nakamba, P., Archard, L., 2005. Preferences for hospital quality in Zambia: results from a discrete choice experiment. Health Econ. 14, 687—701. Kyaddondo, D., Whyte, S.R., 2003. Working in a decentralized system: a threat to health workers’ respect and survival in Uganda. Int. J. Health Plann. Manage. 18, 329—342. LeGrand, J., 2006. Motivation, Agency, and Public Policy. Of Knights and Knaves. Pawns and Queens. Oxford University Press, Oxford. Ministry of Health, 2003a. Client Service Charter, Ministry of Health, United Republic of Tanzania. Government printers, Dar es Salaam, Tanzania. Ministry of Health, 2003b. Second Health Sector Strategic Plan, 2003-8. Ministry of Health and Social Welfare, United Republic of Tanzania. http://www.moh.go.tz/documents/healthstrategy2003.pdf [accessed 18 March 2008]. Nolan, T., Angos, P., Cunha, A.J., Muhe, L., Qazi, S., Simoes, E.A., Tamburlini, G., Weber, M., Pierce, N.F., 2001. Quality of hospital care for seriously ill children in less-developed countries. Lancet 357, 106—110. Peterson, S., Nsungwa-Sabiiti, J., Were, W., Nsabagasani, X., Magumba, G., Nambooze, J., Mukasa, G., 2004. Coping with paediatric referral–Ugandan parents’ experience. Lancet 363, 1955—1956. Reyburn, H., Mwakasungula, E., Chonya, S., Mtei, F., Bygbjerg, I., Poulsen, A., Olomi, R., 2008. Clinical assessment and treatment of children in paediatric wards in North East Tanzania. Bull. World Health Organ. 86, 132—139. Tanzanian National Bureau of Statistics, 2002. Tanzanian National Census. http://www.tanzania.go.tz/census/ [accessed 18 March 2008]. Waitzkin, H., 1984. The micropolitics of medicine: a contextual analysis. Int. J. Health Serv. 14, 339—378.
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/trst
Perceptions of mothers and hospital staff of paediatric care in 13 public hospitals in northern Tanzania Rose Mwangi a,b,∗, Clare Chandler a,b, Fortunata Nasuwa a,c, Hilda Mbakilwa a,c, Anja Poulsen a,d, Ib Christian Bygbjerg d, Hugh Reyburn a,c a
Joint Malaria Programme, P.O. Box 2228, KCMC, Moshi, Tanzania London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK c Kilimanjaro Christian Medical Centre, P.O. Box 3010, KCMC, Moshi, Tanzania d Department of International Health, P.O. Box 2099, University of Copenhagen, ´ 5 Øster Farimagsgade Building 16, DK-1014 Copenhagen K, Denmark b
Received 9 November 2007; received in revised form 23 April 2008; accepted 23 April 2008 Available online 3 June 2008
KEYWORDS Paediatrics; Hospitals; Resource-poor setting; Health personnel attitude; Health knowledge, attitudes, practice; Tanzania
Summary User and provider perceptions of quality of care are likely to affect both use and provision of services. However, little is known about how health workers and mothers perceive the delivery of care in hospital paediatric wards in Africa. Paediatric staff and mothers of paediatric inpatients were interviewed to explore their opinions and experience of the admission process and conditions on the ward. Overcrowding, unsanitary conditions and lack of food were major concerns for mothers on the ward, who were deterred from seeking treatment earlier due to fears that hospital admission posed a significant risk of exposure to infection. While most staff were seen as being sympathetic and supportive to mothers, a minority were reported to be judgemental and authoritarian. Health workers identified lack of trained staff, overwork and low pay as major concerns. Staff shortages, lack of effective training and equipment are established problems but our findings also highlight a need for wards to become more parentfriendly, particularly with regard to food, hygiene and space. Training programmes focused on professional conduct and awareness of the problems that mothers face in seeking and receiving care may result in a more supportive and cooperative attitude between staff and mothers. Crown Copyright © 2008 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved.
