Results for Development (R4D) is a leading non-profit global development partner. We collaborate with change agents around the world — government officials, civil society leaders and social innovators — to create strong systems that support healthy, educated people. We help our partners move from knowing their goal to knowing how to reach it. We combine global expertise in health, education and nutrition with analytic rigor, practical support for decision-making and implementation and access to peer problem-solving networks. Together with our partners, we build self-sustaining systems that serve everyone and deliver lasting results. Then we share what we learn so others can achieve results for development, too. 

We have a unique and vibrant culture at R4D. Diversity, equity and inclusion are at the heart of our work environment and help advance our mission. Diversity—of ideas, identities, perspectives and backgrounds—is vital to who we are and what we do. We seek people who embrace these values and will help reinforce them. Our work culture is collaborative, creative and entrepreneurial. We operate based on trust and respect. Teams across the organization frequently collaborate on programmatic work and support each other in continuously building a better R4D.

We request applications to be sent to lheinkel@r4d.org with the subject “Proposal for Tanzania Data Collection”. The email should have the name and email address for the Offeror’s contact person. All applications should be written in English and include a technical narrative (5 page limit), CVs of key staff, and a detailed budget in Excel. Budgets can be in TZS or USD. The budget ceiling for this proposal is USD 40,000. Applications are due 30 September 2022

1. Introduction and study background

R4D has been working closely with the Reproductive and Child Health Section (RCHS) of the Ministry of Health (MOH) for several years to increase access to childhood pneumonia treatment, amoxicillin dispersible tablets (amox DT), in support of the Government of Tanzania’s goal to reduce childhood mortality by 80% by 2030. As per R4D’s established memorandum of understanding with the MoH and with support from our donor, GiveWell, R4D has been administering catalytic, time-limited funding for the procurement of high-quality amox DT for distribution by the Medical Stores Department (MSD) to all public health facilities in mainland Tanzania since 2016.  

As part of this work, since 2017, R4D has also worked closely with RCHS and the President's Office – Regional Administration and Local Government (PO-RALG) to generate and share evidence around cost-effective interventions that might increase rational use of amox DT and improve quality of care, towards informing RCHS policies and programs. In 2017, R4D, RCHS, and PO-RALG conducted a clinical study that revealed that in Tanzanian public health facilities across three regions, only 18% of children with confirmed pneumonia receive an accurate pneumonia diagnosis from health providers, pointing to a large “Know-Can-Do” gap among health providers (Salisbury et al., 2021).  

R4D is using the  Know-Can-Do causal chain to identify gaps in providers’ accurate diagnosis of childhood pneumonia. In order for providers to make accurate diagnoses, they must know the IMCI guidelines for childhood pneumonia diagnosis, have the skills to execute the diagnostic steps, and successfully conduct those steps in practice when they are seeing patients. Our research has demonstrated that there are several Know-Can and Can-Do challenges to be addressed for accurate diagnosis of childhood pneumonia and rational use of amox DT. 

To address this, R4D, RCHS, and PO-RALG then tested interventions through an operational research study (OR I), including mobile mentorship, job aids, and mobile messages (as a form of mHealth), and found that these interventions had the potential to improve provider knowledge of Integrated Management for Childhood Illness (IMCI), which is the World Health Organization (WHO) standard of care for child pneumonia diagnosis, also recommended by the Tanzanian Pediatric Standard Treatment Guidelines (P.STGs). In 2022, R4D and RCHS have resumed this operational research, with a focus on identifying feasible interventions for improving provider knowledge, skills, and behavior in practice.  

This operational research study will rapidly experiment with and validate small-scale activities to develop better learning outcomes to address the problem of lack of adherence to IMCI guidelines and misdiagnosis of child pneumonia.

 

2. Research objectives

The objectives of the study include: 

1.  Generate rapid evidence on the feasibility and acceptability of cost-effective approaches to improve health care provider behavior around the accurate diagnosis and prescription for childhood pneumonia, focused on integration of IMCI pneumonia steps and nurse-led triage. 

2.   Identify enablers and barriers faced by nurses and clinicians when integrating IMCI pneumonia steps into nurse-led triage. 

3.   Determine whether this approach has the potential to lead to improvement in quality of care, including the comprehensiveness of IMCI diagnostic steps and caregiver experiential quality/satisfaction with care. 

