Impact of the COVID-19 pandemic on type 2 diabetes care and factors associated with care disruption in Kenya and Tanzania.

BACKGROUND: The COVID-19 pandemic affected healthcare delivery globally, impacting care access and delivery of essential services. OBJECTIVES: We investigated the pandemic's impact on care for patients with type 2 diabetes and factors associated with care disruption in Kenya and Tanzania. METHODS: A cross-sectional study was conducted among adults diagnosed with diabetes pre-COVID-19. Data were collected in February-April 2022 reflecting experiences at two time-points, three months before and the three months most affected by the COVID-19 pandemic. A questionnaire captured data on blood glucose testing, changes in medication prescription and access, and healthcare provider access. RESULTS: We recruited 1000 participants (500/country). Diabetes care was disrupted in both countries, with 34.8% and 32.8% of the participants reporting change in place and frequency of testing in Kenya, respectively. In Tanzania, 12.4% and 17.8% reported changes in location and frequency of glucose testing, respectively. The number of health facility visits declined, 14.4% (p < 0.001) in Kenya and 5.6% (p = 0.001) in Tanzania. In Kenya, there was a higher likelihood of severe care disruption among insured patients (adjusted odds ratio [aOR] 1.56, 95% confidence interval [CI][1.05-2.34]; p = 0.029) and a lower likelihood among patients residing in rural areas (aOR, 0.35[95%CI, 0.22-0.58]; p < 0.001). Tanzania had a lower likelihood of severe disruption among insured patients (aOR, 0.51[95%CI, 0.33-0.79]; p = 0.003) but higher likelihood among patients with low economic status (aOR, 1.81[95%CI, 1.14-2.88]; p = 0.011). CONCLUSIONS: COVID-19 disrupted diabetes care more in Kenya than Tanzania. Health systems and emergency preparedness should be strengthened to ensure continuity of service provision for patients with diabetes.

Main findings: The COVID-19 pandemic disrupted diabetes care in Kenya and Tanzania resulting in changes in place and frequency of blood glucose testing, medication prescribed (less oral hypoglycaemics and more insulin), fewer health facility visits and more difficulty accessing healthcare providers.Added knowledge: This study quantifies the impact of the COVID-19 pandemic on diabetes care in Kenya and Tanzania, and describes the factors associated with care disruption in both countries.Global health impact for policy and action: Evidence on diabetes care disruption is useful in making plans and policies responsive to the needs of diabetes patients during pandemics or related emergency situations.

Factors associated with COVID-19 vaccine uptake among people with type 2 diabetes in Kenya and Tanzania: a mixed-methods study.

BACKGROUND: People with type 2 diabetes (T2D) are at increased risk of poor outcomes from COVID-19. Vaccination can improve outcomes, but vaccine hesitancy remains a major challenge. We examined factors influencing COVID-19 vaccine uptake among people with T2D in two sub-Saharan Africa countries that adopted different national approaches to combat COVID-19, Kenya and Tanzania. METHODS: A mixed-methods study was conducted in February-March 2022, involving a survey of 1000 adults with T2D (500 Kenya; 500 Tanzania) and 51 in-depth interviews (21 Kenya; 30 Tanzania). Determinants of COVID-19 vaccine uptake were identified using a multivariate logistic regression model, while thematic content analysis explored barriers and facilitators. RESULTS: COVID-19 vaccine uptake was lower in Tanzania (26%) than in Kenya (75%), which may reflect an initial political hesitancy about vaccines in Tanzania. People with college/university education were four times more likely to be vaccinated than those with no education (Kenya AOR=4.25 (95% CI 1.00 to 18.03), Tanzania AOR=4.07 (1.03 to 16.12)); and people with health insurance were almost twice as likely to be vaccinated than those without health insurance (Kenya AOR=1.70 (1.07 to 2.70), Tanzania AOR=1.81 (1.04 to 3.13)). Vaccine uptake was higher in older people in Kenya, and among those with more comorbidities and higher socioeconomic status in Tanzania. Interviewees reported that wanting protection from severe illness promoted vaccine uptake, while conflicting information, misinformation and fear of side-effects limited uptake. CONCLUSION: COVID-19 vaccine uptake among people with T2D was suboptimal, particularly in Tanzania, where initial political hesitancy had a negative impact. Policy-makers must develop strategies to reduce fear and misconceptions, especially among those who are less educated, uninsured and younger.

