East African Journal of Public Health East African Public Health Association ISSN: 0856-8960 Vol. 3, Num. 2, 2006, pp. 3-9

East African Journal of Public Heath, Vol. 3, No. 2, October 2006, pp. 3-9

PROVISION OF HEALTH INFORMATION AND ADVICE TO ADOLESCENT PATIENTS BY CLINICIANS IN ARUSHA, TANZANIA.

Melkiory C. Masatu^1,2, Gunnar Kvåle², and Knut-Inge Klepp³

Correspondence to: Melkiory C. Masatu, P.O.Box 1162 Arusha, Tanzania and Centre for International Health, University of Bergen, Norway: E-mail:cmasatu@cedha.ac.tz

¹Centre for Educational Development in Health  Arusha, ²Centre for International Health, University of Bergen, Armauer Hansen Building N-5021, Bergen, Norway, ³Department of Nutrition Research, University of Oslo,  P.O.Box 1046 Blindern, NO-0316 Oslo, Norway

Code Number: lp06008

Abstract

Objectives: To determine the extent to which clinicians provide health information and advice about prevention of STDs/HIV, pregnancy and substance use to adolescent patients; and investigate if clinicians’ demographic and practice-related factors are associated with provision of such information and advice.
Methods: Administration of questionnaire to 197 practicing clinicians in health facilities within two districts of Arusha region, Tanzania; investigating provision of health information and advice on STDs/HIV, pregnancy, and substance abuse to adolescent patients in the preceding 3 months. Demographic and practice-related information was collected from respondents. Logistic regression was used to assess if demographic and practice related factors were associated with providing information and advice.
Results: Sixty-four percent of clinicians regularly provided information and advice to adolescent patients about STDs/HIV, 49% about pregnancy and 45% about substance use prevention. Having often attended adolescents with STDs was positively associated with regular provision of information and advice about STDs/HIV, as well as regular provision of information and advice about pregnancy. Being a clinical assistant and having often attended adolescents with cigarette/alcohol-related problems were positively associated with regular provision of information and advice about substance use.
Conclusion: A substantial proportion of clinicians miss important opportunities to prevent disease and promote health of their adolescent patients. Future research should explore barriers to provision of health information and advice to adolescent patients who seek health care services.

Key words:Health information, health promotion, clinicians, adolescents, Tanzania

Introduction

A significant proportion of young people in Tanzania become sexually active at tender ages (1-3). Furthermore, sexuality-related problems such as sexually transmitted diseases (STDs) including HIV/AIDS (4,5) and unwanted pregnancies with associated complications (6,7) are prevalent among young people. Use of substances is another emerging problem in this age group (8,9). Such problems may cause death or long and recurring illnesses, reducing quality of life and the ability of young people to participate actively in various roles in the society. On the other hand, the adoption of healthy behaviours and lifestyles at a young age could have significant impact on health throughout the life span; and could, over time, represent a substantial long term saving in direct medical costs, indirect costs, as well as suffering (10).

Research in the Arusha region, Tanzania, has shown that 85% of school-going young people report having sought help from modern health care facilities at least once in two years, most of the visits being due to illness (11, 12). Visits to health facilities offer opportunities not only for treatment of presented illness, but also, provision of information and preventive advice for a variety of health problems affecting young people, such as those related to unhealthy lifestyles. Use of illness visits as opportunities for providing information and advice to patients in order for them to take preventive measures for health problems, besides prevailing illness, is an important primary prevention strategy.

This strategy is widely being used in developed countries for adults as well as adolescent populations (13-17), and has been found to be effective in promoting healthier behaviours (18,19). Its extent, determinants and potential barriers in developing countries has not been widely explored.

One study in Tanzania found that young people view clinicians as trusted sources of sexual and reproductive health information (20). In the Tanzanian health system clinicians are the foremost contacts for most patients who seek health care. Clinicians are medical or dental personnel, who examine, diagnose and prescribe treatment to patients. They comprise of several professional categories with varying level of medical or dental training. These include dental assistants, clinical assistants, clinical officers, assistant medical/dental officers, medical/dental officers, and medical/dental specialists. Medical/dental officers and medical/dental specialists are University graduates. Except for specialists working in government health facilities, the rest of the clinicians work as general practitioners. Nurses, health officers, pharmacists, X-ray or laboratory staff are not included in the clinician category. Thus, clinicians are well placed to promote health and prevent morbidity and mortality among patients.

 Understanding the extent to which clinicians provide information and advice to their adolescent patients, determinants of such practices and potential barriers, may shed light on what critical areas needs to be addressed in the training of health personnel and in the organization of health services delivery in order to promote adolescent health.

