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Background: Adolescents in Tanzania are at risk of many health problems attributed to limited access to quality sexual and reproductive health services. Health professionals are a crucial part of service delivery, and their perspective on providing care is important in understanding the barriers that hamper access to sexual and reproductive health services for adolescents. Better understanding these barriers will support the development of more effective interventions. This paper explores these perspectives in view of the health-policy context that surrounds them. Objective: This study has aimed to explore and understand health professionals’ perceptions and attitudes regarding the provision of adolescent sexual and reproductive health care in a selected national sexual and reproductive health programme in the Arusha region and Kilimanjaro region, Tanzania. Methods: A qualitative cross-sectional interview design was applied. Sixteen in-depth interviews were conducted with health professionals and community health workers. Data was analysed following inductive thematic analysis. Results: Four main themes are identified in the data: concern about the stigma directed towards adolescents; over-medicalisation of services; difficulty involving adolescent males; and ambiguous policies and contradictory messages. The findings suggest that health professionals providing care in the current adolescent sexual and reproductive health programme must navigate the legacy of vertical health programmes as well as contradicting views and messages that are influenced by social norms, by uncertainties about current laws and by statements from political leaders. Conclusions: The findings suggest that future research, policies and health programmes should consider the perspectives of health professionals and their challenges in delivering care for adolescents to help improve the understanding of how to effectively and sensitively implement sexual and reproductive health programmes for adolescents.
This qualitative study explores the perceptions and attitudes of health professionals providing adolescent sexual and reproductive health care within a national adolescent sexual and reproductive health programme (2018–2020) in the Arusha, Hai, and Moshi districts. This programme is implemented by the Evangelical-Lutheran Church in Tanzania (ELCT), supported by the Church of Sweden, which aims to improve access to sexual and reproductive health information and to provide education and services to adolescents at ten hospitals in ten districts in Tanzania. The ELCT is the second largest church in Tanzania, with 26 dioceses throughout the county. The church is responsible for several national programmes and interventions and provides several public health services such as health- and education services. By implementing a sexual and reproductive health programme for adolescents, the ELCT aims to complement the government’s National Road Map Strategic Plan to Improve Reproductive, Maternal, New-born, Child & Adolescent Health in Tanzania (2016–2020) [32]. Three rural district hospitals were randomly selected by SB and NP for this study: Marangu Lutheran Hospital in Arusha district (Arusha region), Machame Lutheran Hospital in Hai district (Kilimanjaro region) and Selian Lutheran in Moshi rural district (Kilimanjaro region). Two offices at the ELCT Health Department in the city of Arusha were selected for data collection with health professionals working with adolescent sexual and reproductive health at the community level. Purposive sampling was applied to ensure that data was collected with participants matching the specific inclusion and exclusion criteria [33]. Inclusion criteria were that participants should be health professionals, aged 18 years and above, responsible for any sexual and reproductive health service for adolescents or should work within the current programme under the ELCT. Furthermore, all participants had to have been working at the ELCT for at least 1 year. Individuals were excluded if below 18 years of age and if having less than 1-year work experience with sexual and reproductive health care and activities for adolescents. There was an element of snowball sampling involved, whereby some key persons were referred to by those involved in the health programme. A heterogeneous sample [33] was chosen to include individuals with different occupations, education, gender, and work areas to gain diversity in perceptions and experiences. Furthermore, health professionals working at the community level, as well as at the facility level, were included to gain further diversity. A description of the participants is provided in Table 1. Participants included key persons affiliated with the delivery of health services within the adolescent sexual and reproductive health programme, including 9 health professionals working at the district hospitals and 7 community health workers. Eleven females and 5 males are included in the sample, but to protect anonymity, the gender of each participant is not revealed. All participants were contacted by phone or email or were approached at their offices by NP, who is a social worker at the ELCT Health Department with knowledge of health professionals’ roles at the hospitals and ELCT offices. Employees at the hospitals supported NP with the selection of participants who fit the inclusion and exclusion criteria for the study. Participants working at the ELCT Health Department were selected by SB and NP based on inclusion and exclusion criteria. Summary of characteristics of participants. Confidentiality, anonymity and the dissemination strategy were communicated in information sheets and verbally explained. Each participant was informed about their right to withdraw consent or participation at any stage of the interview or study. Data was collected by SB on audio tape using in-depth interviews to understand health professionals’ perceptions of delivering adolescent sexual and reproductive health services [34]. The topic guide (Annex 2) included some open-ended questions but primarily focused on allowing health professionals to describe examples of providing care to adolescents. Probing was used to explore topic themes covered in the literature – for example, their experience of policy and laws and issues related to stigma. One new topic was added after two interviews, which was the role of men when providing services to women. The topic guide was pilot-tested by SB one time with staff at the ELCT Health Department office and was revised after feedback from NP. The pilot interview was not included in the analysis or results. Data collection was conducted in private rooms at the hospitals or at the participants’ respective offices. Interviews were conducted in English when participants felt comfortable and able to do so. A Swahili interpreter was present in three interviews because of language restrictions. The interviews lasted from 21 minutes to 1 hour and 21 minutes. Data saturation was reached when no additional data was being found in successive interviews [33]. In the 14th interview, no new themes were being generated, and it was decided that the data collection had reached saturation. Data collection then continued for two further interviews to ensure and confirm that no new topics emerged. Data was analysed by employing qualitative thematic analysis inspired by Saldaña’s manual for qualitative research [35]. The coding process was performed in NVivo 12. This study is situated in the constructivist paradigm [36,37] to understand the social world of the participants through interpretation of the attitudes and perceptions of health professionals in the context of their practice. An inductive approach was therefore used to analyse the data. The interviews were transcribed verbatim by SB. Transcripts were initially read through several times to gain an understanding of the material by paying attention to repeated patterns of meanings in the interviews. SB performed three rounds of coding. SH performed two rounds of coding. Codes were compared throughout the process, and a coding tree was agreed upon. The procedure of coding and categorizing was done iteratively before the final themes were created. An example of the coding tree is presented in Table 2. Example of moving from text via codes to category and theme. The methods section transparently describes each step of the research process to strengthen the dependability of the research process. SB took extensive notes and wrote a diary to ensure reflexivity was practiced during the data collection. Diary notes were discussed during the analysis procedures to reduce inter-subjectivity and to secure confirmability and credibility. Several rounds of coding by SB and SH were further conducted to increase credibility and confirmability. The above description of this study’s methods enables the results to transfer more easily to similar settings. However, for the results to be transferable to a more diverse sample, a selection of various facilities would be required.
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