Improving social justice in observational studies: protocol for the development of a global and Indigenous STROBE-equity reporting guideline.

BACKGROUND: Addressing persistent and pervasive health inequities is a global moral imperative, which has been highlighted and magnified by the societal and health impacts of the COVID-19 pandemic. Observational studies can aid our understanding of the impact of health and structural oppression based on the intersection of gender, race, ethnicity, age and other factors, as they frequently collect this data. However, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline, does not provide guidance related to reporting of health equity. The goal of this project is to develop a STROBE-Equity reporting guideline extension. METHODS: We assembled a diverse team across multiple domains, including gender, age, ethnicity, Indigenous background, disciplines, geographies, lived experience of health inequity and decision-making organizations. Using an inclusive, integrated knowledge translation approach, we will implement a five-phase plan which will include: (1) assessing the reporting of health equity in published observational studies, (2) seeking wide international feedback on items to improve reporting of health equity, (3) establishing consensus amongst knowledge users and researchers, (4) evaluating in partnership with Indigenous contributors the relevance to Indigenous peoples who have globally experienced the oppressive legacy of colonization, and (5) widely disseminating and seeking endorsement from relevant knowledge users. We will seek input from external collaborators using social media, mailing lists and other communication channels. DISCUSSION: Achieving global imperatives such as the Sustainable Development Goals (e.g., SDG 10 Reduced inequalities, SDG 3 Good health and wellbeing) requires advancing health equity in research. The implementation of the STROBE-Equity guidelines will enable a better awareness and understanding of health inequities through better reporting. We will broadly disseminate the reporting guideline with tools to enable adoption and use by journal editors, authors, and funding agencies, using diverse strategies tailored to specific audiences.

Mapping regional variability of exclusive breastfeeding and its determinants at different infant's age in Tanzania.

INTRODUCTION: Despite its numerous benefits, exclusive breastfeeding (EBF) remains an underutilized practice. Enhancing EBF uptake necessitates a focused approach targeting regions where its adoption is suboptimal. This study aimed to investigate regional disparities in EBF practices and identify determinants of EBF among infants aged 0-1, 2-3, and 4-5 months in Tanzania. METHODS: This cross-sectional study utilized data from the 2015/16 Tanzania Demographic and Health Survey. A total of 1,015 infants aged 0-5 met the inclusion criteria, comprising 378 aged 0-1 month, 334 at 2-3 months, and 303 at 4-5 months. EBF practices were assessed using a 24-hour recall method. A generalized linear mixed model, with fixed covariates encompassing infant and maternal attributes and clusters for enumeration areas (EAs) and regions, was employed to estimate EBF proportions. RESULTS: Regional disparities in EBF were evident among infants aged 0-1, 2-3, and 4-5 months, with decline in EBF proportions as an infant's age increases. This pattern was observed nationwide. Regional and EA factors influenced the EBF practices at 0-1 and 2-3 months, accounting for 17-40% of the variability at the regional level and 40-63% at the EA level. Literacy level among mothers had a significant impact on EBF practices at 2-3 months (e.g., women who could read whole sentences; AOR = 3.2, 95% CI 1.1,8.8). CONCLUSION: Regional disparities in EBF proportions exist in Tanzania, and further studies are needed to understand their underlying causes. Targeted interventions should prioritize regions with lower EBF proportions. This study highlights the clustering of EBF practices at 0-1 and 2-3 months on both regional and EA levels. Conducting studies in smaller geographical areas may enhance our understanding of the enablers and barriers to EBF and guide interventions to promote recommended EBF practices.

Unmet need for modern contraception by HIV status: findings from community-based studies implemented before and after earlier ART initiation program in rural Tanzania.

BACKGROUND: Tanzania Health policy insists on the need to provide all women access to contraception despite HIV status. We used data from two HIV epidemiologic serological surveys carried out at different periods of ART provision in rural Tanzania to assess the level of unmet need for modern contraception by HIV status and associated factors. METHODS: We performed secondary data analysis of two surveys conducted at the Magu Health and Demographic Surveillance System site, in Mwanza, Tanzania. Information on unmet need for modern contraception was derived from fertility desire and contraception use. Unmet need, HIV status, and socioeconomic and demographic variables were analysed. The percentage of women with unmet needs for modern contraception by HIV status is presented for the 2012 and 2017 surveys. Bivariate and multivariate analyses using logistic regression were used to investigate associated factors showing adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs). RESULTS: Data from 3352 and 3196 women aged 15-49 years collected in the 2012 and 2017 surveys, respectively, were analysed. The percentages of women with unmet needs for modern contraception in the 2012 and 2017 surveys were 30.9% (95% CI 29.4-32.6) and 31.6% (95% CI 30.0-33.3), respectively. The unmet need for modern contraception was 26% lower in HIV-uninfected women in 2012 (aOR = 0.74; 95% CI 0.569-0.973); p = 0.031). Risk factors for unmet need for modern contraception in 2012 were HIV uninfected (adjusted OR = 0.74; 95% CI 0.569-0.973); p = 0.031), married marital status (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001), higher education (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001), and taking alcohol (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001). Only two factors were associated with unmet need for modern contraception in 2017: married marital status (adjusted OR = 0.46; 95% CI 0.305-0.722); p = 0.001) and women who earned for their families (aOR = 0.66; 95% CI 0.494-0.887); p = 0.006). DISCUSSION: Nearly one-third of women had an unmet need for modern contraception, which was lower in HIV-uninfected women than in WLHIV-infected women. The study has identified women whose demand for contraception has not been met: WLHIV, post marital women, women with low education and women who were reported to earn money for their families. Family planning interventions should be tailored to these groups of women.

