Journal of Advanced Nursing, 1978, 3 , 437-446
Student nurse rural fieldwork in mainland Tanzania Pamela A. Smith B.Nurs. Cert. Ed. Community Nurse Tutor, Institute ofMedical and Paramedical Sciences, Maputo, Mozambique
Axepted for publication 15 February 1978
SMITH P. A. {igjS) Journal of Advanced Nursing 3, 437-446
Student nurse niral fieldwork in mainland Tanzania The development of the health services in the majority of underdeveloped countries during the colonial period, and immediately after independence, have concentrated on providing a largely hospital-based curative programme. This has also included training of the local population, particularly as nurses, to carry out this programme. Figures show that, for the African region of the World Health Organization (WHO), nursing personnel form a significant group of trained health manpower (WHO 1973). The objective of this paper, therefore, is to raise the question of whether nurses in underdeveloped countries should continue to be trained mainly for their traditional tasks of caring for the sick in hospitals, or whether the majority of them should be channelled into other types of work more appropriate to the major needs of the population. In order to reach this objective, an example is given of the Tanzanian experience 15 years after independence, including a description of a community health project involving a group of student nurses in the rural areas of mainland Tanzania.
THE S O C I O E C O N O M I C C O N T E X T OF H E A L T H C A R E IN THE U N D E R D E V E L O P E D W O R L D The nature of disease in underdeveloped countries, which confronts the majority of health workers, is a direct result of poverty and a low standard of living. Hence, the development of health services in themselves can do very little to eradicate disease if the underlying causes remain. The origin of many of these causes may be found during the colonial era when the major aim of the government was to use the colony as a cheap source of raw materials (like coffee, tea and cotton) and minerals for exportation to the industrial centres of the USA and Europe. The colony was also used as a cheap source of labour for work in mines and plantations, with the result that all internal development largely reinforced this aim. In most ex-colonies today, the population is predominandy rural (80-90%) with a low standard of living from low level peasant agricultural production, and a suprastructure providing a minimum of health, education, transport, and other services. These services are only relatively well-developed in small urban enclaves. 0309-2402/78/0900-0437 $02.00© 1978 Blackwell Scientific Publications
437
438
P. A. Smith
Given these conditions, infectious diseases and subnutrition are the common health problems which affect the young age groups. Forty to 45% of the population is under 15 years of age and one in four children will never reach 5 years of age. Pneumonias, protein-calorie deficiency (kwashiorkor and marasmus), and diarrhoeas are cited as the three big killer diseases responsible for this (Jelliffe 1966a). Measles and malaria also take their toll. Furthermore, nutritional anaemia and intestinal parasites play an important role in death and disease, not only during childhood but also during pregnancy and labour (women of childbearing age constituting another 20-25% of the total population). Maternal and child health services are thus a major priority, but midwives have been trained, (along with doctors, medical assistants and nurses) to staff hospitals and dispensaries to treat the population usually from a context of treating sickness rather than promoting health. Health officers, trained specifically to carry out preventative programmes such as vaccination, health education (including nutrition) and environmental sanitation, have been significantly few in number and mainly urban-based. The traditional division between curative and preventative medicine has thus been propagated by colonialism and explains some of the problems involved in formulating new health policies in many countries since achieving independence. C H A R A C T E R I S T I C S OF THE T A N Z A N I A N HEALTH S E R V I C E S : B A C K G R O U N D T O T H E FIELDWORK PROJECT
Training of health personnel As the training of local health personnel in Tanzania had taken place since the early 1930s, at independence there was a considerable number of already qualified staff with a minimum of 7-8 years schooling. Table i (Chagulla & Tarimo 1975) demonstrates the development of manpower since that time.
TABLE I
Health manpower development in Tanzania
Cadre
Maternal and child health aide/village midwife Health auxilliary Nurse/midwife/psychiatric nurse (Section A) Nurse (Section B) Rural medical aide Medical assistant Assistant medical officer Doctor (Tanzanian) Doctor (Foreign) Total
1961 1969 1971 1973
Projection 1980
400
545
650
750
2500
150
180
230
325
800
683 838 934 1619 2110 2690
380
462
544
621
200
249
289
335
i960 4100 2800 1200
32
103
"5
140
300
12
90
155 324
231 302
700
338 984
413 355 2909 4286 5255 6328
130
14490
Student nurse rural fieldwork experience
439
It can be noted that preventative health personnel have always been a small minority of the total trained manpower. This should be seen in the context of Tanzania being one of the world's poorest countries with a very high infant mortality rate of 160 per 1000 live births per year and with poverty-linked diseases such as infections, parasites and subnutrition, all of which are preventable, being responsible for a large percentage of hospital admissions and deaths (Ministry of Health, Dar-es-Salaam 1970). As can also be noted from Table i, attempts have been made to change this orientation by the formulation of recent policies to increase the number of maternal and child health auxiliaries and medical assistants who will work in the rural areas where about 90% of the population live. However, by 1973 there was no significant change though projections for 1980 aim to alter this situation—the i year course for auxiliary (village) midwives, for example, has been replaced by a more comprehensive training for maternal and child health aides and this new course emphasizes the importance of prevention in the care of under-5s, and pregnant and nursing mothers.