The current study examines the extent to which clinicians provide information and advice to their adolescent patients about prevention of STDs/HIV, pregnancy and substance use (alcohol, cigarettes). In addition, demographic and practice-related factors associated with the provision of information and advice are investigated.

Methods

Participants 

Study participants were recruited from government and privately owned health facilities within Arusha (urban) and Arumeru districts (rural), both located in Arusha region, northern Tanzania. At the time of this survey, there were 50 and 71 registered and functioning health facilities within Arusha and Arumeru district, respectively. The aim was to reach all health facilities and survey all clinicians who had been attending adolescent patients (age 10-19 years) in the preceding 3 months (inclusion criteria). All 50 health facilities in Arusha and 45 health facilities in Arumeru district were eventually reached. Twenty-six health facilities in Arumeru district could not be reached because the roads were impassable by car after being damaged by heavy rainfall. The total number of clinicians registered in the health facilities reached, were 131 for Arusha and 79 for Arumeru district. They were all given the questionnaire. Six clinicians, 2 in Arusha and 4 in Arumeru district, did not return the forms for unknown reasons. Seven participants (6 from Arusha, 1 from Arumeru district) have been excluded from analysis because they reported not attending any adolescent patient within the last 3 months. The analysis is therefore based on 197 participants, 123 from Arusha and 74 from Arumeru district. 

Procedure 

The Tanzanian Ministry of Health approved the research protocol. Permission to conduct the study was also obtained from medical authorities of Arusha and Arumeru districts. In addition, written consent for participating in the study was obtained from the respondents.

A self-administered questionnaire with a code unique for each health facility was handed directly to the participant by the research team whenever possible. Where it was not possible to hand it to the participant, the head of the health facility was given the questionnaire so that he/she hand it to the participant.

Participants were requested to complete the questionnaire in a one-week period. They were instructed to put the completed questionnaire in provided envelope and seal the envelope before handing it to the head of the health facility or returning it to the first author directly. After one week, the research team visited the health facilities to collect the forms that had not been returned. The majority of the respondents completed the questionnaire in the one-week period. For a few respondents, up to two follow-up visits were made in order to retrieve the forms. The six clinicians who did not return their forms after two follow-up visits were regarded as unwilling to participate. The data was collected from August through October 1998.

Instrument

The questionnaire, originally in English and translated into Kiswahili (national language in Tanzania), was developed by the research team. Clinicians were asked whether or not they had been attending adolescent patients (age 10 - 19 years) in the three months period preceding the survey, and if so, they were asked to indicate how often they attended such patients and their characteristics (sex and school status). Further, they were asked to indicate how often they attended adolescents who were pregnant, had sexually transmitted diseases or health problems related to the use of alcohol or cigarettes in the same period of three months. Also, they were asked how often in the past three months they had discussed with their adolescent patients (irrespective of presenting illness) about STDs/HIV, pregnancy, substance use (cigarettes, alcohol) and relevant prevention measures (responses 1 = Never, 5 = Always). In addition, respondents were asked to estimate the number of adolescents that they had advised to use condoms in order to avoid STDs or pregnancy, and also the number of adolescents they had advised not to take alcohol or smoke cigarettes during the previous month. Those who had not advised their adolescent patients to use condoms were asked to indicate one major reason for not doing so, based on a given list of possible options. The options were: it is against government policy, it is culturally/morally inappropriate, fear of making adolescents promiscuous, lack of skills, lack of time, lack of privacy at workplace and not part of clinicians' responsibility. Also included was the "others (specify)" option in order to allow participants to give reasons not listed.

Information regarding clinician's sex, age, marital status and religion was obtained. Also obtained were practice-related information namely; facility type, facility location, facility ownership, consultation place, average number of patient attended per day, average consultation time per patient and exposure to STDs/HIV or substance use counseling training.

Data analysis 

Chi-squared test was used to compare proportions. Factors associated with clinicians' provision of information and advice on STDs/HIV, pregnancy and substance use prevention (dependent variables) were assessed using bivariate and multivariate logistic regression. The dependent variables were defined as 1 = Regular provision of information and advice (original codes "always" or “often"), 0 = Irregular provision of information and advice (original codes "seldom", "rarely", or "never"). This dichotomization aimed at having adequate number of subjects in each cell to allow analysis and meaningful interpretation of the findings. Models were fitted for each dependent variable. Demographic and practice-related characteristics served as independent variables. In the multivariate analysis, adjustments were made for variables significantly associated with the dependent variable in the bivariate model and additional factors which had appreciable effect on the regression parameters. A p-value < .05 was considered statistically significant. Data were analysed using SPSS for Windows version 9.0 (21).

