Accelerating caregivers' HIV status disclosure to community-based lay social welfare volunteers in Tanzania.

BACKGROUND: HIV status disclosure facilitates access to HIV-related prevention and treatment services and increases opportunities for social support, HIV risk reduction with partners, and index testing for sexual partners or children. This study assessed the effect of a program model of community-based social welfare volunteers on HIV status disclosure among caregivers of orphans and vulnerable children (OVC). METHODS: This was a longitudinal study, which was based on OVC caregivers who were beneficiaries of the USAID Kizazi Kipya project in Tanzania. They were enrolled (baseline) by community social welfare volunteers during 2017-2018, received services, and reassessed at midline in 2019. Caregivers who reported having been HIV tested, were asked to voluntarily report the status in order for the volunteers to establish and provide needed services. Those who reported their HIV status as negative or positive were grouped as "disclosed", and those who knew their status but did not report it were documented as "undisclosed". McNemar's tests compared disclosure rates at baseline and midline. Multivariable analysis was conducted using generalized estimating equation (GEE). RESULTS: The study analyzed 140,664 caregivers (72% female) from 81 district councils of Tanzania. Their mean age at enrollment was 47.4 years. Overall, 81.3% of the caregivers disclosed their HIV status to the project staff at baseline; this increased significantly to 96.1% at midline (p < 0.001). Disclosure at baseline varied significantly by sociodemographic characteristic (p < 0.05), with higher disclosure in females, among urban residents, and higher educated caregivers. However, the observed disclosure variations by sociodemographic characteristics at baseline disappeared at midline and disclosure reached around 96% across the characteristics (p > 0.05). In the multivariable analysis, caregivers' likelihood of HIV status disclosure was nearly 6 times higher at midline than at baseline, when baseline characteristics were adjusted for (OR = 5.76, 95% CI 5.59-5.94, p < 0.001). There were 26,329 caregivers who did not disclose their HIV status at baseline (i.e., 0% diclosure rate at baseline), but 94.7% (n = 24,933) had disclosed by midline, and their disclosure trend was rapidly increasing as their duration of exposure to the project increased. CONCLUSIONS: This study detected an increased caregivers' HIV status disclosure to the USAID Kizazi Kipya project staff by 14.8%, from 81.3% at baseline to 96.1% at midline within an average project exposure period of 1.4 years. The observed loss of sociodemographic differences in HIV status disclosure rate at midline implies that community-based interventions may be well-positioned to successfully address and eliminate sociodemographic barriers to service uptake and consequently improve services coverage and health outcomes.

Poor linkage to care for HIV-positive OVC with disabled caregivers: a longitudinal study in Tanzania.

BACKGROUND: Despite extensive efforts to scale up counseling and testing services and care and treatment clinics (CTCs) in Tanzania, linkage between points of diagnosis and CTCs remains low. Studies have looked at barriers such as lack of trained health providers, poor referral system, economic costs or distance to health facilities, but fewer assessed the association between caregivers' vulnerability such as disability and linkage of orphans and vulnerable children (OVCs) in their care to health facilities. This study describes the magnitude of caregivers' disability and assesses its relationship with successful linkage to care of their OVC living with HIV/AIDS in Tanzania. METHODS: Data for this analysis came from the USAID Kizazi Kipya project in 79 councils of Tanzania. Data on HIV risk, service use and ART adherence among OVC aged 0-19 years were collected during the project's quarterly routine data collection (Oct 2017-Sep 2018). Characteristics of caregivers were collected during the project beneficiary screening and enrollment process. Generalized estimating equation models were used to analyze the factors that are associated with linkage of 14,538 HIV positive OVC to CTC, who were taken care of by 11,834 caregivers. RESULTS: The majority of caregivers (70%) were females, had completed primary education (67%), 54% were married or cohabiting. Of all the OVC, 3% were living with disabled caregivers; of whom 89% were physically disabled while 11% were mentally disabled. OVCs living with disabled caregivers were less likely to be linked to care (OR 0.76, 95% CI 0.58, 0.99). Factors positively associated with OVC linkage to care were high caregivers' education level (OR 1.99, 95% CI 1.51, 2.63) and OVC living with a HIV positive caregivers (OR 1.25, 95% CI 1.12, 1.41). OVC living in household with high socio-economic status were less likely to be linked to care (OR 0.76, 95% CI 0.67, 0.86) than those in low-SES households. CONCLUSION: These results suggest HIV positive OVC living with disabled caregivers had poor linkage to care. The findings highlighted the need to focus attention to the disabilities-led household to promote inclusion and improve access to the HIV services.

Determinants of undisclosed HIV status to a community-based HIV program: findings from caregivers of orphans and vulnerable children in Tanzania.