The organizational structure for the delivery of health care As the majority of the rural population live more than 10 kilometres from a hospital, this means that only a few actually have access to health care, given the difficulty of transport and lack of roads (Thomas & Mascarenhas 1973). Figure i illustrates how this problem could be overcome. Level
Existing number
Under construction
1
National referral hospital
2
Regional hospital
138
3
District hospital
4
Health centres
129
52
5
Dispensaries
1670
149
6
1 t t t
First aid posts
Not known
Not known
t
FIGURE I Health and care network in Tanzania on 1 January 1975 (2 way communication system).
There will be few units of levels i, 2 and 3, mainly urban, with the aim to give back-up and support to the many units at levels 4, 5 and 6 responsible for primary health care in the rural areas. First aid posts are staffed by locally selected peasants who have received a 3 month training at the local health centre. More highlytrained technical staff will be located in the hospitals, but will be expected to supervise and support the activities of the auxiliaries working at the periphery.
440
P.A. Smith
Dispensaries and first aid posts are actually situated in villages and may be visited by mobile teams from health centres and hospitals responsible for maternal and child health, environmental sanitation, and health education campaigns. OBJECTIVES OF T H E S T U D E N T N U R S E FIELDWORK PROJECT The Dar-es-Salaam school of nursing is one of three institutions for the preparation of Section A nurses (equivalent to SRN in England and Wales) in mainland Tanzania. For entry to this 4 year course, students require 7 years of primary and 4 years of secondary school education. The community health project comes after 3I years of training when the students have had experience in general, psychiatric and obstetric nursing (female students, at the end of their training, will be qualified midwives and male students psychiatric nurses) in the national referral hospital, as well as in maternal and child health and infectious diseases clinics of Dar-es-Salaam. The general objective of the community health project is to familarize the nursing students, as future administrators of nursing services at provincial and district level, with the common problems so that they can work more effectively as a member of a health team and be able to plan care related to the needs of the population. Moreover, as the vast majority of the Tanzanian people come from the rural areas, by spending at least a small part of their training outside the urban hospital setting they will have an opportunity to experience at first-hand some of the socioeconomic factors related to the disease. This too is in accordance with government orientation, urging students in particular to experience the real problems of the majority of Tanzanians and to relate their skills to these same problems. Organizational aspects of the project A 2 week study period was organized before departure to the project area, during which revision lectures and discussions in political education, sociology, epidemiology, statistics and maternal and child health were given so as to prepare the student for living and working in a rural community. The student groups consisted of 22 and 32, with a male: female ratio of 6:16and 11:21 (respectively). The two teachers who were responsible for supervising the project, achieved their supervision by means of a rota system, spending time with each group of five to eight students placed in the health centre and its satellite villages in two districts of the coast region of Tanzania. The first placement occurred over an 8 week period from January to March 1975, and the second from July to September 1975. Background to the project areas The two districts are, in many respects, representative of many rural areas of Tanzania, having a poor system of internal communication and an uneven distribution of health, education and other services. The main tribal groups share similar
Student nurse rural fieldwork experience
441
customs and beliefs and the use of traditional medicine and midwifery is strong. Both districts are agrarian. In terms of crops, the two areas are also very similar—rice, cashew and sesame being grown as cash crops, and maize, cassava, beans, oranges, vegetables and coconuts as food crops. Primary health care is given at dispensaries or first aid posts, with a referral system to a health centre and district hospital. Mobile teams are responsible for maternal and child health clinics and environmental sanitation.
The problems of transport and its relationship to the general planning of health care in the districts The problem of transport is one of the most widespread obstacles to the satisfactory delivery of health care in the underdeveloped world and the project areas are no exception. Preventative health care, largely carried out by mobile teams, is severely handicapped, as is the distribution of equipment and medicines throughout the network of health units. This problem of transport may also influence the setting of priorities by senior health workers within the district and the students observed that not only did doctors, medical assistants and senior nurses rarely visit the surrounding villages, but to them curative care and administration within the health centre was their most important task. In the more underdeveloped of the two areas, the students visited the district hospital which, at that time, had comparatively few patients. The medical officer attributed this to the poor roads, especially during the rainy season, which made the hospital inaccessible to the catchment population. Preventative health services were also very few, but, for the patients who did manage to come to the hospital, a good curative service was available. For example, many of the people in this and many areas of Tanzania suffer from tropical ulcer, preventable by good nutrition and hygiene and early treatment of cuts and abrasions. In the hospital, skin-grafting operations were carried out (at any one time) for about five patients suffering from severe tropical ulcer. This may be a reflection of the district medical officer's training which has orientated him to concentrate on good curative hospital services as opposed to preventative medicine, support and supervision of primary health care personnel in the dispensaries and health posts.