Results

Sample characteristics 

The majority of the clinicians were male and over 80% were under 45 years of age (Table 1). Female clinicians were more likely to be younger than male clinicians (female under 35 years of age 57%, male 28%; χ ²₍₁₎ = 13.8; p = 0.001). Clinical officers and those working in privately owned health facilities were in the majority. Fifty-one percent of the clinicians had some training on counselling about STDs/HIV, while only 10% had substance use counselling training (Table 1). Of the 100 clinicians who had exposure to STDs/HIV counselling training, only 2 said they had such training at the time they pursued medical studies. Also, of the 19 clinicians who had exposure to substance use counselling training, only 1 said the exposure occurred at the time of medical training.

Most clinicians were working in dispensaries, they attended on average 20 or more patients per day, and they were seeing patients in private rooms. Ninety-one percent of the clinicians reported consultation time per patient of 20 minutes or less (Tables 1). Clinicians working in private health facilities were more likely than those working in government facilities to have been exposed to STDs/HIV counselling training for a duration of 2 weeks or more (42% versus 26%; χ ²₍₁₎ = 4.9; p = 0.03). Similarly, clinicians working in dispensaries were more likely than those working in hospitals or health centres to have been exposed to STDs/HIV counselling training for a duration of 2 weeks or more (49% versus 25%; χ ²₍₁₎ = 11.7; p = 0.001).

Attendance of adolescent patients in the past 3 months 

In the past 3 months, all 197 clinicians included in the analysis had attended adolescent patients. Nearly all (98%) reported they attended both male and female adolescents, and a similar proportion reported that they attended in-school as well as out-of-school adolescents. Ninety-two percent of the clinicians reported having attended adolescent patients every workday or several times a week (Table 2). More than a third (36%) of the clinicians said they attended adolescents having STDs, while a third (33%) said they attended pregnant girls at least several times a week in the past 3 months (Table 2). More than half of the clinicians said they did not attend any adolescent having cigarette or alcohol-related health problems in the past 3 months (Table 2).

Table 1. Demographic and practice characteristics of participants (n = 197)

*Total number may not add up to 197 owing to missing data
Percentages are rounded to nearest whole number
STDs = sexually transmitted diseases;  HIV = human immune deficiency virus

Table 2. Attendance of adolescent patients in the past 3 months (n = 197)

 Provision of information and advice 

Table 3 shows the percent of clinicians reporting having provided information and advice to adolescent patients regarding prevention of STDs/HIV, pregnancy and substance use in the past three months. Provision of information and advice was common practice in relation to STDs/HIV, with 64% of clinicians asserting that they regularly ("always" or "often") did so; compared to 49% and 45% for pregnancy and substance use, respectively.

Information regarding the number of adolescents advised to avoid use of alcohol/cigarettes and the number of adolescents advised to use condoms in the previous month was available for 194 clinicians. Of these, 87 (45%) said they advised between one and five adolescents to avoid alcohol/cigarette use, 25 (13%) advised between 6 and 10, 21 (16%) advised more than 10 and the remaining 51 (26%) did not advise any. Regarding condoms, 91 (47%) clinicians said they advised between one and five adolescents to use them in the previous month, 28 (14%) advised between 6 and 10, 35 (18%) advised more than 10 and the remaining 40 (21%) did not advise any.

Advising about condom use was significantly associated with professional category and attendance of adolescents having STDs. After adjusting for attendance of adolescents having STDs, the category including assistant medical officers, medical officers and specialists was significantly less likely to advise about condom use than clinical assistants (OR = 0.1, 95% CI, 0.04 to 0.5). Clinicians who often (daily/several times a week) attended adolescents having STDs were significantly more likely to advise about condom use than those who seldom (once a week/occasionally/never) attended adolescents having STDs (OR = 3.8, 95% CI, 1.5 to 9.3).

The reasons for not advising condom use to adolescent patients in the previous month were given by 38 of the 40 respondents who did not provide such advice. The reasons, with the number of respondents in parenthesis, were: it is culturally/morally inappropriate (10), fear of making adolescents promiscuous (7), lack of skills (5), lack of time (3), lack of privacy at workplace (1), not part of clinicians' responsibility (2) and patient did not raise the issue (10).