Association between first birth caesarean delivery and adverse maternal-perinatal outcomes in the second pregnancy: a registry-based study in Northern Tanzania.

BACKGROUND: Caesarean delivery (CD) is the commonest obstetric surgery and surgical intervention to save lives of the mother and/or the new-borns. Despite been accepted as safe procedure, caesarean delivery has an increased risk of adverse maternal and fetal outcomes. The rising rate of caesarean delivery has been a major public health concern worldwide and the consequences that come along with it urgently need to be assessed, especially in resource limited settings. We aimed to examine the relationship between first birth caesarean delivery and adverse maternal and perinatal outcomes in the second pregnancy among women who delivered at a tertiary hospital in Northern Tanzania. METHODS: A retrospective cohort study was conducted using maternally-linked data from Kilimanjaro Christian Medical Centre. All women who had singleton second delivery between the years 2011 to 2015 were studied. A total of 5,984 women with singleton second delivery were analysed. Multivariable log-binomial regression was used to determine the association between first caesarean delivery and maternal-perinatal outcomes in the second pregnancy. RESULTS: Caesarean delivery in the first birth was associated with an increased risk of adverse maternal and perinatal outcomes in the second pregnancy. These included repeated CD (ARR 1.19; 95% CI: 1.05-1.34), pre/eclampsia (ARR 1.38; 95% CI: 1.06-1.78), gestational diabetes mellitus (ARR 2.80; 95% CI: 1.07-7.36), uterine rupture (ARR 1.56; CI: 1.05-2.32), peri-partum hysterectomy (ARR 2.28; CI: 1.04-5.02) and preterm birth (ARR 1.21; CI: 1.05-1.38). CONCLUSION: Caesarean delivery in their first pregnancy had an increased risk of repeated caesarean delivery and other adverse maternal-perinatal outcomes in the following pregnancy. Findings from this study highlight the importance of devising regional specific measures to mitigate unnecessary primary caesarean delivery. Additionally, these findings may help both clinicians and women in deciding against or for trial of labor after previous caesarean delivery in an event of absent direct obstetric indication.

Prediction of low Apgar score at five minutes following labor induction intervention in vaginal deliveries: machine learning approach for imbalanced data at a tertiary hospital in North Tanzania.

BACKGROUND: Prediction of low Apgar score for vaginal deliveries following labor induction intervention is critical for improving neonatal health outcomes. We set out to investigate important attributes and train popular machine learning (ML) algorithms to correctly classify neonates with a low Apgar scores from an imbalanced learning perspective. METHODS: We analyzed 7716 induced vaginal deliveries from the electronic birth registry of the Kilimanjaro Christian Medical Centre (KCMC). 733 (9.5%) of which constituted of low (< 7) Apgar score neonates. The 'extra-tree classifier' was used to assess features' importance. We used Area Under Curve (AUC), recall, precision, F-score, Matthews Correlation Coefficient (MCC), balanced accuracy (BA), bookmaker informedness (BM), and markedness (MK) to evaluate the performance of the selected six (6) machine learning classifiers. To address class imbalances, we examined three widely used resampling techniques: the Synthetic Minority Oversampling Technique (SMOTE) and Random Oversampling Examples (ROS) and Random undersampling techniques (RUS). We applied Decision Curve Analysis (DCA) to evaluate the net benefit of the selected classifiers. RESULTS: Birth weight, maternal age, and gestational age were found to be important predictors for the low Apgar score following induced vaginal delivery. SMOTE, ROS and and RUS techniques were more effective at improving "recalls" among other metrics in all the models under investigation. A slight improvement was observed in the F1 score, BA, and BM. DCA revealed potential benefits of applying Boosting method for predicting low Apgar scores among the tested models. CONCLUSION: There is an opportunity for more algorithms to be tested to come up with theoretical guidance on more effective rebalancing techniques suitable for this particular imbalanced ratio. Future research should prioritize a debate on which performance indicators to look up to when dealing with imbalanced or skewed data.

Development of a women's empowerment index for Tanzania from the demographic and health surveys of 2004-05, 2010, and 2015-16.