Measuring user experience of care among caregivers of sick children: Validation and descriptive analysis in a sample of 75 health facilities in rural Tanzania.

OBJECTIVE: User experience is an important aspect of quality of care that is highly valued by patients. However, there are currently no validated tools for measuring user experience among caregivers of sick children in low- and middle-income countries. We aimed to develop and validate a measure of user experience in this population in primary healthcare facilities in rural Tanzania, where major quality improvement efforts to date have not included a large focus on user experience. We then aimed to describe variation in user experience between and within facilities. METHODS: Informed by theory and formative qualitative research, we developed questions to measure user experience across three domains: prompt care, respect, and communication. We then conducted interviewer-administered surveys with caregivers of sick children. Using survey data, we conducted psychometric analyses to inform the development of a composite measure of user experience. Finally, we used multilevel models to describe variation in user experience and examine associations with facility, patient, and caregiver characteristics. RESULTS: Surveys were completed by 1085 caregivers across 75 facilities. In exploratory factor analysis, user experience items did not group according to theoretical domains. We therefore assessed items individually and designed a single 8-item additive measure of user experience. Using this composite measure, and adjusting for differences in case mix across facilities, we found that 69% of variation in user experience was within facilities and 31% was between facilities. Smaller facility size and more caregiver education were positively associated with user experience. CONCLUSIONS: We found that user experience varied significantly across health facilities in rural Tanzania, highlighting opportunities for improvement. Measurement tools are needed to inform efforts to improve user experience and monitor changes over time. The scale developed in this study could serve as a starting point for the measurement of user experience among caregivers in similar settings.

Socio-demographic characteristics and risk factors for HIV transmission in female bar workers in sub-Saharan Africa: a systematic literature review.

BACKGROUND: Although sex workers are considered a key population in the HIV epidemic in sub-Saharan Africa (SSA), less consideration has been given to female bar workers (FBW), whose primary occupation is not sex work but who often engage in transactional sex. Understanding FBWs' risk profiles is central to designing targeted HIV prevention interventions for them. This systematic review describes the socio-demographic characteristics and risk factors for HIV transmission among FBWs in SSA. METHODS: We searched six databases: PubMed, Google Scholar, Web of Science, Popline, Embase and additionally the World Health Organization's WHOLIS database for grey literature between July and September 2017. Inclusion criteria were reporting (1) primary socio-demographic or behavioral data; on (2) women who sold or delivered drinks to clients; (3) in establishments serving alcohol; (4) in SSA. We excluded studies not presenting separate data on FBWs. We extracted quantitative and qualitative data from the selected studies and conducted a qualitative synthesis of findings. RESULTS: We found 4565 potentially eligible articles, including duplicates. After applying inclusion and exclusion criteria, we retained 19 articles. FBWs often migrated from rural to urban areas due to economic need or social marginalization. They began bar-based transactional sex due to low wages, peer pressure and to increase financial independence. FBWs had high HIV risk awareness but low agency to negotiate condom use, particularly with regular partners or when offered higher prices for condomless sex. FBWs were also vulnerable to violence and stigmatization. CONCLUSIONS: FBWs are a vulnerable population for HIV infection. Despite social stigmatization and elevated risk of contracting STIs, bar work remains attractive because it enables unskilled women to both, make a living and maintain some independence. FBWs face HIV-related risk factors at the individual, community and societal level and may benefit from biomedical, behavioral and structural interventions.

Disrespectful treatment in primary care in rural Tanzania: beyond any single health issue.