Activities and problems related to the villages The activities carried out by the project students in the villages can be divided into the following categories: (i) simple treatments and first aid, (2) maternal and child health (including school health), (3) domiciliary visits and (4) health education. When possible, the students participated in the local activities such as farmwork, literacy teaching, sports, culture and political meetings, in order to express solidarity and gain acceptance from the people. These activities were all integrated within the existing health and administrative structures. Statistical records and
442
P.A. Smith
reports were kept throughout the project, including a family case study undertaken by each student. In these villages, with the exception of one which had a dispensary and an experienced rural medical aide, the primary health care was being given by first aiders who only had a minimum of training. Furthermore, the mobile maternal and child health clinics, scheduled to visit at least on a monthly basis, were often unable to visit because of transport difficulties. Consequently, although as nurses the students had not been taught to diagnose and treat disease, demands made upon them in the village health posts (including the provisional maternal and child health clinics which they had set up) included attending to a population suffering from subnutrition, especially children from 0-5 years old (Smith & Bland 1976), and infectious diseases such as respiratory infections, diarrhoea, malaria, conjunctivitis and infected leg ulcers. Also, many patients came to the health posts with complaints of vague aches and pains suggestive of psychosomatic problems—such phenomena have also been described in a study made at the outpatients department of the Muhimbili Hospital, Dar-es-Salaam (Holmes & Speight 1975), and are often overlooked when considering health care in underdeveloped countries. As many villagers can neither afford nor find transport to go to the health centres with these problems, the load rests on the first aider or rural medical aide who is the primary health worker at the village level. The importance of support and supervision for such workers was obvious to the students, particularly during the periods when teachers or senior health staff were not present. Domiciliary visiting is a service that is generally difficult to carry out in underdeveloped countries, although identified as a nursing function in Britain. In Tanzania, transport and staff is costly but there are certain situations where domiciliary visiting may be appropriate (e.g. follow-up of mothers and children from nutrition rehabilitation units, contact tracing and case finding in leprosy and tuberculosis work). However, the students were given the opportunity to see the possibilities of using such a service as a special method of community health care. Thus, with the permission of the village leaders, they undertook to visit as many homes as possible in order to talk with the people about their problems, customs and beliefs, and offer any health advice where appropriate. It also gave them an opportunity to build-up a good relationship with the family that is essential, and yet so often overlooked, in the day-to-day delivery of health care (each student also wrote a case study). The students often found that the family were unable to carry out sound health practice either because the environmental sanitation was inadequate, especially the water supply, or they had insufficient money for food or bus fares to the health centre to complete treatment or to attend maternal and child clinics when these were not available in the village. In one of these groups (32 students), 14 students diagnosed protein calorie malnutrition in one or more children, and four students were called for delivery and post-natal care. The families also had many beliefs about the cause of disease, by witchcraft or unpleased ancestors, and in these instances visits to the traditional healers were, to them, the only means of effecting a complete cure. Housing was often of a temporary nature because some families
Student nurse rural fieldwork experience
443
had recently been moved to more centralized village settlement schemes. These schemes were also responsible for cutting many families off from their traditional plots of land and hence their food supply, but it was seen as a temporary situation that would pass once the new collective village farms could be estabhshed. Health education was not reported as a separate activity by the students as they were expected to integrate it at every opportunity, whether working in the schools, first aid post, or literacy classes. The villagers' response to all these activities is reported below.
Villagers' attitudes to modem methods of health care Villagers, like people all over the world, demand drugs whether they need them or not and students, as well as the regidar health workers, feel the need to give them some sort of medicinal treatment because of this demand. This is very much related to the cultural expectation within the community because if a person goes to the local healer he is automatically given diagnosis and treatment (for which payment is given). In one village there were complaints because many of the minor ailments, i.e. mild diarrhoea, were not treated by prescribing medicines of any kind, but advice was given, related to the possible cause and future prevention of the diarrhoea. Teaching the importance and methods of hydration with sugar, water and salt, especially in young children, was also stressed (Jelliffe 1966b). Discussions followed between villagers and students, but a 6 week stay is clearly insufficient time to persuade most people to change their longstanding expectations of health care. Further examples of this cultural pressure may be drawn from another village where injections were in great demand. Health workers were caught in a vicious circle of prescribing drugs, often unnecessarily, because it was assumed that people would accept no other kind of treatment. Thus, the overprescribing of drugs is perpetuated, as is mistaken consumer expectation of health care as treatment. As mentioned above, villagers believe that only certain disease caused 'by God' can be treated by modern methods. If witchcraft, or ancestral spirits, are responsible then the immediate problem of fever or headache can be alleviated by modern medicine, but the fundamental cause can only be taken care of by the traditional healer. In relation to health care of pregnant women, many mothers would seek the aid of antenatal clinics quite late in their pregnancy because they believe they must not admit they are pregnant in the early months for fear that they will miscarry as a result ofjealousy and subsequent withcraft from others. From the above description it can be concluded that health education is less well accepted by villagers than treatment by drugs. Many reasons were identified for this, one being that immediate results from following advice are not usually obvious. Furthermore, the people in these areas had been exposed to a mass radio campaign called Mtn ni Afya [Man is Health), which stressed good nutrition and environmental sanitation, and local maternal and child health clinics and outpatient sessions are usually preceded by short talks on similar topics. Health education can thus become repetitive and boring for the people, as well as being insufficient in the
444
P-A. Smith
short-term to counteract long-held beliefs and practices, particularly when the material conditions to overcome them do not exist. Such an example is that many pregnant women believe that they must not eat eggs so as to prevent the birth of babies without hair. As eggs continue to be one of the foodstuffs largely inaccessible to the majority of the population, it is clear that this belief is economically reinforced and will not disappear quickly. EVALUATION OF THE P R O J E C T
Evaluation by villagers The problem of evaluation of such a project is always difficult, but the village leaders were asked to write reports on behalf of the other villagers and a public seminar was held in the last week of the project in order to analyse the work carried out during the students stay and make recommendations for the future. Members of the local health and political organizations were present and the improvement of primary health care was considered to be very important, as was the provision of a safe and convenient water supply.