BACKGROUND: Women's empowerment is a multidimensional construct which varies by context. These variations make it challenging to have a concrete definition that can be measured quantitatively. Having a standard composite measure of empowerment at the individual and country level would help to assess how countries are progressing in efforts to achieve gender equality (SDG 5), enable standardization across and within settings and guide the formulation of policies and interventions. The aim of this study was to develop a women's empowerment index for Tanzania and to assess its evolution across three demographic and health surveys from 2004 to 2016. RESULTS: Women's empowerment in Tanzania was categorized into six distinct domains namely; attitudes towards violence, decision making, social independence, age at critical life events, access to healthcare, and property ownership. The internal reliability of this six-domain model was shown to be acceptable by a Cronbach's α value of 0.658. The fit statistics of the root mean squared error of approximation (0.05), the comparative fit index (0.93), and the standardized root mean squared residual (0.04) indicated good internal validity. The structure of women's empowerment was observed to have remained relatively constant across three Tanzanian demographic and health surveys. CONCLUSIONS: The use of factor analysis in this research has shown that women's empowerment in Tanzania is a six-domain construct that has remained relatively constant over the past ten years. This could be a stepping stone to reducing ambiguity in conceptualizing and operationalizing empowerment and expanding its applications in empirical research to study different women related outcomes in Tanzania.

Inequalities in stunting among under-five children in Tanzania: decomposing the concentration indexes using demographic health surveys from 2004/5 to 2015/6.

BACKGROUND: Child stunting is a global health concern. Stunting leads to several consequences on child survival, growth, and development. The absolute level of stunting has been decreasing in Tanzania from from 50% in 1991/92 to 34% in 2016 although the prevalence is still high (34%)Stunting varyies across socioeconomic determinants with a larger burden among the socioeconomic disadvantaged group. The reduction of inequalities in stunting is very crucial as we aim to reduce stunting to 28% by 2021 and hence attain zero malnutrition by 2030 under Sustainable Development Goal 2.2.This study aimed at determining the trend, contributing factors and changes of inequalities in stunting among children aged 3-59 months from 2004 to 2016. METHODS: Data were drawn from the Tanzania Demographic and Health Surveys. The concentration index (CIX) was used to quantify the magnitude of inequalities in stunting. The pooled Poisson regression model was used to determine the factors for stunting, decision criterion for significant determinants was at 5% level of significance. The CIX was decomposed using the Wagstaff and Watanabe decomposition methods., the percentage contribution of each factor to the toal concentration index was used to rank the factors for socioeconomic inequalities in stutning. RESULTS: Inequalities in stunting were significantly concentrated among the poor; evidenced by CIX = - 0.019 (p < 0.001) in 2004, - 0.018 (p < 0.001) in 2010 and - 0.0096 (p < 0.001) in 2015. There was insignificant decline in inequalities in stunting; the difference in CIX from 2004 to 2010 was 0.0015 (p = 0.7658), from 2010 to 2015/6 was - 0.0081 (p = 0.1145). The overall change in CIX from 2004 to 2015/6 was 0.00965 (p = 0.0538). Disparities in the distribution of wealth index (mean contribution > 84.7%) and maternal years of schooling (mean contribution > 22.4%) had positive impacts on the levels of inequalities in stunting for all surveyed years. Rural-urban differences reduced inequalities in stunting although the contribution changed over time. CONCLUSION: Inequalities in stunting declined, differentials in wealth index and maternal education had increased contribution to the levels of inequalities in stunting. Reducing stunting among the disadvantaged groups requires initiatives which should be embarked on the distribution of social services including maternal and reproductive education among women of reproductive age, water and health infrastructures in remote areas.

Building sustainable research capacity at higher learning institutions in Tanzania through mentoring of the Young Research Peers.

BACKGROUND: Sustainability of research culture in Sub-Saharan Africa is threatened in part by the lack of a critical mass of young researchers with the requisite skills and interest to undertake research careers. This paper describes an intensive mentorship programme combining hierarchical (vertical) and peer-to-peer (horizontal) mentoring strategies among young researchers in a resource limited setting in Sub-Saharan Africa. METHODS: A consortium of three partnering large Tanzanian health training institutions (MUHAS, CUHAS and KCMUCo) and two collaborating US institutions (UCSF and Duke University) was formed as part of the five-year Transforming Health Professions Education in Tanzania (THET) project, funded by the NIH through Health Professional Education Partnership Initiative (HEPI). Within THET, the Community of Young Research Peers (CYRP) was formed, comprising of inter-professional and cross-institutional team of 12 Master-level Young Research Peers and 10 co-opted fellows from the former MEPI-Junior Faculty (MEPI-JF) project. The Young Peers received mentorship from senior researchers from the consortium through mentored research awards and research training, and in turn provided reciprocal peer-to-peer mentorship as well as mentorship to undergraduate students. RESULTS: At the end of the first 2 years of the project, all 12 Young Peers were proceeding well with mentored research awards, and some were at more advanced stages. For example, three articles were already published in peer reviewed journals and two other manuscripts were in final stages of preparation. All 12 Young Peers participated in CYRP-wide thematic training workshops on mentoring and secondary data analysis; 11 had undertaken at least three research training short courses in identified areas of need; 9 joined at least one other ongoing research project; 5 made at least one scientific presentation, and 5 participated in at least one submitted grant application. Half of the Young Peers have enrolled in PhD programmes. A collective total of 41 undergraduate students were actively mentored by the Young Peers in research. CONCLUSION: The CYRP has demonstrated to be an effective model for dual vertical and horizontal mentorship in research to young investigators in resource-limited settings. This model is recommended to educators working on developing research competence of early career researchers, particularly in Sub-Saharan Africa.