4.   Identify effective approaches for supporting the integration of IMCI pneumonia steps into nurse-led triage of children under five.

 

3. Research Questions

The study seeks to answer the following questions: 

Do nurses have the capacity to integrate IMCI pneumonia steps into the ETAT process, and do they do this in practice? 

  • Does participation in clinical IMCI training improve nurses’ knowledge of pneumonia signs in children under five? Do nurses retain this knowledge?
  • What approaches are most effective in supporting nurses to retain their knowledge of IMCI pneumonia signs? 
  • Do nurses demonstrate the skills and behavior to effectively identify child pneumonia signs during triage (fast breathing, stridor, and chest indrawing)? 
  • With what frequency do nurses conduct each IMCI pneumonia step for children under five during triage? 
  • To what extent are nurses’ child pneumonia diagnostic knowledge and skills validated by clinicians? 
  • Are nurses able to effectively identify, prioritize, document, and communicate information about potential child pneumonia cases to clinicians?  
  • What approaches are most effective for enabling clear communication between nurses and clinicians about potential child pneumonia cases? 

How does clinician behavior change in practice when supported by an integrated IMCI pneumonia and ETAT triage process? 

  • Do clinicians prioritize potential child pneumonia cases for diagnosis and treatment based on the integrated triage process? 
  • How much time do clinicians spend with potential child pneumonia cases?  
  • How do they use this time to validate or come to a child pneumonia diagnosis, treatment, and follow-up? 
  • With what frequency do clinicians conduct (or complete) each IMCI pneumonia step for children under five? 
  • Do clinicians physically examine their patients? 
  • How do clinicians treat confirmed pneumonia cases vs. non-pneumonia cases? 
  • Do clinicians provide guidance to caregivers on treatment and follow-up? 

4. Cross-cutting Research Questions

In addition, the study will also address cross-cutting research questions related to overall quality of care, IMCI “champions”, and overall enablers and barriers for an integrated ETAT and IMCI pneumonia triage process: 

  • Enablers and Barriers: What enablers and barriers do nurses and clinicians face when incorporating IMCI pneumonia steps into the ETAT process? 
  • IMCI “Champions”:  Do trained nurses and clinicians share their IMCI and ETAT knowledge/skills with other facility staff?  What are the enablers and barriers to sharing of IMCI and ETAT knowledge and skills across facility staff? 
  • Quality of Care:  To what extent do children under five with possible pneumonia receive comprehensive IMCI for pneumonia diagnosis (between nurses and clinicians)? What is the experiential quality and level of satisfaction with care reported by caregivers? 

5. Key tasks

Task 1: Code and pilot survey tools

R4D will provide survey tools in both English and Swahili. Prior to each survey round, the data collection firm will be responsible for coding the survey tools into an electronic data collection format and will pilot the tools in a non-project area agreed upon prior to commencing the first round of data collection. A feedback report over e-mail will be provided to R4D that highlight the s success and challenges experienced during piloting. Upon a satisfactory review by the R4D, the data collection firm will update the survey tools and commence the tasks outlined below.

Task 2: In-person health facility surveys across three rounds of data collection

The data collection team will have the following tasks to complete on site (time estimates for each protocol in brackets): (1) Facility in-charge surveys (Round 1 only) to receive permission to conduct data collection, and receive information about the health facility’s resources and patient demographics (15 min); (2) Direct observation (All rounds) of nurse-patient and nurse-clinician interactions during the triage, diagnosis, and treatment process for children under five with possible pneumonia, including administrative records review (patient charts and booklets) (30 min); (3) Provider (clinicians and nurses) surveys (Round 2 and 3 only) focused on provider experience with and feedback on the IMCI pneumonia and ETAT triage process (30 min); and (4)Caregiver exit surveys (Round 2 and 3 only) focused on experiential quality of care and satisfaction (5 min).

Task 3: Rapid cleaning and processing of data

Following each round of data collection, ‘Learning Checks’ will be held to adapt the triage improvement program. Every effort will be made to minimize open ended responses, such that survey data can be quickly cleaned and processed ahead of rapid analysis. The R4D team will work with the contractor on a feasible timeline for turning around each dataset.