Table 3. Provision of information and advice to adolescent patients in the past 3 months (n= 197)

Percentages are rounded to nearest whole number
STDs = sexually transmitted diseases;  HIV = human immune deficiency virus-

Factors associated with advising regularly on STDs/HIV, pregnancy and substance use prevention

Factors associated with advising regularly on STDs/HIV, pregnancy and substance use prevention were investigated using all the variables shown in Table 1 and Table 2. But, only variables with significant findings in the bivariate analysis are presented in Table 4. In the bivariate logistic regression analysis, having received STDs/HIV counselling training for duration of two or more weeks, working in a dispensary, working in a privately owned health facility, having often (daily/several times a week) attended adolescents having STDs, and having often attended pregnant adolescents were positively associated with regularly advising on STDs/HIV prevention (Table 4). After adjusting for other predictors (exposure to STDs/HIV counselling training, facility type, facility ownership, attendance of adolescents having STDs and attendance of pregnant adolescents if appropriate), only the association between attendance of adolescents having STDs and regular provision of information and advice about STDs/HIV prevention persisted. Clinicians who often attended adolescents having STDs were significantly more likely to regularly advise on STDs/HIV prevention than those who seldom (once a week/occasionally/never) attended adolescents having STDs (OR = 3.5, 95% CI, 1.6 to 7.9).

In the bivariate logistic regression analysis, clinicians who often attended adolescents having STDs were significantly more likely to regularly advise on pregnancy prevention than those who seldom attended adolescents having STDs (Table 4). The association between attendance of adolescents having STDs and advising regularly on pregnancy prevention was retained after adjusting for clinicians' sex, attendance of pregnant adolescents and attendance of adolescents having cigarette/alcohol-related problems (OR = 2.7, 95% CI, 1.3 to 5.4).

In the bivariate logistic regression analysis, advising regularly on substance use was associated with professional category and attendance of adolescents having cigarette/alcohol-related health problems (Table 4). These associations were retained after adjusting for age, professional category and attendance of adolescents having cigarette/alcohol-related health problems as appropriate. The category including assistant medical officers, medical officers and specialists was significantly less likely to advise regularly about substance use prevention than clinical assistants (OR = 0.2, 95% CI, 0.07 to 0.6). Furthermore, clinical officers were also significantly less likely to regularly advise on substance use prevention than clinical assistants (OR = 0.4, 95% CI, 0.2 to 0.8). Clinicians who often attended adolescents having cigarette/alcohol-related health problems were significantly more likely to regularly advice on substance use prevention than those who seldom attended adolescents having cigarette/alcohol-related problems (OR = 5.9, 95% CI, 1.8 to 19.6)

Factors which were not significantly associated with advising regularly on STDs/HIV, pregnancy and substance use prevention were: age, marital status, religion, exposure to substance use counselling training, location of health facility, patient workload per day, consultation place and consultation time per patient.

Table 4. Factors associated with regular provision of information and advice about STDs/HIV, pregnancy and substance use prevention in the past 3 months

Percentages are rounded to nearest whole number
OR = odds ratio; CI = confidence interval; STDs = sexually transmitted diseases;  HIV = human immune deficiency virus
AMO = assistant medical officer; MO = medical officer; SP = specialist---

Discussion

Ideally, every contact with clinicians provides an opportunity for disease prevention and health promotion. The finding in this study that 64%, 49% and 45% of clinicians regularly advised their adolescent patients about STDs/HIV, pregnancy and substance use prevention, respectively, is a step in the right direction. But, it is worrying that only 18% of the clinicians had advised more than 10 adolescent patients regarding condom use in the previous month, despite that 51% of the clinicians had attended an adolescent patient every workday (equivalent to at least 20 adolescents being seen a month). This clearly indicates that most adolescents are not being advised on condom use.

Regular provision of advice was relatively higher for STDs/HIV than pregnancy or substance use prevention. This difference may be due to the fact that from July 1995 to January 1997, two-weeks refresher courses about management of sexually transmitted diseases using a syndrome approach were conducted in several regions in Tanzania including Arusha. These courses targeted clinicians working in private health facilities, and one of the course contents was education and counselling of patients with STDs regarding their sexual behaviour (22). As found in our study, 37% of the respondents reported having been exposed to STDs/HIV counselling training for two weeks or more. Thus, it is plausible that most of these clinicians attended the above-mentioned course and were practising the skill. Indeed, a study of clinicians who attended the above-mentioned course (who were practising in Arusha and Kilimanjaro regions), reported that 95% of the clinicians claimed they were applying the skill of patient education and counselling most of the time (22).