Determinants of isoniazid preventive therapy completion among people living with HIV attending care and treatment clinics from 2013 to 2017 in Dar es Salaam Region, Tanzania. A cross-sectional analytical study.

BACKGROUND: Tuberculosis (TB) disease is a common opportunistic infection among people living with HIV (PLHIV). WHO recommends at least 6 months of isoniazid Preventive Therapy (IPT) to reduce the risk of active TB. It is important to monitor the six-month IPT completion since a suboptimal dose may not protect PLHIV from TB infection. This study determined the six-month IPT completion and factors associated with six-month IPT completion among PLHIV aged 15 years or more in Dar es Salaam region, Tanzania. METHODS: Secondary analysis of routine data from PLHIV attending 58 care and treatment clinics in Dar es Salaam region was used. PLHIV, aged 15 years and above, who screened negative for TB symptoms and initiated IPT from January, 2013 to June, 2017 were recruited. Modified Poisson regression with robust standard errors was used to estimate prevalence ratios (PR) and 95% confidence interval (CI) for factors associated with IPT completion. Multilevel analysis was used to account for health facility random effects in order to estimate adjusted PR (APR) for factors associated with IPT six-month completion. RESULTS: A total of 29,382 PLHIV were initiated IPT, with 21,808 (74%) female. Overall 17,092 (58%) six-month IPT completion, increasing from 42% (773/1857) in year 2013 to 76% (2929/3856) in 2017. Multilevel multivariable model accounting for health facilities as clusters, showed PLHIV who were not on ART had 46% lower IPT completion compared to those were on ART (APR: 0.54: 95%CI: 0.45-0.64). There was 37% lower IPT completion among PLHIV who transferred from another clinic (APR: 0.63: 95% CI (0.54-0.74) compared to those who did not transfer. PLHIV aged 25-34 years had a 6% lower prevalence of IPT completion as compared to those aged 15 to 24 years (APR:0.94 95%CI:0.89-0.98). CONCLUSION: The IPT completion rate in PLHIV increased over time, but there was lower IPT completion in PLHIV who transferred from other clinics, who were aged 25 to 34 years and those not on ART. Interventions to support IPT in these groups are urgently needed.

Prevalence and risk factors for caesarean delivery following labor induction at a tertiary hospital in North Tanzania: a retrospective cohort study (2000-2015).

BACKGROUND: Labor induction is among the common and widely practiced obstetric interventions aiming at achieving vaginal delivery. However, cesarean section (CS) delivery incidences have been reported following its use. This study aimed at determining the prevalence and risk factors for caesarean delivery following labor induction among women who gave birth at a tertiary hospital in north-Tanzania. METHODS: A hospital-based retrospective cohort study was designed using maternally-linked data from Kilimanjaro Christian Medical Centre (KCMC) birth registry among women who gave birth to singleton babies from the year 2000 to 2015. All induced deliveries done in this period were studied. Women with multiple pregnancy, missing information on delivery mode and those with history of CS delivery were excluded. Relative risk and 95% Confidence Interval for risk factors for CS delivery following labor induction were estimated using log-binomial regression models. Robust variance estimation was used to account for repeated deliveries from the same subject. RESULTS: A total of 1088 deliveries were analysed. The prevalence of CS following labour induction was 26.75%. Independent risk factors for CS delivery were; primiparity (RR = 1.46; 95% CI: 1.18-1.81), high birthweight (RR =1.28; 95% CI: 1.02-1.61), post-term pregnancy (RR = 1.45; 95% CI: 1.09-1.93), and urban residence (RR =1.29; 95%CI: 1.05-1.58). CONCLUSION: In patients undergoing labor induction, primiparity, high birthweight, post dates and urban residence were found to associate with an elevated risk of caesarean delivery. Assessment of these factors prior to labor induction intervention is warranted to reduce adverse pregnancy outcomes associated with emergency caesarean delivery.

Factors influencing utilization of skilled birth attendant during childbirth in the Southern highlands, Tanzania: a multilevel analysis.