1. Introduction ∗
Corresponding author. Tel.: +255 27 2750691; fax: +255 27 2753982. E-mail address: [email protected] (R. Mwangi).
Several studies have documented significant problems with the quality of delivery of inpatient paediatric care in Africa (English et al., 2004a; Nolan et al., 2001). In Tanzania, as in many African countries, the Ministry of Health (MOH)
0035-9203/$ — see front matter. Crown Copyright © 2008 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. doi:10.1016/j.trstmh.2008.04.033
806 is striving to improve the quality of care but most of this initiative is understandably focused on quantitative measures, such as availability of trained staff and essential drugs and supplies (Ministry of Health, 2003a). However, the quality of care is also dependent on how staff and especially patients perceive its delivery. In Tanzania, MOH has introduced a ‘Client Service Charter’ that outlines the approach that providers should take towards the provision of care (Ministry of Health, 2003b) and has suggested that quality indicators should include periodic reviews of client satisfaction. However, there is little awareness of these initiatives or evidence of how users of inpatient paediatric care perceive the service that is provided and in what areas they feel it falls short. In this study we aimed to compare and contrast the experience and perceptions of paediatric inpatient care among mothers (since mothers formed more than 90% of those interviewed, we have used this term to encompass all categories of caregiver) with those of staff caring for children on the ward. The study was conducted as part of a larger study to assess the quality of care in public hospitals in northeast Tanzania which took place during January—August 2006, the quantitative findings of which are reported elsewhere (Reyburn et al., 2008).
2. Methods The study was conducted as part of a 5-day assessment of paediatric care in 13 district hospitals in Kilimanjaro and Tanga regions of north-east Tanzania. Six were government district hospitals, five were government-supported mission district hospitals and two were government regional hospitals. The combined population of the two regions is 3.4 million. Malaria ecology varies widely and subsistence agriculture supported by plantations of sisal and coffee are the dominant economic activities. Childhood mortality in 2002 was estimated at 67/1000 and 162/1000 in Kilimanjaro and Tanga regions respectively, a difference that appears to follow the known trends in malaria transmission intensity and socio-economic status in the two regions (Tanzanian National Bureau of Statistics, 2002). Health workers directly involved in the delivery of paediatric care in each hospital were identified from the staff roster and invited for an interview in a private area of the ward. Eligible staff grades were doctors (MD), assistant medical officers (AMO) and clinical officers (CO) (non-physician clinicians with 4 and 3 years of training, respectively), nurses (with 3 years of training) and nurse auxiliaries (with 6 months of basic training). Along with demographic and work history data, staff were asked for opinions of the quality of care delivered, pay, working conditions and the quality of interactions between mothers and hospital staff. Mothers were invited for interview on their child’s day of discharge or after their child had spent 5 days on the ward. On obtaining informed consent, trained field workers conducted semi-structured interviews, recording social and economic details and their opinions of the care that had been provided. Interviews with mothers and health workers took place in a private area near or on the ward and lasted approximately 20 min each.
R. Mwangi et al. Responses were manually recorded verbatim in Swahili and were later translated by a research assistant fluent in both Swahili and English. Data were analysed through thematic analysis; transcripts were initially read through and emerging views and opinions were manually coded. The codes were grouped together into themes that were checked by three different social scientists (RM, CC, FN), systematically generating the themes presented in this paper. Verbal consent for interviews was obtained and names were not recorded. Bereaved mothers were not interviewed.