Evaluation by students Student nurses on their return to Dar-es-Salaam were given a questionnaire to evaluate the theoretical and practical organization of the project, as well as to assess their attitudes to working in rural area. When asked to state whether the fieldwork should be included in their course, all agreed that it should. Reasons given were that it helped students to understand the problems of the rural areas and developed self-reliance and communication with the people. They were also asked to state which disciplines they considered of most use during the project and great importance was attributed to pharmacology, probably reffecting the demands made on the students to make diagnosis and treatments for which, in their training, they are not prepared. Table 2 shows those services which, in the students' opinion, were of most use to the villagers.
TABLE 2 Services considered by project students to be of most use to the Villagers (percentage: 53 students) Service Dispensary or first aid post Health education Maternal and child health Environmental sanitation Domiciliary visiting School Health Other
0/
/o
80
68 52 30 23 II
Student nurse rural jieldwork experience
445
Treatment is seen by the nurses as the most important service rendered to the villagers. This may partly be because of the inadequate primary care available to most of the people in the fieldwork villages and partly because of the tangible nature of curative services as opposed to prevention. However, health education and maternal child health are also considered to be important by over 50% of the students. Many students stressed the need for continuity and follow-up by subsequent student groups in the same villages, recognizing the limitations of an isolated 8 week project. CONCLUSION A group of final year student nurses were able to give limited primary health care and apply some principles of preventative medicine during a 2 month community health project in the rural areas of mainland Tanzania. They were also able to familiarize themselves with some of the problems likely to be encountered in future work situations. The project also illustrates that curative health care continues to be the type of care that the vast majority of the population understand and demand from their health services and, therefore, must be used as a base for integrating preventative aspects of tealth care. Although Tanzania has greatly advanced in the development of health services related to the peoples' needs, there are still problems. The number of primary health workers at village level is still inadequate and they often lack sufficient supervision and support from senior staff in hospitals and health centres. As has been noted, nurses outnumber any other grade of health worker, but the nature of their task continues to be situated within the curative health service and concentrated more on the care of hospitalized patients (a very small proportion of the national sick), outpatients and women during labour and pregnancy. The role of the nurse in many underdeveloped countries has long since deviated from these original tasks in order to meet the health needs of a population served by insufficient numbers of personnel actually trained to diagnose and treat disease. T'his is obviously not an efficient use of manpower and, in order to overcome these problems, it is suggested that specific health workers should be trained as doctor auxiliaries rather than continuing to use inappropriately trained nurses (Gish 1973). On the other hand, each country could develop 'national nursing personal system(s)' (Hall 1976) in order to study local needs and develop an appropriate nursing service capable of meeting those needs. It is probable in this case that nurses, as such, would decline in number. As the project illustrates, such measures are very much needed for as long as nurses continue to be trained in numbers exceeding other types of health workers they can expect to carry out tasks other than those they arc actually trained to do. Furthermore, given the health problems in the third world, these traditional tasks alone become of limited value, witnessed by the fact that in Tanzania most of the hospitalized patients are suffering from preventable diseases that are a direct result of their poor living conditions. Nurses, as much as any other health workers, must
446
P.A. Smith
therefore have an understanding of the nature of disease and its attendant socioeconomic factors. Many problems cannot be overcome without the organization of the people themselves to improve their own health—such as teaching why and how to build their own latrines, or what are the most nutritionally useful crops to produce. A clear structure and clarity of function for nurses, as well as other health workers, is required in order to make full use of their potential and skills. This may take place more easily by developing a health care system that is orientated towards the needs and involvement of the people and allow for teamwork between all grades of personnel. The experience gained by student nurses working in the rural areas of Tanzania would suggest the importance of all health workers to be exposed, during training, to a similar learning experience in order to redress the balance in their future work between hospital- or village-centred care and treatment or prevention of disease.
Acknowledgements The author would like to express her thanks to Miss Ellen Zablon, formerly head of the nursing school, Dar-es-Salaam, and now of the Ministry of Health, Dar-esSalaam, and to Mrs Regina Nzo, community nurse tutor, Dar-es-Salaam whose long years of experience in community health were a fount of inspiration to the author.
References CHAGITLLA W . K . & TARIMO E. (1975) Meeting basic health needs in Tanzania. In Health by the People, ed. Newell K.W. World Health Organisation, Geneva. GiSH O. (1973) Doctor auxiliaries in Tanzania. The Lancet, Vol ii, 1251-1254. HALL D . C . (1976) Nursing personnel systems. JoHrna/ of Advanced Nursing I, 79-87. HOLMES J. A. & SPHGHT A . N . P . (1975) The problems of non-organic illness. In Tanzanian Urban Medical Practice, East African Medical Journal 52, 225-236. JELLDTE D . B . (1966a) Diarrhoea in childhood. In Medical Care for Developing Countries, ed. King M. Oxford University Press. JELLHTE D.B. (1966b) Paediatrics. In Medical Care for Developing Countries, ed. King M. Oxford University Press. MINISTRY OF HEALTH, DAR-ES-SALAAM (1970 Annual Report of the Health Division 1968-1969. Mimeographed. SMITH P.A. & BLAND J . M . (1976) The Nutritional Status of Pre-School Children in Coast Region, Tanzania. (Unpublished paper). THOMAS I . D . & MASCARENHAS A . C . (1973) Health Facilities and Population in Tanzania. Part I: Hospitals in Tanzania and Population within given Distances of their Sites. Research paper no. 21. Bureau of Resource Assessment and Land Use Planning, University of Dar-es-Salaam. WORLD HEALTH ORGANIZATION (1973) Health Progress in Africa 1968-1973. Technical paper no. 6. World Health Organization Regional Office for Africa.