BACKGROUND: HIV status disclosure facilitates receipt of HIV prevention and treatment services. Although disclosure to sexual partners, family members or friends has been extensively studied, disclosure to community-based HIV programs is missing. This study assesses the magnitude of, and factors associated with undisclosed HIV status to a community-based HIV prevention program among caregivers of orphans and vulnerable children (OVC) in Tanzania. METHODS: Data are from the USAID-funded Kizazi Kipya project that seeks to increase uptake of HIV, health, and social services by OVC and their caregivers in Tanzania. Data on OVC caregivers who were enrolled in the project during January-March 2017 in 18 regions of Tanzania were analyzed. Caregivers included were those who had complete information on their HIV status disclosure, household socioeconomic status, and sociodemographic characteristics. HIV status was self-reported, with undisclosed status representing all those who knew their HIV status but did not disclose it. Multilevel mixed-effects logistic regression, with caregivers' HIV status disclosure being the outcome variable was conducted. RESULTS: The analysis was based on 59,683 OVC caregivers (mean age = 50.4 years), 71.2% of whom were female. Of these, 37.2% did not disclose their HIV status to the USAID Kizazi Kipya program at the time of enrollment. Multivariate analysis showed that the likelihood of HIV status non-disclosure was significantly higher among: male caregivers (odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.16-1.28); unmarried (OR = 1.12, 95% CI 1.03-1.23); widowed (OR = 1.12, 95% CI 1.07-1.18); those without health insurance (OR = 1.36, 95% CI 1.28-1.45); age 61 + years (OR = 1.72, 95% CI 1.59-1.88); those with physical or mental disability (OR = 1.14, 95% CI 1.04-1.25); and rural residents (OR = 1.58, 95% CI 1.34-1.86). HIV status non-disclosure was less likely with higher education (p < 0.001); and with better economic status (p < 0.001). CONCLUSION: While improved education, economic strengthening support and expanding health insurance coverage appear to improve HIV status disclosure, greater attention may be required for men, unmarried, widowed, rural residents, and the elderly populations for their higher likelihood to conceal HIV status. This is a clear missed opportunity for timely care and treatment services for those that may be HIV positive. Further support is needed to support disclosure in this population.

ART use and associated factors among HIV positive caregivers of orphans and vulnerable children in Tanzania.

BACKGROUND: Utilization of antiretroviral therapy (ART) is crucial for better health outcomes among people living with the human immunodeficiency virus (PLHIV). Nearly 30% of the 1.6 million PLHIV in Tanzania are not on treatment. Since HIV positive status is the only eligibility criterion for ART use, it is critical to understand the obstacles to ART access and uptake to reach universal coverage of ART among PLHIV. For the caregivers of orphans and vulnerable children (OVC) LHIV and not on ART, attempts to identify them and ensure that they initiate and continue using ART is critical for their wellbeing and their ability to care for their children. METHODS: Data are from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya project that aims at scaling up the uptake of HIV/AIDS and other health and social services by orphans and vulnerable children (OVC) and their caregivers. HIV positive caregivers of OVC who were enrolled in the USAID Kizazi Kipya project between January 2017 and June 2018 were included in this cross-sectional study. The caregivers were drawn from 11 regions: Arusha, Iringa, Katavi, Kigoma, Mara, Mbeya, Morogoro, Ruvuma, Simiyu, Singida, and Tanga. The outcome variable was ART status (either using or not), which was enquired of each OVC caregiver LHIV at enrollment. Data analysis involved multivariable analysis using random-effects logistic regression to identify correlates of ART use. RESULTS: In total, 74,999 caregivers living with HIV with mean age of 44.4 years were analyzed. Of these, 96.4% were currently on ART at enrollment. In the multivariable analysis, ART use was 30% lower in urban than in rural areas (adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.61-0.81). Food security improved the odds of being on ART (OR = 1.29, 95% CI 1.15-1.45). Disabled caregivers were 42% less likely than non-disabled ones to be on ART (OR = 0.58, 95% CI 0.45-0.76). Male caregivers with health insurance were 43% more likely than uninsured male caregivers to be on ART (OR = 1.43, 95% CI 1.11-1.83). Caregivers aged 40-49 years had 18% higher likelihood of being on ART than the youngest ones. Primary education level was associated with 26% increased odds of being on ART than no education (OR = 1.26, 95% CI 1.13-1.41). CONCLUSIONS: Although nearly all the caregivers LHIV in the current study were on ART (96.4%), more efforts are needed to achieve universal coverage. The unreached segments of the population LHIV, even if small, may lead to worse health outcomes, and also spur further spread of the HIV epidemic due to unachieved viral suppression. Targeting caregivers in urban areas, food insecure households, who are uninsured, and those with mental or physical disability can improve ART coverage among caregivers LHIV.

Understanding the association between caregiver sex and HIV infection among orphans and vulnerable children in Tanzania: learning from the USAID Kizazi Kipya project.

