Cross-Sector Referral Processes to Meet the Health and Social Service Needs of Adolescents in Tanzania

Background: There are global calls to further promote adolescent health in lower- and middle countries (LMICs), yet preventative healthcare for this population is rare. The VITAA cohort study is testing a clinic-based and school-facilitated Adolescent Wellness Visit (AWVs) model delivered during the last year of primary school in Tanzania. AWVs include a range of health services and physical health concerns are addressed in the health system. As a clinical trial adhering to ethical best practices, our team also supports follow up for psychosocial concerns identified during the study (mental health, domestic violence, and household hunger) that may not be fully addressed within Tanzania’s health care system. The purpose of this study is (1) to explore service referral processes to promote adolescent development across three government sectors—health, education, and social welfare, and (2) to examine professionals’ experiences with and perceptions of cross-sector referral processes, and associated challenges and facilitators for completed referrals.

Methods: Twenty Tanzanian primary schools were recruited and randomized to either intervention or control arms. A total of 1,095 adolescents (526 boys + 569 girls; mean age 13) were enrolled. Participants in both arms were asked about experiences of depression, domestic violence, and household hunger. Data include descriptive statistics; and 22 focus group discussion (FGD) transcripts from 10 FGDs held with healthcare providers, 10 FGDs with school staff; and 2 FGDs with principals. Team-based thematic analysis was informed by the IOM Framework for Domains for Healthcare Quality.

Results: Among all participants, 45 (4%) experienced physical or emotional violence in the past 12 months; 8 (1%) experienced moderate/severe depression in the past two weeks; and 88 (8%) indicated moderate/severe household hunger in the past month. In the AWV intervention arm, 96 (19%) had mild or severe malnutrition. Domestic violence and depression related referrals went first to the education sector and then might have been followed up in the health and/or social welfare sectors; while malnutrition referrals were handled in the health sector first with possible follow-up in the social service sector.

Issues of equity and efficacy of referrals were the most prevalent themes from the FGDs, followed by patient-centered care. Health and education professionals indicated that many adolescents experience barriers to completing referrals, often financial. Educators reported traditionally handling domestic violence referrals, and they had concerns about how effective and patient-centered their referrals were for youth. Both health and education professionals identified access to social welfare officers as a key facilitator for completing referrals. All professionals wanted more opportunities for relationship building between the social service, education and health sectors (e.g. site visits).

Discussion: Tanzanian adolescents require access to both health and social service resources, yet referrals processes for social service-related needs is often locally variable. The ability to rely on school staff (principals and school counselors) is optimal, particularly in primary school, but as students start dropping out (or never starting) secondary school, the options for community-based screenings, referrals and follow-up care are more complex and require further stakeholder engagement to foster quality cross-sector referrals.