3. Results 3.1. Mothers Two hundred and sixty-five mothers were interviewed and four refused to participate; 126 (48%) were interviewed on the day of discharge and 135 (51%) had stayed in the ward for 5 days. Table 1 shows the relationship of the respondent to the child (93% mothers, 99% female) and selected socioeconomic characteristics. Almost all the mothers (249, 95%) spent more than 75% of their time on the ward while their child was in hospital and 261 (98%) slept on the ward. Ninety (34%) mothers reported sharing a bed with another child and his/her mother at some time during their admission. 3.1.1. The admission process and physical conditions on the ward Many caregivers (80, 31%) were surprised that their child was admitted and although 198 (76%) felt that the reason for admission had been explained, 193 (74%) still wanted more information on their child’s illness. Most mothers felt that the medical care and politeness of staff prior to admission were as expected or better but over 30% found waiting times were longer than they had expected.
Table 1
Socio-economic characteristics of mothers n = 261 (%)
Relationship to child Mother Grandmother Other, female Other, male
242 (93) 10 (4) 7 (3) 2 (1)
Education None
16 (6) 29 (11) 191 (73) 27 (10)
Present in the home Flush toilet Electricity Mobile phone Bicycle Non-mud floor Radio
32 (12) 66 (25) 88 (34) 134 (51) 147 (56) 203 (78)
Perceptions of paediatric hospital care in Tanzania Several mothers reported concerns on admission that they would be unavailable to care for other children at home, unable to meet out-of-pocket costs in hospital, especially for food, and be exposed to risk of infection from other children. Few of the hospitals provided food for mothers, the poorer of whom reported surviving on maize porridge (ugali). Food storage and cooking facilities were basic or absent and women reported having to store food in bedside lockers or plastic bags on the floor. Poor toilet facilities and contamination with faeces of other children were frequently mentioned. ‘‘We share the cabinets; the four of us are forced to keep the children’s food on the floor or on the shared beds and it is not hygienic especially because the wards are dirty.’’ (Mother, Hosp. 3) ‘‘There should be food for mothers and children because some of us are staying far and we do not have money to buy food, so we are forced to demand to be discharged even if children are not cured because they cannot get treatment only without food. The child may improve but then die because of drugs being too strong on an empty stomach.’’ (Mother, Hosp. 6) ‘‘The toilets do not have a door, there is not enough water for flushing, therefore many people leave the toilets without flushing them.’’ (Mother, Hosp. 3) ‘‘I do not like it when some of the women take their children to go to the toilet on the grass. . . sometimes one wants to rest outside and you find faeces all round the grasses.’’ (Mother, Hosp. 9) ‘‘The beds are small and four children are meant to sleep in one which causes the children to fall out and you will find that we are sleeping on the floor and it is not easy to see the child falling out, you only notice it when it is already down.’’ (Mother, Hosp. 12) 3.1.2. Technical standards of care While technical standards of care were often not in line with best practice (Reyburn et al., 2008) most mothers were satisfied with this aspect of care. For example, 212 (81%) thought that the medical checks on progress and reexamination were satisfactory and many were pleased with their treatment. ‘‘I am satisfied because they have never talked to me rudely. For example when I came here the child started to use tablets and I saw its condition had not yet improved and continued to get worse. When I told them they came to take medical examination again and they changed the dose to an injection and the child is progressing well.’’ (Mother, Hosp. 11) Dissatisfaction was most often expressed when poor care occurred in conjunction with perceived rudeness or indifference by staff, more frequently involving nurses than other cadres. ‘‘The nurse injected the child on the day before yesterday and she did not record in the file. I reminded her to record on the following day and she told me that that was not my work. What made me tell her is because
807 Table 2 Qualifications and duration of service of interviewed health workers in 13 Tanzanian hospitals Qualification
n (%)
Mean (median) years in current post
Auxiliary nurse Nurse Clinical officer (CO) Asst. medical officer (AMO) Medical doctor (MD)
19 (23) 13.7 (10) 45 (56) 11.4 (11) 9 (11) 6.9 (5) 3 (4) 2.0 (2) 5 (6) 4.0 (4)
Total
81 (100) 11.2 (10)