BACKGROUND: Tanzania has met only 50.1% of the 90% target for diagnosing HIV in children. The country's pediatric case finding strategy uses global best practices of index testing, provider-initiated counselling and testing, and targeted community testing of at-risk populations to find about 50,000 children living with HIV (CLHIV) who are undiagnosed. However, context-specific strategies are necessary to find the hidden children to meet the full 90% target. This study assesses whether sex of the caregiver is associated with HIV status of orphans and vulnerable children (OVC) as a valuable strategy for enhanced pediatric case findings. METHODS: Data originate from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya Project, which works towards increasing OVC's and their caregivers' uptake of HIV/AIDS and other health and social services in Tanzania. Included in this study are 39,578 OVC ages 0-19 years who the project enrolled during January through March 2017 in 18 regions of Tanzania and who voluntarily reported their HIV status. Data analysis involved multi-level logistic regression, with OVC HIV status as the outcome of interest and caregiver's sex as the main independent variable. RESULTS: Three-quarters (74.3%) of the OVC included in the study had female caregivers, and their overall HIV prevalence was 7.1%. The prevalence was significantly higher (p < 0.001) among OVC with male caregivers (7.8%) than among OVC with female caregivers (6.8%), and indeed, multivariate analysis showed that OVC with male caregivers were significantly 40% more likely to be HIV-positive than those with female caregivers (OR = 1.40, 95% CI 1.08-1.83). This effect was the strongest among 0-4 year-olds (OR = 4.02, 95% CI 1.61-10.03), declined to 1.72 among 5-9 year-olds (OR = 1.72, 95% CI 1.02-2.93), and lost significance for children over age 9 years. Other significant factors included OVC age and nutritional status; caregiver HIV status and marital status; household health insurance status, and family size; and rural versus urban residence. CONCLUSIONS: OVC in Tanzania with male caregivers have a 40% higher likelihood of being HIV-positive than those with female caregivers. HIV risk assessment activities should target OVC with male caregivers, as well as OVC who have malnutrition, HIV-positive caregivers, or caregivers who do not disclose their HIV status to community volunteers. Further, younger HIV-positive OVC are more likely to live in rural areas, while older HIV-positive OVC are more likely to live in urban areas. These factors should be integrated in HIV risk assessment algorithms to enhance HIV testing yields and pediatric case-finding in the OVC population in Tanzania.

The impact of paid community health worker deployment on child survival: the connect randomized cluster trial in rural Tanzania.

BACKGROUND: This paper reports on a rigorously designed non-masked randomized cluster trial of the childhood survival impact of deploying paid community health workers to provide doorstep preventive, promotional, and curative antenatal, newborn, child, and reproductive health care in three rural Tanzanian districts. METHODS: From August, 2011 to June 2015 ongoing demographic surveillance on 380,000 individuals permitted monitoring of neonatal, infant and under-5 mortality rates for 50 randomly selected intervention and 51 comparison villages. Over the initial 2 years of the project, logistics and supply support systems were managed by the Ifakara Health Institute. In 2013, the experiment transitioned its operational design to logistical support managed by the Ministry of Health and Social Welfare with the goal of enhancing government operational ownership and utilization of results for policy. RESULTS: The baseline under 5 mortality rate was 81.3 deaths per 1000 live births with a 95% confidence interval (CI) of 77.2-85.6 in the intervention group and 82.7/1000 (95% CI 78.5-87.1) in the comparison group yielding an adjusted hazard ratio (HR) of 0.99 (95% CI 0.88-1.11, p = 0.867). After 4 years of implementation, the under 5 mortality rate was 73.2/1000 (95% CI 69.3-77.3) in the intervention group and 77.4/1000 (95% CI 73.8-81.1) in the comparison group (adjusted HR 0.95 [95% CI 0.86-1.07], p = 0.443). The intervention had no impact on neonatal mortality in either the first 2 years (HR 1.10 [95% CI 0.89-1.36], p = .392) or last 2 years of implementation (HR 0.98 [95% CI 0.74-1.30], p = .902). Although community health worker deployment significantly reduced mortality among children aged 1-59 months during the first 2 years of implementation (HR 0.85 [95% CI 0.76-0.96], p = 0.008), mortality among post neonates was the same in both groups in years three and four (HR 1.03 [95% CI 0.85-1.24], p = 0.772). Results adjusted for stock-out effects show that diminishing impact was associated with logistics system lapses that constrained worker access to essential drugs and increased post-neonatal mortality risk in the final two project years (HR 1.42 [95% CI 1·07-1·88], p = 0·015). CONCLUSIONS: Community health worker home-visit deployment had a null effect among neonates, and 2 years of initial impact among children over 1 month of age, but a null effect when tests were based on over 1 month of age data merged for all four project years. The atrophy of under age five effects arose because workers were not continuously equipped with essential medicines in years three and four. Analyses that controlled for stock-out effects suggest that adequately supplied workers had survival effects on children aged 1 to 59 months. TRIAL REGISTRATION: Registration for trial number ISRCTN96819844 was retrospectively completed on June 21, 2012.

Stakeholders' opinions and questions regarding the anticipated malaria vaccine in Tanzania.

