A Qualitative process evaluation of training for non-physician clinicians/ associate clinicians (NPCs/ACs) in emergency maternal, neonatal care and clinical leadership, impact on clinical services improvements in rural Tanzania: The ETATMBA project

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Study Justification:
The study, titled “A Qualitative process evaluation of training for non-physician clinicians/ associate clinicians (NPCs/ACs) in emergency maternal, neonatal care and clinical leadership, impact on clinical services improvements in rural Tanzania: The ETATMBA project,” aimed to explore the implementation of a training program for non-physician clinicians in Tanzania, its reception, and its impact on clinical practice. The study was conducted to assess the effectiveness of the training program and identify challenges faced in its implementation.
Highlights:
– The training program was well received by the trainees, resulting in increased knowledge and skills.
– The study found evidence that the training program had a positive impact on health outcomes, such as maternal and neonatal mortality.
– Trainees shared their new knowledge and skills with others, contributing to the improvement of healthcare in the country.
Recommendations:
– Provide better support and resources to non-physician clinicians to enable them to make a greater contribution to healthcare in Tanzania.
– Address ongoing challenges related to infrastructure, including upgrading facilities, ensuring access to electricity and water, and providing basic supplies and drugs.
Key Role Players:
– Non-physician clinicians/associate clinicians (NPCs/ACs)
– District medical officers (DMOs)
– Trainers
– Research scientists from the Ifakara Health Institute (IHI)
– Research assistants
– Principal investigator
– Management/oversight from Warwick, UK
Cost Items for Planning Recommendations:
– Upgrading facilities
– Ensuring access to electricity and water
– Providing basic supplies and drugs
– Training and capacity building for non-physician clinicians
– Research and evaluation activities
– Monitoring and supervision of the training program
– Communication and coordination between stakeholders

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative process evaluation, which provides valuable insights into the implementation and acceptability of the ETATMBA training program. The abstract mentions interviews with various stakeholders, including trainees, district medical officers, colleagues, and trainers. The results indicate that the training was well received, increased knowledge and skills, and had an effect on health outcomes. However, there are challenges related to infrastructure and the availability of basic supplies and drugs. To improve the strength of the evidence, it would be beneficial to include more specific details about the interview process, such as the number of interviews conducted, the selection criteria for participants, and the interview questions used. Additionally, providing more specific examples of how the training has led to changes in clinical practice would further support the findings.

Objectives: The Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival in sub-Saharan Africa (ETATMBA) project is training non-physician clinicians as advanced clinical leaders in emergency maternal and newborn care in Tanzania and Malawi. The main aims of this process evaluation were to explore the implementation of the programme of training in Tanzania, how it was received, how or if the training has been implemented into practice and the challenges faced along the way. Design: Qualitative interviews with trainees, trainers, district officers and others exploring the application of the training into practice. Participants: During late 2010 and 2011, 36 trainees including 19 assistant medical officers one senior clinical officer and 16 nurse midwives/nurses (anaesthesia) were recruited from districts across rural Tanzania and invited to join the ETATMBA training programme. Results: Trainees (n=36) completed the training returning to 17 facilities, two left and one died shortly after training. Of the remaining trainees, 27 were interviewed at their health facility. Training was well received and knowledge and skills were increased. There were a number of challenges faced by trainees, not least that their new skills could not be practised because the facilities they returned to were not upgraded. Nonetheless, there is evidence that the training is having an effect locally on health outcomes, like maternal and neonatal mortality, and the trainees are sharing their new knowledge and skills with others. Conclusions: The outcome of this evaluation is encouraging but highlights that there are many ongoing challenges relating to infrastructure (including appropriate facilities, electricity and water) and the availability of basic supplies and drugs. This cadre of workers is a dedicated and valuable resource that can make a difference, which with better support could make a greater contribution to healthcare in the country.