6. Methodology

Data will be collected in three rounds to enable learning and adaptation during the pilot, including two rounds of direct observation, caregiver exit surveys, and patient record review prior to the beginning and at the end of the pilot and two rounds of provider surveys midway through implementation and at the end of the pilot (see Figure 2). The direct observation, caregiver exit survey, and patient record review process is described below:

We are open to applicant’s feedback on team structure, but we envision a team of three collaborating as described below:

  • A first enumerator observes consultations conducted by the nurse during the triage process for children under 5. An enumerator will be stationed at the nurses’ triage station in the Reproductive and Child Health (RCH) department of the facility to observe all consultations. With the consent of the caregiver, the enumerator will complete the Nurse Triage Direct Observation Checklist during each consultation with children under 5 (or suspected to be under five) to note the IMCI pneumonia steps and diagnostic techniques completed by the nurse. The enumerator will also record the determinations made by the nurse as to whether the child has respiratory symptoms that may indicate pneumonia and the child’s triage status (emergent case, priority case, non-urgent case). 
  • The nurse records patient data in the chart booklet and sends children under 5 with respiratory symptoms that may indicate pneumonia to the priority or emergent queues for clinician examination.  Emergent cases, including potential severe pneumonia cases, will be excluded from the study for immediate referral and treatment. The first enumerator will also observe the referral process between the triage nurse and the clinician. 
  • A second enumerator observes consultations conducted by the clinician for non-emergent children under 5 with respiratory symptoms. Children under 5 with respiratory symptoms that may indicate pneumonia will be classified as priority or emergent cases during triage and will be accordingly prioritized and seen by the clinician. During clinician consultation, the enumerator will complete the Clinician Direct Observation Checklist to note the IMCI pneumonia steps and diagnostic techniques completed by the clinician. The enumerator will also record the final diagnosis made by the clinician and the treatment prescribed, as well as the information and guidance provided to the caregiver. 
  • Following clinician examination, diagnosis, and prescription, a third enumerator conducts a brief survey with caregivers. With caregiver consent, a third enumerator will conduct a brief exit survey with caregivers of children under 5 with respiratory symptoms, using the Caregiver Questionnaire. This exit survey will focus on perceptions of and satisfaction with care received. As part of the caregiver exit survey, the enumerator will request permission to photograph the relevant pages of the patient chart booklet for patient record review as described above. 

The study team will work closely with RCHS, PO-RALG, and PAT to turn findings into action by facilitating one or more “Learning Check” meetings during which findings will be shared, implications discussed, and next steps/action plans developed. The following sub-sections describe data sources and sampling, analysis, dissemination of findings, and study limitations. Learning Checks will take place at pivot points within the operational research timeline (see Figure 3).

7. Data Sources and Sampling

Facilities criteria

  • Facilities in the following districts: Magu, Ukerewe, Ilemela, Nyamgana
  • Facilities that are already implementing ETAT 
  • Facilities that are covered by the recent USAID ETAT training, and had nurses/clinicians sampled for that training 
  • Note: The final sample is still under consideration, but it will be between 11 and 17 facilities (dispensaries, health centers, and hospitals)

Nurses ​​​​​​​

  • Selection criteria – nurses who attended recent USAID ETAT training AND who attend the pneumonia refresher training, who is responsible for triage of children under five in facilities (RCH departments, if relevant) 
  • Direct observation of nurses triaging all children under five to see if they are consistently conducting the IMCI pneumonia steps 

Clinicians ​​​​​​​

  • Selection criteria – clinicians who attended recent USAID ETAT training AND who attend the pneumonia refresher training, who are responsible for treating children under five (RCH departments, if relevant) 
  • Direct observation of clinicians examining/diagnosing only children who have been prioritized by nurses as potential pneumonia cases

Caregivers ​​​​​​​

  • Survey caregivers who come to facilities with a child under five displaying potential pneumonia symptoms (identified via the triage process) 
  • Survey all caregivers who have children flagged as possible pneumonia during triage, regardless of the final diagnosis. 

Administrative records  

  • Review/photograph patient chart booklets from caregivers surveyed

8. Responsibilities

R4D responsibilities:

 

  • Obtain ethical approval for the study from the National Institute for Medical Research (NIMR).
  • Provide firm with all data collection tools (in English and Swahili).
  • Provide firm with the list of health facilities that will be included in Tasks 1, 2, and 3.
  • Support preparation for data collection, as needed.
  • Work with data collection supervisors to oversee data collection.