Student nurse rural fieldwork in mainland Tanzania Pamela A. Smith B.Nurs. Cert. Ed. Community Nurse Tutor, Institute ofMedical and Paramedical Sciences, Maputo, Mozambique
Axepted for publication 15 February 1978
SMITH P. A. {igjS) Journal of Advanced Nursing 3, 437-446
Student nurse niral fieldwork in mainland Tanzania The development of the health services in the majority of underdeveloped countries during the colonial period, and immediately after independence, have concentrated on providing a largely hospital-based curative programme. This has also included training of the local population, particularly as nurses, to carry out this programme. Figures show that, for the African region of the World Health Organization (WHO), nursing personnel form a significant group of trained health manpower (WHO 1973). The objective of this paper, therefore, is to raise the question of whether nurses in underdeveloped countries should continue to be trained mainly for their traditional tasks of caring for the sick in hospitals, or whether the majority of them should be channelled into other types of work more appropriate to the major needs of the population. In order to reach this objective, an example is given of the Tanzanian experience 15 years after independence, including a description of a community health project involving a group of student nurses in the rural areas of mainland Tanzania.
THE S O C I O E C O N O M I C C O N T E X T OF H E A L T H C A R E IN THE U N D E R D E V E L O P E D W O R L D The nature of disease in underdeveloped countries, which confronts the majority of health workers, is a direct result of poverty and a low standard of living. Hence, the development of health services in themselves can do very little to eradicate disease if the underlying causes remain. The origin of many of these causes may be found during the colonial era when the major aim of the government was to use the colony as a cheap source of raw materials (like coffee, tea and cotton) and minerals for exportation to the industrial centres of the USA and Europe. The colony was also used as a cheap source of labour for work in mines and plantations, with the result that all internal development largely reinforced this aim. In most ex-colonies today, the population is predominandy rural (80-90%) with a low standard of living from low level peasant agricultural production, and a suprastructure providing a minimum of health, education, transport, and other services. These services are only relatively well-developed in small urban enclaves. 0309-2402/78/0900-0437 $02.00© 1978 Blackwell Scientific Publications
437
438
P. A. Smith
Given these conditions, infectious diseases and subnutrition are the common health problems which affect the young age groups. Forty to 45% of the population is under 15 years of age and one in four children will never reach 5 years of age. Pneumonias, protein-calorie deficiency (kwashiorkor and marasmus), and diarrhoeas are cited as the three big killer diseases responsible for this (Jelliffe 1966a). Measles and malaria also take their toll. Furthermore, nutritional anaemia and intestinal parasites play an important role in death and disease, not only during childhood but also during pregnancy and labour (women of childbearing age constituting another 20-25% of the total population). Maternal and child health services are thus a major priority, but midwives have been trained, (along with doctors, medical assistants and nurses) to staff hospitals and dispensaries to treat the population usually from a context of treating sickness rather than promoting health. Health officers, trained specifically to carry out preventative programmes such as vaccination, health education (including nutrition) and environmental sanitation, have been significantly few in number and mainly urban-based. The traditional division between curative and preventative medicine has thus been propagated by colonialism and explains some of the problems involved in formulating new health policies in many countries since achieving independence. C H A R A C T E R I S T I C S OF THE T A N Z A N I A N HEALTH S E R V I C E S : B A C K G R O U N D T O T H E FIELDWORK PROJECT
Training of health personnel As the training of local health personnel in Tanzania had taken place since the early 1930s, at independence there was a considerable number of already qualified staff with a minimum of 7-8 years schooling. Table i (Chagulla & Tarimo 1975) demonstrates the development of manpower since that time.
TABLE I
Health manpower development in Tanzania
Cadre
Maternal and child health aide/village midwife Health auxilliary Nurse/midwife/psychiatric nurse (Section A) Nurse (Section B) Rural medical aide Medical assistant Assistant medical officer Doctor (Tanzanian) Doctor (Foreign) Total
1961 1969 1971 1973
Projection 1980
400
545
650
750
2500
150
180
230
325
800
683 838 934 1619 2110 2690
380
462
544
621
200
249
289
335
i960 4100 2800 1200
32
103
"5
140
300
12
90
155 324
231 302
700
338 984
413 355 2909 4286 5255 6328
130
14490
Student nurse rural fieldwork experience
439
It can be noted that preventative health personnel have always been a small minority of the total trained manpower. This should be seen in the context of Tanzania being one of the world's poorest countries with a very high infant mortality rate of 160 per 1000 live births per year and with poverty-linked diseases such as infections, parasites and subnutrition, all of which are preventable, being responsible for a large percentage of hospital admissions and deaths (Ministry of Health, Dar-es-Salaam 1970). As can also be noted from Table i, attempts have been made to change this orientation by the formulation of recent policies to increase the number of maternal and child health auxiliaries and medical assistants who will work in the rural areas where about 90% of the population live. However, by 1973 there was no significant change though projections for 1980 aim to alter this situation—the i year course for auxiliary (village) midwives, for example, has been replaced by a more comprehensive training for maternal and child health aides and this new course emphasizes the importance of prevention in the care of under-5s, and pregnant and nursing mothers.