she was telling me the child is left with two more injections while I knew only one injection was left. I felt bad because if that nurse was not around the child could get an overdose.’’ (Mother, Hosp. 3) ‘‘I do not have any problem with this child but last time her twin was very sick. I called the nurse and she kept telling me that she was coming and the child’s condition continued to worsen. When I saw she was not turning up, I decided to go and call the doctor who was there at that time. He answered me that someone like me should not call him but by the nurse who is the one supposed to address him [doctor]. I was forced to go back to the ward. When I went back to the ward, the child’s condition continued to worsen till it died. I was not happy with it at all because I know my child could have survived if only they had attended it on time. I see it as their ignorance and negligence.’’ (Mother, Hosp. 12)
3.2. Health workers A total of 81 health workers were interviewed, amongst whom clinical staff were slightly under-represented due to their lack of availability during the assessment. Most nurses had worked in the hospital for more than 10 years, while this period was much shorter for clinical staff (Table 2). 3.2.1. Problems with ward facilities and food Health workers were generally critical of the ward facilities, both for accommodation and clinical care; in almost all categories fewer than half of the staff thought these facilities were adequate or good (Figure 1). Staff rated the quality and availability of patient food, hygiene of the toilets and space for patients to sleep as particularly deficient. However, some health workers did not see food as integral to clinical care but more a personal responsibility of patients: ‘‘We don’t have anything to do with food, parents bring their own food for the children and it’s difficult to tell if they have enough or not. We concentrate more on saving the lives of the children.’’ (Clinical officer, Hosp. 10) 3.2.2. Staffing levels, training and motivation Staff reported serious staff shortages on paediatric wards; only four hospitals had a fully qualified doctor (MD) on site and only one of these was a paediatrician. The remaining paediatric wards were run by an assistant medical officer (AMO) and there were five unfilled paediatric medical posts.
808
Figure 1
R. Mwangi et al.
Proportion of respondents reporting ‘good or adequate’ facilities in the ward for both accommodation and clinical care.
Qualified staff were often reported not to be replaced when they were away and staff felt underpaid (nurses were commonly paid under US$100 per month at the time of the study), with inadequate fringe benefits. These deficiencies made them feel undervalued and demotivated. One clinical officer said: ‘‘If today I was given the retirement benefits I would quit the job without even saying goodbye’’. Although regular (generally weekly) staff meetings were held in all hospitals and 66% reported having attended an all-day training session in the previous year, many staff felt that in-service training was inadequate and provided limited career prospects. Not knowing how best to manage severely ill children was a particular problem expressed by nurses. In spite of these demotivating factors, staff felt that the nature of their work brought satisfaction and respect from the community and this was clearly important to all the staff interviewed. There was much evidence of human kindness and resulting friendships between mothers and staff. ‘‘A child came having tetanus, unconscious and with fits. Everybody was touched with child’s condition and we all volunteered to help. I felt good being able to follow up the medication. Also I was able to buy for it milk and fruits. Its condition is good and it can walk and eat by itself. I was happy to see it in that situation because I thought the child was going die.’’ (Nurse, Hosp. 7) ‘‘The child came having severe anaemia and its mother had given up. We introduce to it dose of quinine drip but its condition was still bad, so when it finished the dose it started to be fine. I was glad for being able to give the child food because the mother was poor so I volunteered to buy for her milk everyday. . . The mother was so happy and whenever she comes to the clinic she always comes to greet me.’’ (Nurse, Hosp. 3)