Advising regularly on STDs/HIV prevention was associated with exposure to STDs/HIV counselling training, type of the health facility and ownership of the facility in the bivariate but not in the multivariate analyses, after simultaneous adjustment for the effect of these variables. This can be explained by the fact that majority of the clinicians who had exposure to STDs/HIV counselling training were working in privately owned dispensaries. Most of these clinicians might have undergone the course on syndromic management of STDs mentioned earlier (22). Therefore, the association between facility type and regularly advising on STDs/HIV prevention, as well as the association between facility ownership and regularly advising on STDs/HIV prevention, noted in the bivariate logistic regression analysis, is an effect of exposure to STDs/HIV training.

Clinicians' professional category was associated with provision of condom use advice and also with regularly advising on substance use prevention. Clinical assistants were significantly more likely to provide condom use advice and regularly advice on substance use prevention than clinical officers or the category including assistant medical officers, medical officers and specialists. According to the training programme in Tanzania, clinical assistants receive less intensive medical training compared to clinical officers, assistant medical officers, medical officers or specialists. Given this fact, one would expect clinical officers and the category comprising of assistant medical officers, medical officers and specialists to engage in preventive work more than clinical assistants, but this was not the case. The reasons for this discrepancy are unclear.

In this study, advising on STDs/HIV prevention in the past three months and on condom use in the previous month were associated with the rate at which clinicians attended adolescents having STDs. Similarly, advising on substance use prevention in the past three months was associated with the rate at which clinicians attended adolescents having cigarette/alcohol-related health problems. These findings suggest that most clinicians were preferentially targeting advice to adolescents who had symptoms of a particular problem. This practice is common among physicians (23-25). However, the practice has been criticised by other people; arguing that it is often too late for the desired behaviour change to be effective (25).

Studies have indicated that younger (14) as well as female physicians (15,17,26,27) may be more involved in preventive practice. Our findings did not confirm this.

Health workers cite a number of obstacles to providing disease prevention information and advice to all patients during illness visits, including providers' lack of knowledge and skills, time constraints owing to heavy workload, perception that the topics may be irrelevant to patients, and thinking that such practice is not part of their responsibility (28,29). Other barriers are provider's lack of confidence in being effective in this approach and concern that the approach may jeopardize the doctor-patient relationship (25). In our study lack of skills, lack of time, and thinking that it is not part of clinician’s responsibility were mentioned by respondents as reasons for not advising all adolescents on condom use. However, reasons for not advising on STDs/HIV, pregnancy and substance use prevention were not investigated. Thus, future studies should ellucidate such factors.

Some limitations are worthy noting when interpreting the findings of this study. First, clinicians were only asked whether or not they discussed with their adolescent patients about STDs/HIV, pregnancy, substance use and relevant prevention measures. The detail of the discussion, such as, who initiated it, what specific prevention measures were discussed, and quality of information given is unknown. Secondly, generalizability of the results is limited since the sample was small and drawn from a localized geographical area. Also, some eligible clinician did not take part in the study because they were inaccessible. The small sample size also reduced the power of the study to detect statistically significant differences among some participants' subgroups. Thirdly, as with any study utilizing self-reports, clinicians' responses regarding provision of information and advice may not accurately reflect their actual practice. Previous research has found that physicians over-report their practices (14).

Despite these limitations, our study provides important information with implications for clinicians' training and future research. A substantial proportion of clinicians has never been trained on counselling about STDs/HIV, and even fewer clinicians, on substance use. Given the vulnerability of adolescent population to sexuality and substance use-related problems, it is important that clinicians' basic and continuing education training programmes incorporate counselling training on health risk behaviours as an essential part of the curriculum.

Many demographic and practice-related factors investigated in this study were not significantly associated with provision of information and advice to adolescents by clinicians, suggesting that other factors may be operating. Future work should explore factors such as clinicians' attitudes, subjective norms, and self-efficacy in provision of information and advice to adolescent patients. These factors have been found to predict health practitioners' counselling of young adults (30) and children (31).

In conclusion, a substantial proportion of clinicians miss important opportunities to promote the health of their adolescent patients. There is need for clinicians to seize every opportunity of interacting with adolescents in health care facilities and offer health education and preventive advice to them. Future research should investigate barriers to provision of information and preventive advice to adolescent patients about STDs/HIV, pregnancy and substance use during illness-related visits to health care facilities.

Acknowledgements

We thank the Norwegian Council of Universities' Programme for Development Research and Education for funding the research. We are grateful to all respondents and to Mrs. Florence Eseko and the late Miss. Caroline Sangiwa for invaluable support in data collection.

Conflicts of interest

The authors do not have any conflicting interests

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