The organizational structure for the delivery of health care As the majority of the rural population live more than 10 kilometres from a hospital, this means that only a few actually have access to health care, given the difficulty of transport and lack of roads (Thomas & Mascarenhas 1973). Figure i illustrates how this problem could be overcome. Level
Existing number
Under construction
1
National referral hospital
2
Regional hospital
138
3
District hospital
4
Health centres
129
52
5
Dispensaries
1670
149
6
1 t t t
First aid posts
Not known
Not known
t
FIGURE I Health and care network in Tanzania on 1 January 1975 (2 way communication system).
There will be few units of levels i, 2 and 3, mainly urban, with the aim to give back-up and support to the many units at levels 4, 5 and 6 responsible for primary health care in the rural areas. First aid posts are staffed by locally selected peasants who have received a 3 month training at the local health centre. More highlytrained technical staff will be located in the hospitals, but will be expected to supervise and support the activities of the auxiliaries working at the periphery.
440
P.A. Smith
Dispensaries and first aid posts are actually situated in villages and may be visited by mobile teams from health centres and hospitals responsible for maternal and child health, environmental sanitation, and health education campaigns. OBJECTIVES OF T H E S T U D E N T N U R S E FIELDWORK PROJECT The Dar-es-Salaam school of nursing is one of three institutions for the preparation of Section A nurses (equivalent to SRN in England and Wales) in mainland Tanzania. For entry to this 4 year course, students require 7 years of primary and 4 years of secondary school education. The community health project comes after 3I years of training when the students have had experience in general, psychiatric and obstetric nursing (female students, at the end of their training, will be qualified midwives and male students psychiatric nurses) in the national referral hospital, as well as in maternal and child health and infectious diseases clinics of Dar-es-Salaam. The general objective of the community health project is to familarize the nursing students, as future administrators of nursing services at provincial and district level, with the common problems so that they can work more effectively as a member of a health team and be able to plan care related to the needs of the population. Moreover, as the vast majority of the Tanzanian people come from the rural areas, by spending at least a small part of their training outside the urban hospital setting they will have an opportunity to experience at first-hand some of the socioeconomic factors related to the disease. This too is in accordance with government orientation, urging students in particular to experience the real problems of the majority of Tanzanians and to relate their skills to these same problems. Organizational aspects of the project A 2 week study period was organized before departure to the project area, during which revision lectures and discussions in political education, sociology, epidemiology, statistics and maternal and child health were given so as to prepare the student for living and working in a rural community. The student groups consisted of 22 and 32, with a male: female ratio of 6:16and 11:21 (respectively). The two teachers who were responsible for supervising the project, achieved their supervision by means of a rota system, spending time with each group of five to eight students placed in the health centre and its satellite villages in two districts of the coast region of Tanzania. The first placement occurred over an 8 week period from January to March 1975, and the second from July to September 1975. Background to the project areas The two districts are, in many respects, representative of many rural areas of Tanzania, having a poor system of internal communication and an uneven distribution of health, education and other services. The main tribal groups share similar
Student nurse rural fieldwork experience
441
customs and beliefs and the use of traditional medicine and midwifery is strong. Both districts are agrarian. In terms of crops, the two areas are also very similar—rice, cashew and sesame being grown as cash crops, and maize, cassava, beans, oranges, vegetables and coconuts as food crops. Primary health care is given at dispensaries or first aid posts, with a referral system to a health centre and district hospital. Mobile teams are responsible for maternal and child health clinics and environmental sanitation.
The problems of transport and its relationship to the general planning of health care in the districts The problem of transport is one of the most widespread obstacles to the satisfactory delivery of health care in the underdeveloped world and the project areas are no exception. Preventative health care, largely carried out by mobile teams, is severely handicapped, as is the distribution of equipment and medicines throughout the network of health units. This problem of transport may also influence the setting of priorities by senior health workers within the district and the students observed that not only did doctors, medical assistants and senior nurses rarely visit the surrounding villages, but to them curative care and administration within the health centre was their most important task. In the more underdeveloped of the two areas, the students visited the district hospital which, at that time, had comparatively few patients. The medical officer attributed this to the poor roads, especially during the rainy season, which made the hospital inaccessible to the catchment population. Preventative health services were also very few, but, for the patients who did manage to come to the hospital, a good curative service was available. For example, many of the people in this and many areas of Tanzania suffer from tropical ulcer, preventable by good nutrition and hygiene and early treatment of cuts and abrasions. In the hospital, skin-grafting operations were carried out (at any one time) for about five patients suffering from severe tropical ulcer. This may be a reflection of the district medical officer's training which has orientated him to concentrate on good curative hospital services as opposed to preventative medicine, support and supervision of primary health care personnel in the dispensaries and health posts.