more distant and some mothers reported being able to turn to nurses for advice or help. Health worker opinions of mothers tended to label mothers as at fault for late presentation and described mothers as ignorant or incompetent: ‘‘there are many children who die because local medicines and the hospital ones are combined and this causes deaths’’ or ‘‘it would be good if mothers were educated’’ were common sentiments from the nurses. These attitudes sometimes resulted in confrontations with mothers. ‘‘The child had severe malaria and pneumonia when it was brought here, we did its [malaria] tests and we put it on a drip. The child’s mother decided to increase the quinine by opening up the drip to the end and the child’s condition worsened. We were forced to stop the drip for some time and to advise the woman. The next day we put the child on another drip, in the afternoon the relatives came with the local medicines and gave them to the child; the child’s condition worsened again. What caused the child’s death were the mother’s ignorance and the mixing of drugs.’’ (Clinical officer, Hosp. 8) In crowded wards nurses were often in the position of rationing attention or making judgements about the mothers’ competence and this was often resented by mothers if it was done in an uncaring way. Some mothers reported use of various coping strategies. ‘‘It is difficult for us to explain the child’s problem to the nurses, for example you can tell the nurse the child’s problem and she will answer, ‘you do not listen! Wait for the doctor and tell him’, this discourages us to ask anything.’’ (Mother, Hosp. 1)
‘‘There was a child who had burns around the stomach. We worked hard to see the child got better. The mother was very poor and did not have any clothes for her child so I brought clothes from home.’’ (Nurse, Hosp. 6) 3.2.3. Relations between mothers and staff While most mothers found staff to be friendly, there were a number of reports that some nursing staff were found to be too strict, uncaring or rude (Figure 2). Mothers were more likely to criticise nurses’ than doctors’ attitudes towards them. Nurses were more accessible, while medical staff
Figure 2 Opinions of caregivers on the attitude of staff during admission. CO: clinical officer; AMO: assistant medical officer.
Perceptions of paediatric hospital care in Tanzania ‘‘I try to be kind; for example there is a certain nurse who is so cruel and when I need her support I start with an apology because they like being flattered most of the time.’’ (Mother, Hosp. 10) ‘‘I was attending this child who had severe malaria and worked very hard every day to see the child improve, although initially I did not think he would survive. This particular day the child looked much better. When I went to give an injection, I saw the baby [nine months] at the edge of the bed almost falling down. When I looked for the mother, she was washing her hands on the sink and also chatting with another woman. But when I shouted to tell her to watch the baby, it almost fell but I was fast enough to catch it. I went to the mother and slapped her very hand I felt pain on my palm! I took the baby with me and gave him the injection and looked at him until my shift was over. It was pure negligence of the mother and had the baby fell on his head he would have died.’’ (Nurse, Hosp. 3)
4. Discussion Our study provides a snapshot of the human experience of the delivery of care for sick children where the burden of disease is high and resources very limited. While standards of technical care, both in these particular hospitals and in African hospitals generally, have been shown to be seriously deficient in a number of important areas mothers rarely reported this as a problem. It is possible that mothers of children who died (and were excluded for ethical reasons) may have had more to say but given that few mothers in our study had received more than primary education it is not surprising that mothers lacked awareness of what constitutes good standards of care and is consistent with a similar study in Kenya (English et al., 2004b). What concerned mothers most was ward hygiene, food and politeness of staff, while staff were most concerned with low pay, overwork and poor career prospects. Overcrowding and bed-sharing, blocked toilets and lack of food and cooking facilities were major concerns for mothers and these were likely to deter timely seeking of hospital care. Many of these concerns would require major investment to rectify but we also observed that minor repairs such as broken taps, non-functional sinks and blocked toilets remained unattended for extended periods. Although ward staff were aware of these, they did not report them with the same urgency as mothers or feel empowered to initiate action within the hospital system to correct them. We found a striking difference between health workers and mothers in accounting for delays in bringing sick children to hospital. Mothers avoided hospitals due to concerns around hygiene and food-related issues, while health workers consistently complained that children were brought too late due to the mothers’ ignorance and inappropriate use of medicines (either traditional or approved). Such assumptions of mothers’ ignorance are likely to restrict an understanding of the real and complex reasons for late presentation (Peterson et al., 2004) and tend to reinforce a hierarchy based on possession of technical knowledge. This undermines the personal agency of mothers and supports a