A qualitative process evaluation (interviews) exploring the implementation and acceptability of the ETATMBA training programme from the perspective of a number of stakeholders including the trainees, the trainees’ district medical officers (DMOs), colleagues (whom they have cascaded ETATMBA skills to) and their trainers. Evidence of changing clinical practice was also explored. The research team was mainly composed of Research Scientist from the Ifakara Health Institute (IHI) Dar es Salaam, Tanzania. The primary data collection team consisted of two local research assistants (AS and FM) based at IHI. Both of the research assistants had great experience in qualitative research. The principal investigator at the IHI (GM) gave support to the local team while management/oversight was provided by DRE from Warwick, UK. During late 2010, early 2011, 36 trainees (AMOs and nurse midwives/nurses (anaesthesia)) were recruited from districts across Tanzania and invited to undertake the ETATMBA training programme (see web appendix for more information).1 While there was some attrition (eg, withdrawal from the training), the remaining trainees represent the sample from which we invited all to participate in evaluation interviews. In addition, we identified a number of DMOs and cascadees to be involved in interviews from facilities where trainees had been working. A cascadee was a nurse, midwife, AMO or CO with whom ETATMBA trainees shared their ETATMBA skills and knowledge. We also purposively invited a number of the local training facilitators to be interviewed. As a first step, the researchers identified the facilities where trainees were based. A letter of invitation including an information sheet and a copy of a consent form was then sent via email to all trainees from the IHI. Second, letters and information to the DMOs were similarly emailed. The letter had two purposes: first to inform them about our research in general, and second to invite them to participate. A copy of the consent form was included. In recognition that Tanzania is a very large country and road access is at times problematic, the research team arranged a ‘grand tour’ of all of the included districts and health facilities. This was undertaken in January/February 2014. This limited the opportunities to carry out interviews with everyone. In all districts the researchers invited all of the available trainees, cascadees and DMOs for interview. The research team developed an interview guide prior to the ‘grand tour’ that was used in all interviews. It was designed to cover the whole experience surrounding the training and specifically pressed for actual examples as evidence of changing practice. It was not enough for the trainee in the interview to just to say ‘yes’ or ‘no’ when questioned about the training; we encouraged them to provide specific examples. The semistructured Interviews were carried out at or near the health facilities at mutually agreeable times and held in a quiet private room during the researcher’s visit; confidentiality was assured. The IHI researchers conducted most of the interviews in Kiswahili to ensure no loss of meaning in expressions. English is officially the second language in Tanzania but it is commonly spoken and all of the trainees have good levels of English; however, it was found that they were more comfortable using Kiswahili. There were no formal inclusion exclusion criteria for this evaluation as we were targeting specific populations. Those outside these groups were not invited. Interviews were digitally recorded, subject to the permission of each participant and, where transcribed, verbatim. Recordings were stored in a secure digital environment accessible only to members of the research team. Participants were not identified by name; instead, a participant code number was used to identify transcripts. Data were analysed using the Framework method described by Ritchie and Spencer13 and Pope and Mays14 (see box 1). * Adapted from Ritchie and Spencer.13 The computer package NVivo V.10 was used to facilitate this process. The data were coded by the local researchers (AS and FM). Researcher bias was minimised through regular cross-checking of data and findings by the members of the research team DRE in the UK provided validation of themes. We note here that analysis of the process evaluation data (the interviews) was carried out before and without the knowledge of results from the quantitative studies (which will be reported elsewhere). Quotations are used as exemplars of themes. Each quotation has an identifier. The ‘ETATMBA trainer’ is identified thus, as are the three Obstetricians. Trainees are identified as T, followed by their profession, for example, NPC/AC, NA (anaesthetic nurse), NMW (nurse midwife) and finally a number (1–27). Cascadees (those who have received training from our trainees) are identified by CA and a number (1–12). DMOs and doctors in charge are identified as managers (MA) and a number (1–5). The study was reviewed and approved by the Biomedical Research Ethics Committee (BREC) at the University of Warwick, UK (REGO-2013-572) and The National Institute for Medical Research, Institutional review board, Dar es Salaam, Tanzania (no.35, dated 9 March 2012).

The ETATMBA project in Tanzania is an innovative training program that aims to improve access to emergency maternal and newborn care by training non-physician clinicians as advanced clinical leaders. The program has several key features:

1. Training non-physician clinicians: The program focuses on training assistant medical officers, senior clinical officers, and nurse midwives/nurses in emergency maternal and newborn care. By equipping these non-physician clinicians with advanced skills, they can provide essential care in rural areas where access to doctors may be limited.