Activities and problems related to the villages The activities carried out by the project students in the villages can be divided into the following categories: (i) simple treatments and first aid, (2) maternal and child health (including school health), (3) domiciliary visits and (4) health education. When possible, the students participated in the local activities such as farmwork, literacy teaching, sports, culture and political meetings, in order to express solidarity and gain acceptance from the people. These activities were all integrated within the existing health and administrative structures. Statistical records and
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reports were kept throughout the project, including a family case study undertaken by each student. In these villages, with the exception of one which had a dispensary and an experienced rural medical aide, the primary health care was being given by first aiders who only had a minimum of training. Furthermore, the mobile maternal and child health clinics, scheduled to visit at least on a monthly basis, were often unable to visit because of transport difficulties. Consequently, although as nurses the students had not been taught to diagnose and treat disease, demands made upon them in the village health posts (including the provisional maternal and child health clinics which they had set up) included attending to a population suffering from subnutrition, especially children from 0-5 years old (Smith & Bland 1976), and infectious diseases such as respiratory infections, diarrhoea, malaria, conjunctivitis and infected leg ulcers. Also, many patients came to the health posts with complaints of vague aches and pains suggestive of psychosomatic problems—such phenomena have also been described in a study made at the outpatients department of the Muhimbili Hospital, Dar-es-Salaam (Holmes & Speight 1975), and are often overlooked when considering health care in underdeveloped countries. As many villagers can neither afford nor find transport to go to the health centres with these problems, the load rests on the first aider or rural medical aide who is the primary health worker at the village level. The importance of support and supervision for such workers was obvious to the students, particularly during the periods when teachers or senior health staff were not present. Domiciliary visiting is a service that is generally difficult to carry out in underdeveloped countries, although identified as a nursing function in Britain. In Tanzania, transport and staff is costly but there are certain situations where domiciliary visiting may be appropriate (e.g. follow-up of mothers and children from nutrition rehabilitation units, contact tracing and case finding in leprosy and tuberculosis work). However, the students were given the opportunity to see the possibilities of using such a service as a special method of community health care. Thus, with the permission of the village leaders, they undertook to visit as many homes as possible in order to talk with the people about their problems, customs and beliefs, and offer any health advice where appropriate. It also gave them an opportunity to build-up a good relationship with the family that is essential, and yet so often overlooked, in the day-to-day delivery of health care (each student also wrote a case study). The students often found that the family were unable to carry out sound health practice either because the environmental sanitation was inadequate, especially the water supply, or they had insufficient money for food or bus fares to the health centre to complete treatment or to attend maternal and child clinics when these were not available in the village. In one of these groups (32 students), 14 students diagnosed protein calorie malnutrition in one or more children, and four students were called for delivery and post-natal care. The families also had many beliefs about the cause of disease, by witchcraft or unpleased ancestors, and in these instances visits to the traditional healers were, to them, the only means of effecting a complete cure. Housing was often of a temporary nature because some families
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had recently been moved to more centralized village settlement schemes. These schemes were also responsible for cutting many families off from their traditional plots of land and hence their food supply, but it was seen as a temporary situation that would pass once the new collective village farms could be estabhshed. Health education was not reported as a separate activity by the students as they were expected to integrate it at every opportunity, whether working in the schools, first aid post, or literacy classes. The villagers' response to all these activities is reported below.
Villagers' attitudes to modem methods of health care Villagers, like people all over the world, demand drugs whether they need them or not and students, as well as the regidar health workers, feel the need to give them some sort of medicinal treatment because of this demand. This is very much related to the cultural expectation within the community because if a person goes to the local healer he is automatically given diagnosis and treatment (for which payment is given). In one village there were complaints because many of the minor ailments, i.e. mild diarrhoea, were not treated by prescribing medicines of any kind, but advice was given, related to the possible cause and future prevention of the diarrhoea. Teaching the importance and methods of hydration with sugar, water and salt, especially in young children, was also stressed (Jelliffe 1966b). Discussions followed between villagers and students, but a 6 week stay is clearly insufficient time to persuade most people to change their longstanding expectations of health care. Further examples of this cultural pressure may be drawn from another village where injections were in great demand. Health workers were caught in a vicious circle of prescribing drugs, often unnecessarily, because it was assumed that people would accept no other kind of treatment. Thus, the overprescribing of drugs is perpetuated, as is mistaken consumer expectation of health care as treatment. As mentioned above, villagers believe that only certain disease caused 'by God' can be treated by modern methods. If witchcraft, or ancestral spirits, are responsible then the immediate problem of fever or headache can be alleviated by modern medicine, but the fundamental cause can only be taken care of by the traditional healer. In relation to health care of pregnant women, many mothers would seek the aid of antenatal clinics quite late in their pregnancy because they believe they must not admit they are pregnant in the early months for fear that they will miscarry as a result ofjealousy and subsequent withcraft from others. From the above description it can be concluded that health education is less well accepted by villagers than treatment by drugs. Many reasons were identified for this, one being that immediate results from following advice are not usually obvious. Furthermore, the people in these areas had been exposed to a mass radio campaign called Mtn ni Afya [Man is Health), which stressed good nutrition and environmental sanitation, and local maternal and child health clinics and outpatient sessions are usually preceded by short talks on similar topics. Health education can thus become repetitive and boring for the people, as well as being insufficient in the
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short-term to counteract long-held beliefs and practices, particularly when the material conditions to overcome them do not exist. Such an example is that many pregnant women believe that they must not eat eggs so as to prevent the birth of babies without hair. As eggs continue to be one of the foodstuffs largely inaccessible to the majority of the population, it is clear that this belief is economically reinforced and will not disappear quickly. EVALUATION OF THE P R O J E C T
Evaluation by villagers The problem of evaluation of such a project is always difficult, but the village leaders were asked to write reports on behalf of the other villagers and a public seminar was held in the last week of the project in order to analyse the work carried out during the students stay and make recommendations for the future. Members of the local health and political organizations were present and the improvement of primary health care was considered to be very important, as was the provision of a safe and convenient water supply.