809 socio-cultural order that disadvantages the most vulnerable (Waitzkin, 1984). Staff morale is a crucial factor in the quality of care. We found that staff were acutely aware of demotivating factors in their work (low pay, overwork etc) but this was offset by the respect and gratitude they experienced from mothers and the community at large and this was of the utmost importance to them, a finding supported by other studies (Kyaddondo and Whyte, 2003). While in many cases such respect seemed to be justified by supportive and kindly treatment of mothers, there was a tendency to devalue mothers’ knowledge and competence that inherently elevated health workers’ own status. This appeared to be tolerated but certainly not welcomed by mothers, who appeared very sensitive to the way they were treated and reported flattery or wariness towards certain nurses as coping strategies. Staff attitudes have been found to be important in the perception of both the quality of care (Gilson et al., 1994) and the willingness to pay (Hanson et al., 2005) in other studies in Africa but in our study mothers seemed to have limited options to express these. Patients in any healthcare setting have two primary options for expressing dissatisfaction with services: voice or exit (LeGrand, 2006). In settings such as Tanzania, alternatives to the district hospital for inpatient care are few or non-existent and we did not find any functioning patient complaint systems at the hospitals studied. Empowering patients to make their voices heard when dissatisfied and strengthening management systems within health facilities to enable them to listen and to act may be effective in improving the delivery of both interpersonal and technical aspects of care. In our study, nurses were generally reported to be more authoritarian than clinical staff, with one nurse reporting that she’d found occasion to physically strike a mother. The reasons for this apparent difference between staff grades are not clear but may reflect nurses’ own vulnerabilities; while clinicians could gain respect from their clinical knowledge and authority to prescribe, lower cadres may feel the need to assert their authority more directly. In addition, nurses are closer to the day-to-day operation of the ward and are often reliant on the cooperation of mothers for ward cleaning etc. Evans (1994) has suggested that in requiring mothers to conduct menial rather than caring tasks, nurses can reinforce their own power while creating resistance among mothers, thereby widening the social gap between mothers and health workers. Mothers’ reports of interactions between themselves and health workers suggest a need for a more deliberate approach to ensuring that hospital staff have a deeper understanding of the problems faced by mothers, an understanding of which has been shown to correlate with indicators of quality of care and patient satisfaction (Cleary and McNeil, 1988; Christakis et al., 2002). In conclusion, our findings highlight how mothers and health workers experience the strains of caring for severely ill children in these settings. The problems of providing basic care with few resources can be exacerbated by dysfunctional and authoritarian attitudes towards mothers and there is a need for health planners and providers to become more aware of mothers’ experiences, particularly in relation to food, basic hygiene and the need to be treated with consideration and respect. While much remains to be done to
810 improve care in African hospitals, some of the problems perceived as most pressing by mothers can be tackled with modest additional resources and a greater awareness of their importance. Authors’ contributions: RM and HR conceived the study; RM, HR, CC, AP and IB designed the study; RM and HR supervised data collection; FN and HM collected the data; RM, HR, CC, AP, IB, FN and HM analysed the data; RM, HR, AP and IB interpreted the data; RM, HR and CC drafted the manuscript; AP, IB, FN and HM critically revised the paper. All authors read and approved the final manuscript. RM and HR are guarantors of the paper. Acknowledgements: The authors are grateful to the caregivers and their children who participated and to the research assistants of the Joint Malaria Program. We thank the Regional Medical Officer, District Medical Officers, and the hospital staff in the two regions and 13 districts for providing support and cooperation. Chris Whitty provided critical comments on the manuscript. Funding: The study was funded by a grant from the European Union SANTE/2004/078-607. Conflicts of interest: None declared. Ethical approval: The study was approved by the ethical review board of the National Institute for Medical Research in Tanzania (Approval No. NIMR: NIMR/HQ/R.8a IX/498).
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