Knowing how patients are treated in care is foundational for creating patient-centred, high-quality health systems and identifying areas where policies and practices need to adapt to improve patient care. However, little is known about the prevalence of disrespectful treatment of patients in sub-Saharan Africa outside of maternity care. We used data from a household survey of 2002 women living in rural Tanzania to describe the extent of disrespectful care during outpatient visits, who receive disrespectful care, and determine the association with patient satisfaction, rating of quality and recommendation of the facility to others. We asked about women's most recent outpatient visit to the local clinic, including if they were made to feel disrespected, if a provider shouted at or scolded them, and if providers made negative or disparaging comments about them. Women who answered yes to any of these questions were considered to have experienced disrespectful care. We report risk ratios with standard errors clustered at the facility level. The most common reasons for seeking care were fever or malaria (33.9%), vaccination (33.6%) and non-emergent check-up (13.4%). Disrespectful care was reported by 14.3% of women and was more likely if the visit was for sickness compared to a routine check-up [risk ratio (RR): 1.6, 95% confidence interval (CI): 1.1-2.2]. Women who did not report disrespectful care were 2.1 times as likely to recommend the clinic (95% CI: 1.6-2.7). While there is currently a lot of attention on disrespectful maternity care, our results suggest that this is a problem that goes beyond this single health issue and should be addressed by more horizontal health system interventions and policies.

Structural, interpersonal, psychosocial, and behavioral risk factors for HIV acquisition among female bar workers in Dar es Salaam, Tanzania.

In sub-Saharan Africa, female bar workers (FBWs) often serve as informal sex workers. Little is known about the prevalence of HIV and HIV-related risk factors among FBWs in Dar es Salaam (DSM), Tanzania. Using an adapted Structural HIV Determinants Framework, we identified structural, interpersonal, psychosocial, and behavioral risk factors for HIV acquisition. We compared the prevalence of HIV and HIV-related risk factors among a random sample of 66 FBWs from DSM to an age-standardized, representative sample of female DSM-residents from the 2016 Demographic and Health and 2011-2012 AIDS Indicator Surveys. Compared to other women in DSM, FBWs had elevated prevalence of all four groups of risk factors. Key risk factors included gender and economic inequalities (structural); sexual violence and challenges negotiating condom use (interpersonal); depression, post-traumatic stress disorder, and low social support (psychosocial); and history of unprotected sex, multiple sex partners, and high alcohol consumption (behavioral). HIV prevalence did not differ between FBWs (7.1%, 95% CI 3.7-13.3%) and survey respondents (7.7%, 95% CI: 5.3-11.1%), perhaps due to FBWs' higher - though sub-optimal - engagement with HIV prevention strategies. Elevated exposure to HIV-related risk factors but low HIV prevalence suggests economic, psychosocial, and biomedical interventions may prevent HIV among FBWs in DSM.

HIV risk and pre-exposure prophylaxis interest among female bar workers in Dar es Salaam: cross-sectional survey.

OBJECTIVE: Female bar workers (FBW) in East Africa often conduct sex work to supplement their incomes, and may be vulnerable to HIV acquisition. Pre-exposure prophylaxis (PrEP) offers protection against HIV acquisition. However, there is little research on FBW's sexual health. Our objective was to determine HIV risk behaviours and interest in PrEP among FBW in the largest city in East Africa. DESIGN: Cross-sectional survey covering respondents' work and personal lives, including social and behavioural risk factors for HIV. The survey aimed to determine the feasibility of working with FBW and HIV prevalence estimates. Those who did not report being HIV positive were asked about their knowledge of and interest in PrEP. All women were offered free on-site HIV testing and counselling (HTC). SETTING: Eight randomly selected workplaces, that is, bars, in Kinondoni district, Dar es Salaam (DSM). PARTICIPANTS: 66 FBW (≥18 years) selected at random from all women working in selected bars on the day of visit. RESULTS: Half of respondents reported having had sex for money: 20% with bar clients only, 15% with other men only and 15% with both. Almost all (98%) reported ≥1 non-commercial partners in the past 12 months; only 30% reported using condoms with these partners. 85% of respondents had ever been pregnant; 44% had had an unintended pregnancy. Only 5% of respondents had ever heard of PrEP. However, 54% were somewhat/very interested in daily-pill PrEP and 79% were somewhat/very interested in long-acting injectable PrEP. When asked to rank modalities, long-acting injectable PrEP was the most preferred. Seven per cent of the 56 respondents who completed HTC tested HIV positive. CONCLUSIONS: FBW in DSM have elevated risk factors for HIV acquisition, and PrEP appears highly acceptable. Studies developing PrEP delivery models and assessing PrEP initiation and adherence in FBW appear warranted.