BACKGROUND: Within the context of combined interventions, malaria vaccine may provide additional value in malaria prevention. Stakeholders' perspectives are thus critical for informed recommendation of the vaccine in Tanzania. This paper presents the views of stakeholders with regards to malaria vaccine in 12 Tanzanian districts. METHODS: Quantitative and qualitative methods were employed. A structured questionnaire was administered to 2123 mothers of under five children. Forty-six in-depth interviews and 12 focus group discussions were conducted with teachers, religious leaders, community health workers, health care professionals, and scientists. Quantitative data analysis involved frequency distributions and cross tabulations using Chi square test to determine the association between malaria vaccine acceptability and independent variables. Qualitative data were analysed thematically. RESULTS: Overall, 84.2% of the mothers had perfect acceptance of malaria vaccine. Acceptance varied significantly according to religion, occupation, tribe and region (p < 0.001). Ninety two percent reported that they will accept the malaria vaccine despite the need to continue using insecticide-treated nets (ITNs), while 88.4% reported that they will accept malaria vaccine even if their children get malaria less often than non-vaccinated children. Qualitative results revealed that the positive opinions towards malaria vaccine were due to a need for additional malaria prevention strategies and expectations that the vaccine will reduce visits to the health facility, deaths, malaria episodes and treatment-related expenses. Vaccine related questions included its side effects, efficacy, protective duration, composition, interaction with other medications, provision schedule, availability to the pregnant women, mode of administration (oral or injection?) and whether a child born of HIV virus or with a chronic illness will be eligible for the vaccine? CONCLUSION: Stakeholders had high acceptance and positive opinions towards the combined use of the anticipated malaria vaccine and ITNs, and that their acceptance remains high even when the vaccine may not provide full protection, this is a crucial finding for malaria vaccine policy decisions in Tanzania. An inclusive communication strategy should be designed to address the stakeholders' questions through a process that should engage and be implemented by communities and health care professionals. Social cultural aspects associated with vaccine acceptance should be integrated in the communication strategy.

A time-use study of community health worker service activities in three rural districts of Tanzania (Rufiji, Ulanga and Kilombero).

BACKGROUND: Despite expanding international commitment to community health worker (CHW) deployment, little is known about how such workers actually use their time. This paper investigates this issue for paid CHWs named "Community Health Agents," which in Swahili is "Wawezeshaji wa Afya ya Jamii" ("WAJA"), trained for 9 months in primary health care service delivery and deployed to villages as subjects of a randomized trial of their impact on childhood survival in three rural districts of Tanzania. METHODS: To capture information about time allocation, 30 WAJA were observed during conventional working hours by research assistants for 5 days each over a period of 4 weeks. Results were presented in term of percentage time allocation for direct client treatment, documentation activities, health education, health promotion non-work-related activities and personal activities. RESULTS: During routine 8-h workdays, 59.5 % of WAJA time was spent on the provision of health services and other work-related activities. Overall, WAJA spent 27.8 % of their work on traveling from home to home, 33.1 % on health education, 9.9 % of health promotion and only 12.3 % on direct patient care. Other activities related to documentation (7.8 %) and supervision (2.5 %). CONCLUSIONS: Results reflect the pressing obligations of WAJA to engage in activities other than direct work responsibilities during routine work hours. Time spent on work activities is primarily used for health education, promotion, moving between households, and direct patient care. However, greater effort should be directed to strengthening supervisory systems and follow-up of challenges WAJAs facing in order to increase proportion of working hours.

Unit cost analysis of training and deploying paid community health workers in three rural districts of Tanzania.

BACKGROUND: Tanzania, like other African countries, faces significant health workforce shortages. With advisory and partnership from Columbia University, the Ifakara Health Institute and the Tanzanian Training Centre for International Health (TTCIH) developed and implemented the Connect Project as a randomized cluster experimental trial of the childhood survival impact of recruiting, training, and deploying of a new cadre of paid community health workers (CHW), named "Wawazesha wa afya ya Jamii" (WAJA). This paper presents an estimation of the cost of training and deploying WAJA in three rural districts of Tanzania. METHODS: Costing data were collected by tracking project activity expenditure records and conducting in-depth interviews of TTCIH staff who have led the training and deployment of WAJA, as well as their counterparts at Public Clinical Training Centres who have responsibility for scaling up the WAJA training program. The trial is registered with the International Standard Randomized Controlled Trial Register number ( ISRCTN96819844 ). RESULTS: The Connect training cost was US$ 2,489.3 per WAJA, of which 40.1 % was for meals, 20.2 % for accommodation 10.2 % for tuition fees and the remaining 29.5 % for other costs including instruction and training facilities and field allowance. A comparable training program estimated unit cost for scaling-up this training via regional/district clinical training centres would be US$ 833.5 per WAJA. Of this unit cost, 50.3 % would involve the cost of meals, 27.4 % training fees, 13.7 % for field allowances, 9 % for accommodation and medical insurance. The annual running cost of WAJA in a village will cost US$ 1.16 per capita. CONCLUSION: Costs estimated by this study are likely to be sustainable on a large scale, particularly if existing regional/district institutions are utilized for this program.