Data collection firm responsibilities:

  • Facilitate any outstanding study approvals (beyond NIMR approval). Pilot all survey tools and provide feedback on the successes and challenges encountered during piloting. Ensure that all surveys have been properly coded and that the electronic data collection devices are ready to use in the field. Ensure that the data collection hardware and software are fully functional and error free. Conduct regular and consistent quality control measures on data collected through regular checks of the data using Stata as well as robust back- and spot-check plan for a subset of facilities.
  • Hire and compensate field enumerators and supervisors in accordance with local laws. Hiring a field team local to Mwanza preferred.
  • Input into training materials for enumerators and supervisors (all training materials will be co-authored with the R4D team).
  • Handle all logistics for training and piloting survey tools prior to each round of data collection.
  • Train the field enumerators and supervisors, ensuring that all staff used are well trained and conversant with survey implementation processes and the survey instruments.
  • Maintain constant communication with R4D during data collection, immediately reporting any issues/problems encountered.
  • Provide progress updates to R4D every two weeks while data collection is ongoing to summarize number of facilities visited, questionnaires completed, issues/problems encountered, and steps taken to resolve those issues/problems.
  • Provide R4D access to the raw data upon request.
  • Clean data and resolve any inconsistencies prior to submission of the final data set.
  • Adhere to the agreed upon timeline of major activities.
  • Submit deliverables as per agreed upon schedule.
  • Ensure complete confidentiality of the information collected in this survey with respect to all regulations and restrictions required by the National Institute for Medical Research (NIMR).

9. Deliverables

The data collection firm shall deliver the following for each round of data collection according to the schedule below:

1.   Enumerator training manual, to be delivered prior to training and piloting activities and updated for each round

2.   Coded survey tool to be delivered one week after the end of data collection activities

3.    Report on piloting to be delivered one week after the end of data collection activities

4.    Final work/field plan specifying enumerator teams and data collection timeline in each district to be delivered one week after the end of data collection activities

5.    Fully cleaned data set in Stata .dta format with accompanying codebook to be delivered one week after the end of data collection activities

6.    Technical project completion report documenting the survey process to be delivered one week after the end of data collection activities.

 

10. Survey team qualifications and expectations

Qualifications

Expectations and team structure

  • During data collection, the firm will provide a brief update on progress in the field after the first few days of data collection, as well as a concise progress report every two weeks, including the number of completed surveys, and main quality control figures. The training, designed by the data collection firm and approved by R4D, will consist of instructions and training modules on high quality data collection and data collection best practices, as well as to familiarize the team with the survey. R4D reserves the right to request removal of any enumerator throughout the duration of the survey citing the reasons why. Such a request will be discussed with R4D and acted on as necessary and in accordance with the laws of Tanzania. Survey tools will be piloted across all three facility types: hospitals, health centers, and dispensaries. All enumerators will be required to attend training sessions, as well as re-training sessions, throughout the data collection period.  R4D reserves the right to notify the data collection firm of any concerns with enumerator work and survey activities and to jointly investigate and identify solutions and actions as required.

  • Below is a list of minimum qualifications for the data collection team:
  • Good interpersonal skills for all survey staff.
  • Familiarity with health facility settings.
  • Project supervisors fluent in English and Kiswahili.
  • Prior experience conducting rapid surveys.

11. Approximate timing of activities

  • Round 1:

  • Preparation: Electronic surveys programmed; enumerators trained; instruments piloted and updated (Est. to be completed by October 7, 2022)

  • Data Collection: Round 1 data collected; cleaned dataset to be submitted to R4D (Est. to be completed by October 21, 2022)
  • Round 2:
  • Preparation: Refresher training on new tools introduced at Round 2 (caregiver survey and observation protocol) (Est. to be completed by November 4)
  • Data Collection: Round 2 data collected; cleaned dataset to be submitted to R4D (Est. to be completed by November 18, 2022)
  • Round 3:
  • Preparation: Round 2 data collected; cleaned dataset to be submitted to R4D R4D (Est. to be completed by December 2, 2022)
  • Data Collection: Round 3 data collected; cleaned dataset to be submitted to R4D (Est. to be completed by December 16, 2022)

12. Deliverables and payment schedule

  • The SOW described in this document includes three (3) total rounds of data collection. Because each round of data collection happens in rapid succession, we propose one payment of 50% of costs after the training report on piloting is submitted and the remaining 50% payment at the conclusion of data collection activities.