Pay for performance: an analysis of the context of implementation in a pilot project in Tanzania.

BACKGROUND: Pay for performance schemes are increasingly being implemented in low income countries to improve health service coverage and quality. This paper describes the context within which a pay for performance programme was introduced in Tanzania and discusses the potential for pay for performance to address health system constraints to meeting targets. METHOD: 40 in-depth interviews and four focus group discussions were undertaken with health workers, and regional, district and facility managers. Data was collected on work environment characteristics and staff attitudes towards work in the first phase of the implementation of the pilot. A survey of 75 facilities and 101 health workers were carried out to examine facility resourcing, and health worker employment conditions and job satisfaction. RESULTS: Five contextual factors which affect the implementation of P4P were identified by health workers: salary and employment benefits; resource availability, including staff, medicines and functioning equipment; supervision; facility access to utilities; and community preferences. The results suggest that it is important to consider contextual issues when implementing pay for performance schemes in low income settings. It highlights the importance of basic infrastructures being in place, a minimum number of staff with appropriate education and skills as well as sufficient resources before implementing pay for performance. CONCLUSION: Health professionals working within a pay for performance scheme in Tanzania were concerned about challenges related to shortages of resources, limited supplies and unfavourable community preferences. The P4P scheme may provide the incentive and means to address certain constraints, in so far as they are within the control of providers and managers, however, other constraints will be harder to address.

Thermal care for newborn babies in rural southern Tanzania: a mixed-method study of barriers, facilitators and potential for behaviour change.

BACKGROUND: Hypothermia contributes to neonatal morbidity and mortality in low-income countries, yet little is known about thermal care practices in rural African settings. We assessed adoption and community acceptability of recommended thermal care practices in rural Tanzania. METHODS: A multi-method qualitative study, enhanced with survey data. For the qualitative component we triangulated birth narrative interviews with focus group discussions with mothers and traditional birth attendants. Results were then contrasted to related quantitative data. Qualitative analyses sought to identify themes linked to a) immediately drying and wrapping of the baby; b) bathing practices, including delaying for at least 6 hours and using warm water; c) day to day care such as covering the baby's head, covering the baby; and d) keeping the baby skin-to-skin. Quantitative data (n = 22,243 women) on the thermal care practices relayed by mothers who had delivered in the last year are reported accordingly. RESULTS: 42% of babies were dried and 27% wrapped within five minutes of birth mainly due to an awareness that this reduced cold. The main reason for delayed wrapping and drying was not attending to the baby until the placenta was delivered. 45% of babies born at a health facility and 19% born at home were bathed six or more hours after birth. The main reason for delayed bathing was health worker advice. The main reason for early bathing believed that the baby is dirty, particularly if the baby had an obvious vernix as this was believed to be sperm. On the other hand, keeping the baby warm and covered day-to-day was considered normal practice. Skin-to-skin care was not a normalised practice, and some respondents wondered if it might be harmful to fragile newborns. CONCLUSION: Most thermal care behaviours needed improving. Many sub-optimal practices had cultural and symbolic origins. Drying the baby on birth was least symbolically imbued, although resisted by prioritizing of the mothers. Both practical interventions, for instance, having more than one attendant to help both mother and baby, and culturally anchored sensitization are recommended.

Protocol for the evaluation of a pay for performance programme in Pwani region in Tanzania: a controlled before and after study.