Multilevel Analysis of Childbearing in Childhood in Tanzania's Rufiji District.

OBJECTIVES: To examine levels, trends and correlates of childbearing in childhood (CiC) in the Rufiji district of Tanzania from 2002 to 2010. METHODS: Using longitudinal data collected in, and by, the Rufiji health and demographic surveillance system in Tanzania from 2002 to 2010, all women who initiated childbearing in this period (n = 5491) were selected for analysis. CiC was defined as childbearing initiation before age 18. Data analysis involved one-way tabulations of each variable-most of which were socio-demographic-to obtain frequency distributions, cross-tabulations of CiC and each of the independent variables with a Chi square test for associations, and multivariate analysis using multilevel logistic regression to examine covariates of CiC. RESULTS: CiC was 44 % and remained constant over the 2002-2010 period (P = 0.623). The relative odds of CiC was significantly reduced by 83 percent among women with secondary or higher educational attainment relative to CiC among uneducated women (OR = 0.17, CI 0.12-0.23). Moreover, the odds of CiC significantly declines monotonically as relative household wealth increases by quintile (OR = 0.70, CI 0.57-0.86). CiC also declines significantly with employment and marital status of the respondent. CONCLUSIONS: CiC represents a challenging social and health problem. Forty-four percent of first time mothers in Rufiji district of Tanzania are of childhood age, and this has not changed over the past 9 years since 2002. Prioritizing girls' formal education-especially up to secondary level or higher-as well as devising some economic empowerment modalities, may be worthwhile measures towards curbing CiC in the study area.

Predictors of Health Care Seeking Behavior During Pregnancy, Delivery, and the Postnatal Period in Rural Tanzania.

Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are the World Health Organization recommendations for women to optimize maternal health outcomes. This study examines maternal compliance with the full recommended maternal health visits in rural Tanzania with the goal of illuminating interventions to reduce inequalities in maternal health. Methods Analysis included 907 women who had given birth within two years preceding a survey of women of reproductive age. Multinomial logistic regression was used to assess the influence of maternal, household, and community-level characteristics on four alternative classes defining relative compliance with optimal configuration of maternal health care seeking behavior. Results Parity, wealth index, timeliness of ANC initiation, nearest health facility type, religion, and district of residence were significant predictors of maternal health care seeking when adjusted for other factors. Multiparous women compared to primiparous were less likely to seek care at the high level [RRR 0.16, 95 % confidence interval (CI) 0.06-0.46], at the mid-level (RRR 0.22, 95 % CI 0.09-0.58), and the mid-low level (RRR 0.27, 95 % CI 0.09-0.80). Women in the highest wealth index compared to those in the poorest group were almost three times more likely to seek the highest two levels of care versus the lowest level (high RRR 2.92, 95 % CI 1.27-6.71, mid-level RRR 2.71, 95 % 1.31-5.62). Conclusion Results suggest that efforts to improve the overall impact of services on the continuum of care in rural Tanzania would derive particular benefit from strategies that improve maternal health coverage among multiparous and low socioeconomic status women.

Factors associated with compliance with the recommended frequency of postnatal care services in three rural districts of Tanzania.

BACKGROUND: High neonatal mortality persists in Tanzania. Rates of decline are slow, in part because postnatal care (PNC) services for addressing this problem remain severely underutilized. This study assesses factors associated with utilization of PNC among mothers in rural Tanzania. METHODS: This study analyzed household survey data collected in 2011 to understand health service utilization patterns among women of reproductive age and children less than 5 years of age in the Rufiji, Kilombero, and Ulanga districts of Tanzania. A total of 889 mothers were eligible for the current analysis. Multinomial logistic regression was used to determine factors associated with the likelihood of mothers seeking the WHO recommended PNC visits. RESULTS: The percent of newborns and their mothers with full PNC was low (10.4%). Factors explaining PNC completion were district of residence, ethnic group, pregnancy wantedness, ANC attendance, place of delivery, and any incidence of newborn. Mothers of unwanted pregnancies were less likely to attend PNC services compared to mothers of wanted pregnancies [for at least two PNC: aRRR = 0.57, 95% CI 0.35-0.94]. Sick newborns were more likely to receive PNC than newborns who were not sick during the first month after childbirth [for at least two PNC, aRRR = 3.52, 95% CI 2.12-5.86]. Mothers who attended ANC services more frequently were more likely to receive PNC services compared to those who had attended fewer than 2 ANC services [for 1 PNC, aRRR = 1.89, 95% CI 1.23-2.90]. Mothers who delivered at a health facility were less likely to attend PNC services compared to mothers who delivered outside a facility [for at least 2 PNC: aRRR = 0.42, 95% CI 0.26-0.76]. Model with interactions between ANC attendance and place of delivery shown that only ANC attendance had a positive and statistically significant effect on PNC visit. CONCLUSION: To achieve the WHO recommended number of PNC in rural Tanzania, our findings suggest the need to provide PNC through the community-based primary health care. Efforts to improve coverage of PNC should include expanding health education and counseling during childbirth and neonatal period to more effectively advocate PNC for newborns perceived to be healthy.