BACKGROUND: Use of skilled health provider (SBA) during and after childbirth has been reported to reduce maternal and newborn deaths; and is one of the key indicators monitored in Sustainable Development Goals (SDGs). Progress, levels and factors influencing utilization of SBA differ within and between countries. In Tanzania, SBA coverage stands at 64% while the national target is 80%; with wide variability between regions (42-96%). This study aimed at determining factors associated with utilization of skilled births providers during childbirth in Mbeya Region, Southern highlands, Tanzania. METHODS: This was a cross-sectional analytical study conducted in December 2015 to January 2016, in Mbeya Region. A total of 2844 women of reproductive age were enrolled, but only 1777 women who reported a live birth 5 years prior to the survey were included in this analysis. Multilevel logistic regression analyses were used to determine independent factors influencing utilization of SBA during childbirth. Random effects logistic model was used to assess the variability between clusters on the odds of using skilled birth attendants during delivery. RESULTS: In this setting, 81% of the women reported utilization of skilled births attendants during childbirth. ANC visits four times or more (aOR = 1.63-95% CI = 1.26, 2.10; p < 0.001) and having secondary education or higher (aOR = 2.16; 95% CI = 1.19-3.90; p = 0.011) were associated with increased SBA use during childbirth whereas having two (aOR = 0.51; 95% CI: 0.33-0.79; p = 0.003) or three children (aOR = 0.37; 95% CI: 0.27-0.58; p < 0.001) relative to one child, 30 to 60 min walking distance to the health facility (aOR = 0.66; 95% CI: 0.48-0.92; p = 0.012) and more than 1 h walking distance to the health facility (aOR = 0.43; 95% CI: 0.32-0.57; p < 0.001) compared to < 30 min; were associated with decreased SBA use during childbirth. CONCLUSION: The proportion of births attended by skilled births attendants was high, but 19% of the women are still left behind. Concentrated efforts to improve utilization of SBA should be targeted to women with low education, with higher number of children, and with low frequency of ANC attendance. Furthermore, community and facility interventions addressing transport for pregnant women are needed. Qualitative study to explore the barriers of SBA use among the 19% who are not using skilled assistance during childbirth is needed.

Modifiable risk factors for community-acquired pneumonia in children under 5 years of age in resource-poor settings: a case-control study.

OBJECTIVE: Despite the availability of vaccines and antibiotics, pneumonia remains the leading cause of mortality among children under 5 years of age. The objective of this study was to identify modifiable risk factors for community-acquired pneumonia (CAP) in children under 5 years of age in a vaccinated population. METHODS: A case-control study was conducted between January and December 2017. The cases included children aged 2-59 months with X-ray-confirmed pneumonia, whereas the controls were children from the community with no history of respiratory infection. A multivariable logistic regression model was used to determine the modifiable risk factors for CAP. RESULTS: A total of 113 children with X-ray-confirmed pneumonia and 350 healthy children were enrolled in this study. The median ages for the cases and controls were 13.7 (IQR = 7.2-25.3) and 13.4 (IQR = 6.0-24.8) months respectively. One (0.9%) child died after the enrolment. The independent predictors of CAP included a lack of exclusive breastfeeding for 6 months (aOR = 1.7, 95% CI = 1.0-2.9), underweight (aOR = 2.1, 95% CI = 1.0-4.5), unclean cooking fuel (aOR = 1.8, 95% CI = 1.0-3.3) and low income (aOR = 2.9, 95% CI = 1.6-5.4). No association was found between vaccination status and CAP. CONCLUSION: In addition to a lack of exclusive breastfeeding, children from families of low-economic status were at risk of contracting CAP. Since the risk factors are complex, the study results call for more concerted efforts by and collaboration among the health, agriculture and development sectors to address mortality caused by CAP.

OBJECTIF: Malgré la disponibilité des vaccins et des antibiotiques, la pneumonie reste la principale cause de mortalité chez les enfants de moins de cinq ans. L'objectif de cette étude était d'identifier les facteurs de risque modifiables pour la pneumonie acquise en communauté (PAC) chez les enfants de moins de cinq ans dans une population vaccinée. MÉTHODES: Une étude cas-témoins a été menée entre janvier et décembre 2017. Les cas concernaient des enfants âgés de 2 à 59 mois atteints de pneumonie confirmée par la radiographie, alors que les témoins étaient des enfants de la communauté sans antécédents d'infection respiratoire. Un modèle de régression logistique multivariée a été utilisé pour déterminer les facteurs de risque modifiables pour la PAC. RÉSULTATS: Au total, 113 enfants atteints de pneumonie confirmée par la radiographie et 350 enfants en bonne santé ont été inclus dans cette étude. Les âges médians pour les cas et les témoins étaient respectivement de 13,7 (IQR = 7,2 - 25,3) et de 13,4 (IQR = 6,0 - 24,8) mois. Un enfant (0,9%) est décédé après l'inscription. Les prédicteurs indépendants de la PAC comprenaient une absence d'allaitement exclusif pendant six mois (aOR = 1,7; IC95%: 1,0 - 2,9), un poids insuffisant (aOR = 2,1; IC95%: 1,0 - 4,5), un combustible de cuisson non propre (aOR = 1,8; IC95%: 1,0 - 3,3) et un faible revenu (aOR = 2,9; IC95%: 1,6 - 5,4). Aucune association n'a été trouvée entre le statut de vaccination et la PAC. CONCLUSION: Outre l'absence d'allaitement maternel exclusif, les enfants issus de familles à faible statut économique étaient à risque de contracter la PAC. Les facteurs de risque étant complexes, les résultats de l'étude appellent à des efforts plus concertés et une collaboration accrue entre les secteurs de la santé, de l'agriculture et du développement afin de lutter contre la mortalité causée par la PAC.