Evaluation by students Student nurses on their return to Dar-es-Salaam were given a questionnaire to evaluate the theoretical and practical organization of the project, as well as to assess their attitudes to working in rural area. When asked to state whether the fieldwork should be included in their course, all agreed that it should. Reasons given were that it helped students to understand the problems of the rural areas and developed self-reliance and communication with the people. They were also asked to state which disciplines they considered of most use during the project and great importance was attributed to pharmacology, probably reffecting the demands made on the students to make diagnosis and treatments for which, in their training, they are not prepared. Table 2 shows those services which, in the students' opinion, were of most use to the villagers.
TABLE 2 Services considered by project students to be of most use to the Villagers (percentage: 53 students) Service Dispensary or first aid post Health education Maternal and child health Environmental sanitation Domiciliary visiting School Health Other
0/
/o
80
68 52 30 23 II
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Treatment is seen by the nurses as the most important service rendered to the villagers. This may partly be because of the inadequate primary care available to most of the people in the fieldwork villages and partly because of the tangible nature of curative services as opposed to prevention. However, health education and maternal child health are also considered to be important by over 50% of the students. Many students stressed the need for continuity and follow-up by subsequent student groups in the same villages, recognizing the limitations of an isolated 8 week project. CONCLUSION A group of final year student nurses were able to give limited primary health care and apply some principles of preventative medicine during a 2 month community health project in the rural areas of mainland Tanzania. They were also able to familiarize themselves with some of the problems likely to be encountered in future work situations. The project also illustrates that curative health care continues to be the type of care that the vast majority of the population understand and demand from their health services and, therefore, must be used as a base for integrating preventative aspects of tealth care. Although Tanzania has greatly advanced in the development of health services related to the peoples' needs, there are still problems. The number of primary health workers at village level is still inadequate and they often lack sufficient supervision and support from senior staff in hospitals and health centres. As has been noted, nurses outnumber any other grade of health worker, but the nature of their task continues to be situated within the curative health service and concentrated more on the care of hospitalized patients (a very small proportion of the national sick), outpatients and women during labour and pregnancy. The role of the nurse in many underdeveloped countries has long since deviated from these original tasks in order to meet the health needs of a population served by insufficient numbers of personnel actually trained to diagnose and treat disease. T'his is obviously not an efficient use of manpower and, in order to overcome these problems, it is suggested that specific health workers should be trained as doctor auxiliaries rather than continuing to use inappropriately trained nurses (Gish 1973). On the other hand, each country could develop 'national nursing personal system(s)' (Hall 1976) in order to study local needs and develop an appropriate nursing service capable of meeting those needs. It is probable in this case that nurses, as such, would decline in number. As the project illustrates, such measures are very much needed for as long as nurses continue to be trained in numbers exceeding other types of health workers they can expect to carry out tasks other than those they arc actually trained to do. Furthermore, given the health problems in the third world, these traditional tasks alone become of limited value, witnessed by the fact that in Tanzania most of the hospitalized patients are suffering from preventable diseases that are a direct result of their poor living conditions. Nurses, as much as any other health workers, must
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therefore have an understanding of the nature of disease and its attendant socioeconomic factors. Many problems cannot be overcome without the organization of the people themselves to improve their own health—such as teaching why and how to build their own latrines, or what are the most nutritionally useful crops to produce. A clear structure and clarity of function for nurses, as well as other health workers, is required in order to make full use of their potential and skills. This may take place more easily by developing a health care system that is orientated towards the needs and involvement of the people and allow for teamwork between all grades of personnel. The experience gained by student nurses working in the rural areas of Tanzania would suggest the importance of all health workers to be exposed, during training, to a similar learning experience in order to redress the balance in their future work between hospital- or village-centred care and treatment or prevention of disease.
Acknowledgements The author would like to express her thanks to Miss Ellen Zablon, formerly head of the nursing school, Dar-es-Salaam, and now of the Ministry of Health, Dar-esSalaam, and to Mrs Regina Nzo, community nurse tutor, Dar-es-Salaam whose long years of experience in community health were a fount of inspiration to the author.
References CHAGITLLA W . K . & TARIMO E. (1975) Meeting basic health needs in Tanzania. In Health by the People, ed. Newell K.W. World Health Organisation, Geneva. GiSH O. (1973) Doctor auxiliaries in Tanzania. The Lancet, Vol ii, 1251-1254. HALL D . C . (1976) Nursing personnel systems. JoHrna/ of Advanced Nursing I, 79-87. HOLMES J. A. & SPHGHT A . N . P . (1975) The problems of non-organic illness. In Tanzanian Urban Medical Practice, East African Medical Journal 52, 225-236. JELLDTE D . B . (1966a) Diarrhoea in childhood. In Medical Care for Developing Countries, ed. King M. Oxford University Press. JELLHTE D.B. (1966b) Paediatrics. In Medical Care for Developing Countries, ed. King M. Oxford University Press. MINISTRY OF HEALTH, DAR-ES-SALAAM (1970 Annual Report of the Health Division 1968-1969. Mimeographed. SMITH P.A. & BLAND J . M . (1976) The Nutritional Status of Pre-School Children in Coast Region, Tanzania. (Unpublished paper). THOMAS I . D . & MASCARENHAS A . C . (1973) Health Facilities and Population in Tanzania. Part I: Hospitals in Tanzania and Population within given Distances of their Sites. Research paper no. 21. Bureau of Resource Assessment and Land Use Planning, University of Dar-es-Salaam. WORLD HEALTH ORGANIZATION (1973) Health Progress in Africa 1968-1973. Technical paper no. 6. World Health Organization Regional Office for Africa.