Social cognitive determinants of HIV voluntary counselling and testing uptake among married individuals in Dar es Salaam Tanzania: Theory of Planned Behaviour (TPB).

BACKGROUND: Cumulative evidence indicates increasing HIV infection among married individuals. Voluntary Counselling and Testing for HIV (HCT) is known to be an effective intervention to induce safer sex behaviour and access to early treatment, care and support among married individuals, which are important for HIV prevention. In this context, knowledge of factors associated with HCT uptake among married individuals is critical in promoting the use of the services. This study therefore intended to identify the social cognitive factors associated with acceptance of HCT among married individuals. METHODS: In a cross-sectional analytical study face to face questionnaires were administered among 200 randomly selected married individuals in Kinondoni district, Dar es Salaam Tanzania. The questionnaire included self-reported HCT, socio-demographic variables and social cognitive variables (attitude, subjective norms, perceived control and perceived risk). Logistic regression was used to identify the independent association of social cognitive predictors of HCT among married individuals. RESULTS: Nearly half (42%) of the respondents had never had HCT. Of the social cognitive constructs, the strongest predictor of HCT uptake was attitude (OR per additional score point = 1.07, 95% CI 1.04-1.10) followed by perceived behavioural control (OR = 1.04, 95% CI 1.02-1.06). Subjective norm and perceived risk were not associated with HCT uptake. CONCLUSION: Public health interventions targeting married individuals should be designed to enhance their positive attitude towards HCT and empower them to overcome barriers to the use of the services.

Childhood Illness Prevalence and Health Seeking Behavior Patterns in Rural Tanzania.

INTRODUCTION: This paper identifies factors influencing differences in the prevalence of diarrhea, fever and acute respiratory infection (ARI), and health seeking behavior among caregivers of children under age five in rural Tanzania. METHODS: Using cross-sectional survey data collected in Kilombero, Ulanga, and Rufiji districts, the analysis included 1,643 caregivers who lived with 2,077 children under five years old. Logistic multivariate and multinomial regressions were used to analyze factors related to disease prevalence and to health seeking behavior. RESULTS: One quarter of the children had experienced fever in the past two weeks, 12.0 % had diarrhea and 6.7 % experienced ARI. Children two years of age and older were less likely to experience morbidity than children under one year [ORfever = 0.77, 95 % CI 0.61-0.96; ORdiarrhea = 0.26, 95 % CI 0.18-0.37; ORARI = 0.60 95 % CI 0.41-0.89]. Children aged two and older were more likely than children under one to receive no care or to receive care at home, rather than to receive care at a facility [RRRdiarrhea = 3.47, 95 % CI 1.19-10.17 for "No care"]. Children living with an educated caregiver were less likely to receive no care or home care rather than care at a facility as compared to those who lived with an uneducated caregiver [RRRdiarrhea = 0.28, 95 % CI 1.10-0.79 for "No care"]. Children living in the wealthiest households were less likely to receive no care or home care for fever as compared to those who lived poorest households. Children living more than 1 km from health facility were more likely to receive no care or to receive home care for diarrhea rather than care at a facility as compared to those living less than 1 km from a facility [RRRdiarrhea = 3.50, 95 % CI 1.13-10.82 for "No care"]. Finally, caregivers who lived with more than one child under age five were more likely to provide no care or home care rather than to seek treatment at a facility as compared to those living with only one child under five. CONCLUSIONS: Our results suggest that child age, caregiver education attainment, and household wealth and location may be associated with childhood illness and care seeking behavior patterns. Interventions should be explored that target children and caregivers according to these factors, thereby better addressing barriers and optimizing health outcomes especially for children at risk of dying before the age of five.

Factors affecting uptake of optimal doses of sulphadoxine-pyrimethamine for intermittent preventive treatment of malaria in pregnancy in six districts of Tanzania.