Enrollment in HIV Care and Treatment Clinic and Associated Factors Among HIV Diagnosed Patients in Magu District, Tanzania.

HIV care and treatment clinics (CTC) are important for management of HIV morbidity and mortality, and to reduce HIV transmission. Enrollment in HIV care and treatment clinics remains low in many developing countries. We followed up 632 newly diagnosed HIV patients aged 15 years and above from Magu District, Tanzania. Logistic regression was used to assess factors significantly associated with enrollment for CTC services. Kaplan-Meier plots and log-rank tests were used to evaluate differences in timing uptake of services. Among 632 participants, 214 (33.9%) were enrolled in CTC, and of those enrolled 120 (56.6%) took longer than 3 months to enroll. Those living in more rural villages were less likely to be enrolled than in the villages with semi-urban settings (OR 0.36; 95% CI 0.17-0.76). Moreover, those with age group 35-44 years and with age group 45 years and above were 2 times higher odds compared to those with age group 15-24 years, (OR 2.03; 95% CI 1.05-3.91) and (OR 2.69; 95% CI 1.40-5.18) respectively. Enrollment in the CTC in Tanzania is low. To increase uptake of antiretroviral therapy, it is critical to improve linkage between HIV testing and care services, and to rollout these services into the primary health facilities.

Attitudes Toward Long-Term Use of Antiretroviral Therapy Among HIV-Infected Pregnant Women in Moshi, Tanzania: A Longitudinal Study.

Adherence to antiretroviral therapy (ART) during pregnancy and the postpartum period is necessary to prevent vertical HIV transmission and to secure the long-term health of an HIV-infected woman. Health behavior theory suggests that patients' attitudes towards medication can predict their medication-taking behaviour. This study sought to understand how women's attitudes towards ART changes between the pregnancy and postpartum periods, and the factors associated with these attitudes. The study enrolled 200 pregnant women living with HIV. Structured surveys were administered during pregnancy and at three and 6 months postpartum. Overall, attitudes towards ART were stable over time. More positive attitudes towards ART were associated with HIV acceptance, lower levels of depression, and lower levels of shame. Counselling interventions are needed to help HIV-infected women accept their status and reduce shameful emotions. Depression screening and treatment should be integrated into PMTCT services. This study emphasizes the importance of early attention to attitudes towards ART, in order to establish a trajectory of sustained care engagement.

Effect of isoniazid preventive therapy on tuberculosis incidence and associated risk factors among HIV infected adults in Tanzania: a retrospective cohort study.

BACKGROUND: Tuberculosis (TB) continues to be the leading cause of morbidity and mortality among human immunodeficiency virus (HIV) infected individuals in Sub Saharan Africa including Tanzania. Provision of isoniazid preventive therapy (IPT) is one of the public health interventions to reduce the burden of TB among HIV infected persons. However there is limited information about the influence of IPT on TB incidence in Tanzania. This study aimed at ascertaining the effect of IPT on TB incidence and to determine risk factors for TB among HIV positive adults in Dar es Salaam region. METHODS: A retrospective cohort study was conducted using secondary data of HIV positive adults receiving care and treatment services in Dar es Salaam region from 2011 to 2014. TB incidence rate among HIV positive adults on IPT was compared to those who were not on IPT during the follow up period. Risk factors for incident TB were estimated using multivariate Cox proportional hazards regression model. RESULTS: A total of 68,378 HIV positive adults were studied. The median follow up time was 3.4 (IQR = 1.9-3.8) years for patients who ever received IPT and 1.3 (IQR = 0.3-1.3) years among those who never received IPT. A total of 3124 TB cases occurred during 114,926 total person-years of follow up. The overall TB incidence rate was 2.7/100 person-years (95%CI; 2.6-2.8). Patients on IPT had 48% lower TB incidence rate compared to patients who were not on IPT (IRR = 0.52, 95%CI; 0.46-0.59). Factors associated with higher risk for incident TB included; being male (aHR = 1.8, 95% CI; 1.6-2.0), WHO stage III (aHR = 2.7, 95% CI; 2.3-3.3) and IV (aHR = 2.4, 95% CI; 1.9-3.1),being underweight (aHR = 1.7, 95% CI; 1.5-1.9) while overweight (aHR = 0.7, 95% CI; 0.6-0.8), obese (aHR = 0.5, 95% CI; 0.4-0.7), having baseline CD4 cell count between 200 and 350 cells/µl (aHR = 0.7, 95% CI; 0.6-0.8) and CD4 count above 350 cells/µl (aHR = 0.5, 95% CI; 0.4-0.6) were associated with lower risk of developing TB. CONCLUSION: Isoniazid preventive therapy (IPT) has shown to be effective in reducing TB incidence among HIV infected adults in Dar es Salaam. More efforts are needed to increase the provision and coverage of IPT.