BACKGROUND: The use of supply-side incentives to increase health service utilisation and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is a paucity of evidence on the impact of such schemes, their cost-effectiveness, and the process of implementation and potential unintended consequences in these settings. A pay for performance (P4P) programme was introduced in Pwani region of Tanzania in 2011. METHODS/DESIGN: An evaluation of the programme will be carried out to inform a potential national rollout. A controlled before and after study will examine the effect of the P4P programme on quality, coverage, and cost of targeted maternal and newborn healthcare services and selected non-targeted services at facilities in Tanzania. Data will be collected from a survey of 75 facilities, 750 patients exiting consultations, over 75 health workers, and 1,500 households of women who delivered in the previous year, in all seven intervention districts. Data will be collected from the same number of respondents in four control districts. A process evaluation will examine: whether the P4P programme was implemented as planned; stakeholder response to the programme and its acceptability; and implementation bottlenecks and facilitating factors. Three rounds of process data collection will be conducted including a review of available P4P documents, individual interviews and focus group discussions with key informants working at facility and district level in five of the intervention districts, and at the regional and national levels. An economic evaluation will measure the cost-effectiveness of P4P relative to current practice from a societal perspective. DISCUSSION: This evaluation will contribute robust evidence on the impact and cost-effectiveness of P4P in a low income setting, as well as generate a better understanding of the feasibility of integrating complex intervention packages like P4P within health systems in resource poor settings.

Clean home-delivery in rural Southern Tanzania: barriers, influencers, and facilitators.

The study explored the childbirth-related hygiene and newborn care practices in home-deliveries in Southern Tanzania and barriers to and facilitators of behaviour change. Eleven home-birth narratives and six focus group discussions were conducted with recently-delivering women; two focus group discussions were conducted with birth attendants. The use of clean cloth for delivery was reported as common in the birth narratives; however, respondents did not link its use to newborn's health. Handwashing and wearing of gloves by birth attendants varied and were not discussed in terms of being important for newborn's health, with few women giving reasons for this behaviour. The lack of handwashing and wearing of gloves was most commonly linked to the lack of water, gloves, and awareness. A common practice was the insertion of any family member's hands into the vagina of delivering woman to check labour progress before calling the birth attendant. The use of a new razor blade to cut the cord was near-universal; however, the cord was usually tied with a used thread due to the lack of knowledge and the low availability of clean thread. Applying something to the cord was near-universal and was considered essential for newborn's health. Three hygiene practices were identified as needing improvement: family members inserting a hand into the vagina of delivering woman before calling the birth attendant, the use of unclean thread, and putting substances on the cord. Little is known about families conducting internal checks of women in labour, and more research is needed before this behaviour is targeted in interventions. The use of clean thread as cord-tie appears acceptable and can be addressed, using the same channels and methods that were used for successfully encouraging the use of new razor blade.

"These are not good things for other people to know": how rural Tanzanian women's experiences of pregnancy loss and early neonatal death may impact survey data quality.

Little research in low-income countries has compared the social and cultural ramifications of loss in childbearing, yet the social experience of pregnancy loss and early neonatal death may affect demographers' ability to measure their incidence. Ninety-five qualitative reproductive narratives were collected from 50 women in rural southern Tanzania who had recently suffered infertility, miscarriage, stillbirth or early neonatal death. An additional 31 interviews with new mothers and female elders were used to assess childbearing norms and social consequences of loss in childbearing. We found that like pregnancy, stillbirth and early neonatal death are hidden because they heighten women's vulnerability to social and physical harm, and women's discourse and behaviors are under strong social control. To protect themselves from sorcery, spiritual interference, and gossip--as well as stigma should a spontaneous loss be viewed as an induced abortion--women conceal pregnancies and are advised not to mourn or grieve for "immature" (late-term) losses. Twelve of 30 respondents with pregnancy losses had been accused of inducing an abortion; 3 of these had been subsequently divorced. Incommensurability between Western biomedical and local categories of reproductive loss also complicates measurement of losses. Similar gender inequalities and understandings of pregnancy and reproductive loss in other low-resource settings likely result in underreporting of these losses elsewhere. Cultural, terminological, and methodological factors that contribute to inaccurate measurement of stillbirth and early neonatal death must be considered in designing surveys and other research methods to measure pregnancy, stillbirth, and other sensitive reproductive events.