BACKGROUND: Intermittent preventive treatment during pregnancy (IPTp) with optimal doses (two+) of sulphadoxine-pyrimethamine (SP) protects pregnant women from malaria-related adverse outcomes. This study assesses the extent and predictors of uptake of optimal doses of IPTp-SP in six districts of Tanzania. METHODS: The data come from a cross-sectional survey of random households conducted in six districts in Tanzania in 2012. A total of 1,267 women, with children aged less than two years and who had sought antenatal care (ANC) at least once during pregnancy, were selected for the current analysis. Data analysis involved the use of Chi-Square (χ2) for associations and multivariate analysis was performed using multinomial logistic regression. RESULTS: Overall, 43.6% and 28.5% of the women received optimal (two+) and partial (one) doses of IPTp-SP respectively during pregnancy. Having had been counseled on the dangers of malaria during pregnancy was the most pervasive determinant of both optimal (RRR = 6.47, 95% CI 4.66-8.97) and partial (RRR = 4.24, 95% CI 3.00-6.00) uptake of IPTp-SP doses. Early ANC initiation was associated with a higher likelihood of uptake of optimal doses of IPTp-SP (RRR = 2.05, 95% CI 1.18-3.57). Also, women with secondary or higher education were almost twice as likely as those who had never been to school to have received optimal SP doses during pregnancy (RRR = 1.93, 95% CI 1.04-3.56). Being married was associated with a 60% decline in the partial uptake of IPTp-SP (RRR = 0.40, 95% CI 0.17-0.96). Inter-district variations in the uptake of both optimal and partial IPTp-SP doses existed (P < 0.05). CONCLUSION: Counseling to pregnant women on the dangers of malaria in pregnancy and formal education beyond primary school is important to enhance uptake of optimal doses of SP for malaria control in pregnancy in Tanzania. ANC initiation in the first trimester should be promoted to enhance coverage of optimal doses of IPTp-SP. Programmes should aim to curb geographical barriers due to place of residence to enhance optimal coverage of IPTp-SP in Tanzania.

Access to institutional delivery care and reasons for home delivery in three districts of Tanzania.

INTRODUCTION: Globally, health facility delivery is encouraged as a single most important strategy in preventing maternal and neonatal morbidity and mortality. However, access to facility-based delivery care remains low in many less developed countries. This study assesses facilitators and barriers to institutional delivery in three districts of Tanzania. METHODS: Data come from a cross-sectional survey of random households on health behaviours and service utilization patterns among women and children aged less than 5 years. The survey was conducted in 2011 in Rufiji, Kilombero, and Ulanga districts of Tanzania, using a closed-ended questionnaire. This analysis focuses on 915 women of reproductive age who had given birth in the two years prior to the survey. Chi-square test was used to test for associations in the bivariate analysis and multivariate logistic regression was used to examine factors that influence institutional delivery. RESULTS: Overall, 74.5% of the 915 women delivered at health facilities in the two years prior to the survey. Multivariate analysis showed that the better the quality of antenatal care (ANC) the higher the odds of institutional delivery. Similarly, better socioeconomic status was associated with an increase in the odds of institutional delivery. Women of Sukuma ethnic background were less likely to deliver at health facilities than others. Presence of couple discussion on family planning matters was associated with higher odds of institutional delivery. CONCLUSION: Institutional delivery in Rufiji, Kilombero, and Ulanga district of Tanzania is relatively high and significantly dependent on the quality of ANC, better socioeconomic status as well as between-partner communication about family planning. Therefore, improving the quality of ANC, socioeconomic empowerment as well as promoting and supporting inter-spousal discussion on family planning matters is likely to enhance institutional delivery. Programs should also target women from the Sukuma ethnic group towards universal access to institutional delivery care in the study area.

Predictors of mistimed, and unwanted pregnancies among women of childbearing age in Rufiji, Kilombero, and Ulanga districts of Tanzania.

BACKGROUND: While unintended pregnancies pose a serious threat to the health and well-being of families globally, characteristics of Tanzanian women who conceive unintentionally are rarely documented. This analysis identifies factors associated with unintended pregnancies-both mistimed and unwanted-in three rural districts of Tanzania. METHODS: A cross-sectional survey of 2,183 random households was conducted in three Tanzanian districts of Rufiji, Kilombero, and Ulanga in 2011 to assess women's health behavior and service utilization patterns. These households produced 3,127 women age 15+ years from which 2,199 gravid women aged 15-49 were selected for the current analysis. Unintended pregnancies were identified as either mistimed (wanted later) or unwanted (not wanted at all). Correlates of mistimed, and unwanted pregnancies were identified through Chi-squared tests to assess associations and multinomial logistic regression for multivariate analysis. RESULTS: Mean age of the participants was 32.1 years. While 54.1% of the participants reported that their most recent pregnancy was intended, 32.5% indicated their most recent pregnancy as mistimed and 13.4% as unwanted. Multivariate analysis revealed that young age (<20 years), and single marital status were significant predictors of both mistimed and unwanted pregnancies. Lack of inter-partner communication about family planning increased the risk of mistimed pregnancy significantly, and multi-gravidity was shown to significantly increase the risk of unwanted pregnancy. CONCLUSIONS: About one half of women in Rufiji, Kilombero, and Ulanga districts of Tanzania conceive unintentionally. Women, especially the most vulnerable should be empowered to avoid pregnancy at their own will and discretion.

Multivariate mixed-effects ordinal logistic regression models with difference-in-differences estimator of the impact of WORTH Yetu on household hunger and socioeconomic status among OVC caregivers in Tanzania.