Grand multiparity as a predictor of adverse pregnancy outcome among women who delivered at a tertiary hospital in Northern Tanzania.

BACKGROUND: Grand multiparity has been associated with increased risks of adverse pregnancy outcomes such as post-partum hemorrhage,gestational hypertension, gestationaldiabetes mellitus and high perinatal mortality.There is limited information about the impact of high parity on pregnancy outcomes in Tanzania. This study aimed to determine prevalence, trend and associated adverse pregnancy outcomes of grand multiparity in a tertiary hospital in Northern Tanzania. METHODS: A retrospective cross-sectional study was conducted at Kilimanjaro Christian Medical Centre (KCMC) using maternally linked data from medical birth registry. Women with singleton deliveries from 2006 to 2014 were analyzed. The prevalence of grand-multiparity was computed as proportion to estimate the trend over years. Adverse pregnancy outcomes associated with grand multiparity were estimated using multivariable logistic regression models. A p-value of < 0.05 was considered statistically significant. RESULTS: The overall prevalence of grand multiparity was 9.44% ranging from 9.72% in 2006 to 8.49% in 2014. The grand multiparous women had increased odds of prelabour rupture of membranes (Adjusted odds ratio [AOR] 1.78: 95% CI:1.28-2.49), stillbirth (AOR 1.66: 95% CI:1.31-2.11) and preterm birth delivery (AOR 1.28; 95% CI: 1.05-1.56) as compared to women in the lower parity group. CONCLUSIONS: The prevalence of grand multiparity among women in North-Tanzania was 9.44%. It was significantly associated with adverse pregnancy outcomes. This calls for a need to increase community awareness on its risks, encourage birth control among older women. Delivery-care facilities should prepare for emergency situation when attending deliveries of high parity group.

Knowledge towards cervical cancer prevention and screening practices among women who attended reproductive and child health clinic at Magu district hospital, Lake Zone Tanzania: a cross-sectional study.

BACKGROUND: Cervical cancer is a global leading cause of morbidity and mortality, attributable to the death of approximately 266,000 women every year. Majority (87%) of cervical cancer deaths occur in developing countries including Tanzania. Though knowledge of cervical cancer is an important determinant of women's participation in prevention and screening for cervical cancer, little is known about this topic in Tanzania. This study aimed to determine the knowledge of cervical cancer prevention services and screening practices among women who attended Reproductive Child Health clinic at a district hospital in Lake Zone, Tanzania. This information is important to help designing appropriate interventions and scaling up cervical cancer control programs, hence accelerate the achievement towards Sustainable Development Goals. METHODS: A cross-sectional study was conducted from March to June 2017, involving 307 women attending reproductive and child health clinic at Magu district hospital. A questionnaire adopted from the validated Cervical Cancer Awareness Measure was used to collect data from the study participants. Data was analysed using SPSS version 20. Descriptive statistics were summarized using frequencies and percentages for categorical variables while mean and standard deviation was used for continuous variables. Multivariable logistic regressions model was used to estimate Adjusted Odds ratio with 95% CI for factors associated with knowledge. RESULTS: Knowledge of cervical cancer was low, where 82.7% of the women scored less than 50%. Majority (82.4%) were aware about cervical cancer. Secondary education or higher (OR = 7.77, 95% CI: 1.70-35.48) and "knowing someone who has ever had cervical cancer" (OR = 2.19, 95% CI: 1.16-4.13) were significantly associated with higher knowledge. Only 14.3% of participants practiced cervical cancer screening. CONCLUSIONS: Majority of women lack comprehensive knowledge of cervical cancer and only few utilize screening services. Strategies for awareness creation about cervical cancer may help to improve knowledge and utilization of cancer screening practices.

The association between pre pregnancy body mass index and risk of preeclampsia: a registry based study from Tanzania.