2. Qualitative process evaluation: The project includes a qualitative evaluation component, which involves conducting interviews with trainees, trainers, district officers, and other stakeholders to assess the implementation and impact of the training program. This evaluation helps identify challenges and areas for improvement.

3. Cascading of skills: Trainees are encouraged to share their new knowledge and skills with others, such as nurses, midwives, and other healthcare professionals. This cascading approach helps to expand the reach of the training program and improve access to emergency maternal and newborn care across different healthcare facilities.

4. Local research team: The project involves collaboration between the Ifakara Health Institute in Tanzania and researchers from the University of Warwick in the UK. This partnership ensures local expertise and knowledge are utilized in the implementation and evaluation of the training program.

5. Infrastructure and resource challenges: The evaluation highlights ongoing challenges related to infrastructure, including the availability of appropriate facilities, electricity, water, and basic supplies and drugs. Addressing these challenges is crucial to fully leverage the skills and knowledge of the trained non-physician clinicians.

Overall, the ETATMBA project demonstrates an innovative approach to improving access to maternal health by training non-physician clinicians and evaluating the implementation and impact of the training program. By addressing infrastructure challenges and promoting the cascading of skills, this project has the potential to make a significant contribution to healthcare in rural Tanzania.
AI Innovations Description
The recommendation to improve access to maternal health based on the ETATMBA project is to address the ongoing challenges related to infrastructure, availability of basic supplies and drugs, and support for the cadre of non-physician clinicians/associate clinicians (NPCs/ACs) trained in emergency maternal and newborn care.

1. Infrastructure: Improve the facilities, including upgrading health facilities, ensuring access to electricity and water, and creating appropriate spaces for maternal and neonatal care. This will enable trained NPCs/ACs to practice their new skills effectively.

2. Availability of supplies and drugs: Ensure a consistent and reliable supply of basic medical supplies and drugs in health facilities. This will enable NPCs/ACs to provide quality maternal and newborn care.

3. Support for NPCs/ACs: Provide ongoing support and mentorship for NPCs/ACs to enhance their clinical leadership skills and ensure the sustainability of the training program. This can include regular supervision, continuing education opportunities, and opportunities for professional growth.

By addressing these recommendations, the ETATMBA project can have a greater impact on improving maternal health outcomes in rural Tanzania and beyond.
AI Innovations Methodology
The ETATMBA project aims to improve access to emergency maternal and newborn care in rural Tanzania through training non-physician clinicians as advanced clinical leaders. The project conducted a qualitative process evaluation to explore the implementation of the training program, its impact on clinical practice, and the challenges faced.

The methodology used in the evaluation involved conducting interviews with various stakeholders, including trainees, district medical officers, colleagues who received cascaded training, and trainers. The research team consisted of research scientists from the Ifakara Health Institute in Tanzania, with support from the principal investigator at IHI and oversight from a researcher from Warwick, UK.

The evaluation included 36 trainees who were recruited from districts across Tanzania and invited to participate in the ETATMBA training program. Interviews were conducted with trainees, cascadees, DMOs, and trainers to gather their perspectives on the training program and its implementation. The researchers developed an interview guide to cover the entire training experience and encouraged participants to provide specific examples of how the training had influenced their practice.

Interviews were conducted in Kiswahili, the local language, to ensure clear communication and were digitally recorded with participants’ permission. The data were analyzed using the Framework method, which involved coding the data and identifying themes. The analysis was carried out by the local researchers, with regular cross-checking and validation of themes by the research team.

The evaluation highlighted the positive reception of the training program and the increase in knowledge and skills among trainees. However, it also identified challenges related to infrastructure and the availability of basic supplies and drugs. The evaluation provided valuable insights into the implementation of the training program and its impact on health outcomes, such as maternal and neonatal mortality.

Overall, the qualitative process evaluation provided a comprehensive understanding of the ETATMBA training program’s implementation and its effects on clinical practice. The findings can inform future improvements in the program and highlight the importance of addressing infrastructure and resource challenges to enhance healthcare delivery in rural Tanzania.

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