BACKGROUND: Preeclampsia is among the leading causes of maternal mortality and morbidity worldwide, occurs in 2-8% of all pregnancies, and is estimated to account for at least 9 % of maternal deaths in Africa. Studies from developed countries show that high pre pregnancy body mass index (BMI) increases the risk of preeclampsia. We examined the association between pre pregnancy BMI and the risk of preeclampsia in Tanzania, a low income country. METHODS: Data from the Kilimanjaro Christian Medical Center (KCMC) Medical Birth Registry recorded between July 2000 and May 2013 were used. We restricted the study population to singleton deliveries among women with no or one previous pregnancy. Pre pregnancy BMI (kg/m2) was categorized according to the WHO categories of underweight (less than 18.5), normal (18.5 - 24.9), overweight (25.0 - 29.9) and obese (30 or more). Potential confounders were adjusted for in multivariable analyses. RESULTS: Among the 17,738 singleton births, 6.6% of the mothers were underweight, 62.1% were of normal BMI, 24.0% were overweight, and 7.3% were obese. Five hundred and eighty-two pregnancies (3.3%) were affected by preeclampsia. Compared to those with normal BMI, overweight and obese women had a higher risk of preeclampsia (aOR (95% CI) 1.4 (1.2 - 1.8) and 1.8 (1.3 - 2.4)), respectively, while underweight women had a lower risk (0.7 (0.4-1.1)). CONCLUSIONS: Pre pregnancy maternal overweight and obesity were associated with an increased risk of preeclampsia in Tanzania. Risks were similar to those reported in high income countries.

The decision delivery interval in emergency caesarean section and its associated maternal and fetal outcomes at a referral hospital in northern Tanzania: a cross-sectional study.

BACKGROUND: Decision delivery interval (DDI) is the time line between a decision to conduct an emergency caesarean section and actual delivery of the baby. Prolong DDI constitute a third phase delay in provision of emergency obstetric care. Intervention designed to minimize DDI are vital, in attempt to prevent maternal morbidity and neonatal morbidity and mortality. The feasibility and practicability of the recommended DDI in recent studies have been questioned especially in limited resource setting and therefore the objective of our study was to determine the DDI and its associated fetalmaternal outcomes at a tertiary referral hospital in Tanzania. METHODS: This was a retrospectivecross-sectional study of inpatient cases who underwent emergency caesarean section from January to September 2014. Data were collected from birth registry and case files of patients. Data analysis was performed using statistical package for social science (SPSS) version 22.0. Odds ratio (ORs) and 95% confidence interval for maternal and fetal outcomes associated with DDI were estimated using Logistic regression models. A p-value of less than 5% was considered statistically significant. RESULTS: A total of 598 women who underwent emergency caesarean section were recruited. The median Decision Delivery Interval was 60 min [IQR 40-120]. Only 12% were operated within 30 min from decision time. Shortest DDI was seen in patients with Cephalopelvic Disproportion (CPD) and uterine rupture (40 min and 45.5 min) as compared to other conditions. Cases with impending uterine rupture, cord prolapse, APH and fetal distress showed to have shorter DDI. There was no significant association between DDI and neonatal transfer,1st and 5thminute Apgar score, maternal blood loss (OR: 5.79; 95% CI 0.63-1.64) and hospital stay (OR: 1.02; 95% 0.63-1.64). CONCLUSIONS: Contrary to the recommended DDI by ACOG & AAP of 30 min is not feasible in our setting, time frame of 75 min could be acceptable but clinical judgment is required to assess on the urgency of caesarean section in order to prevent maternal and neonatal morbidity and mortality.

Assessing the effects of mosquito nets on malaria mortality using a space time model: a case study of Rufiji and Ifakara Health and Demographic Surveillance System sites in rural Tanzania.

BACKGROUND: Although malaria decline has been observed in most sub-Saharan African countries, the disease still represents a significant public health burden in Tanzania. There are contradictions on the effect of ownership of at least one mosquito net at household on malaria mortality. This study presents a Bayesian modelling framework for the analysis of the effect of ownership of at least one mosquito net at household on malaria mortality with environmental factors as confounder variables. METHODS: The analysis used longitudinal data collected in Rufiji and Ifakara Health Demographic Surveillance System (HDSS) sites for the period of 1999-2011 and 2002-2012, respectively. Bayesian framework modelling approach using integrated nested laplace approximation (INLA) package in R software was used. The space time models were established to assess the effect of ownership of mosquito net on malaria mortality in 58 villages in the study area. RESULTS: The results show that an increase of 10 % in ownership of mosquito nets at village level had an average of 5.2 % decrease inall age malaria deaths (IRR = 0.948, 95 % CI = 0.917, 0.977) in Rufiji HDSS and 12.1 % decrease in all age malaria deaths (IRR = 0.879, 95 % CI = 0.806, 0.959) in Ifakara HDSS. In children under 5 years, results show an average of 5.4 % decrease of malaria deaths (IRR = 0.946, 95 % CI = 0.909, 0.982) in Rufiji HDSS and 10 % decrease of malaria deaths (IRR = 0.899, 95 % CI = 0.816, 0.995) in Ifakara HDSS. Model comparison show that model with spatial and temporal random effects was the best fitting model compared to other models without spatial and temporal, and with spatial-temporal interaction effects. CONCLUSION: This modelling framework is appropriate and provides useful approaches to understanding the effect of mosquito nets for targeting malaria control intervention. Furthermore, ownership of mosquito nets at household showed a significant impact on malaria mortality.