BACKGROUND: Although most of the livelihood programmes target women, those that involve women and men have been evaluated as though men and women were a single homogenous population, with a mere inclusion of gender as an explanatory variable. This study evaluated the impact of WORTH Yetu (an economic empowerment intervention to improve livelihood outcomes) on household hunger, and household socioeconomic status (SES) among caregivers (both women and men) of orphaned and vulnerable children (OVC) in Tanzania. The study hypothesized that women and men respond to livelihood interventions differently, hence a need for gender-disaggregated impact evaluation of such interventions. METHODS: This is a secondary analysis of longitudinal data, involving caregivers' baseline (2016-2019) and follow-up (2019-2020) data from the USAID Kizazi Kipya project in 25 regions of Tanzania. Two dependent variables (ie, outcomes) were assessed; household hunger which was measured using the Household Hunger Scale (HHS), and Socioeconomic Status (SES) using the Principal Component Analysis (PCA). WORTH Yetu, a livelihood intervention implemented by the USAID Kizazi Kipya project was the main independent variable whose impact on the two outcomes was evaluated using multivariate analysis with a multilevel mixed-effects, ordinal logistic regression model with difference-in-differences (DiD) estimator for impact estimation. RESULTS: The analysis was based on 497,293 observations from 249,655 caregivers of OVC at baseline, and 247,638 of them at the follow-up survey. In both surveys, 70% were women and 30% were men. Their mean age was 49.3 (±14.5) years at baseline and 52.7 (±14.8) years at the follow-up survey. Caregivers' membership in WORTH Yetu was 10.1% at the follow-up. After adjusting for important confounders there was a significant decline in the severity of household hunger by 46.4% among WORTH Yetu members at the follow-up compared to the situation at the baseline (adjusted Odds Ratio (aOR) = 0.536, 95% Confidence Interval (CI) [0.521, 0.553]). The decline was 45.7% among women (aOR = 0.543 [0.524, 0.563]) and 47.5% among men (aOR = 0.525 [0.497, 0.556]). Regarding SES, WORTH Yetu members were 15.9% more likely to be in higher wealth quintiles at the follow-up compared to the situation at the baseline (aOR = 1.159 [1.128, 1.190]). This impact was 20.8% among women (aOR = 1.208 [1.170, 1.247]) and 4.6% among men (aOR = 1.046 [0.995, 1.101]). CONCLUSION: WORTH Yetu was associated with a significant reduction in household hunger, and a significant increase in household SES among OVC caregivers in Tanzania within an average follow-up period of 1.6 years. The estimated impacts differed significantly by gender, suggesting that women and men responded to the WORTH Yetu intervention differently. This implied that the design, delivery, and evaluation of such programmes should happen in a gender responsive manner, recognising that women and men are not the same with respect to the programmes.

How mistimed and unwanted pregnancies affect timing of antenatal care initiation in three districts in Tanzania.

BACKGROUND: Early antenatal care (ANC) initiation is a doorway to early detection and management of potential complications associated with pregnancy. Although the literature reports various factors associated with ANC initiation such as parity and age, pregnancy intentions is yet to be recognized as a possible predictor of timing of ANC initiation. METHODS: Data originate from a cross-sectional household survey on health behaviour and service utilization patterns. The survey was conducted in 2011 in Rufiji, Kilombero and Ulanga districts in Tanzania on 3,127 women from whom 910 of reproductive age who had given birth in the past two years and sought ANC at least once during pregnancy were selected for the current analysis. ANC initiation was considered to be early only if it occurred in the first trimester of pregnancy gestation. A recently completed pregnancy was defined as mistimed if a woman wanted it later, and if she did not want it at all the pregnancy was termed as unwanted. Chi-square was used to test for associations and multinomial logistic regression was conducted to examine how mistimed and unwanted pregnancies relate with timing of ANC initiation. RESULTS: Although 49.3% of the women intended to become pregnant, 50.7% (34.9% mistimed and 15.8% unwanted) became pregnant unintentionally. While ANC initiation in the 1st trimester was 18.5%, so was 71.7% and 9.9% in the 2nd and 3rd trimesters respectively. Multivariate analysis revealed that ANC initiation in the 2nd trimester was 1.68 (95% CI 1.10-2.58) and 2.00 (95% CI 1.05-3.82) times more likely for mistimed and unwanted pregnancies respectively compared to intended pregnancies. These estimates rose to 2.81 (95% CI 1.41-5.59) and 4.10 (95% CI 1.68-10.00) respectively in the 3rd trimester. We controlled for gravidity, age, education, household wealth, marital status, religion, district of residence and travel time to a health facility. CONCLUSION: Late ANC initiation is a significant maternal and child health consequence of mistimed and unwanted pregnancies in Tanzania. Women should be empowered to delay or avoid pregnancies whenever they need to do so. Appropriate counseling to women, especially those who happen to conceive unintentionally is needed to minimize the possibility of delaying ANC initiation.

Gender-based distributional skewness of the United Republic of Tanzania's health workforce cadres: a cross-sectional health facility survey.

BACKGROUND: While severe shortages, inadequate skills and a geographical imbalance of health personnel have been consistently documented over the years as long term critical challenges in the health sector of the United Republic of Tanzania, there is limited evidence on the gender-based distribution of the health workforce and its likely implications. Extant evidence shows that some people may not seek healthcare unless they have access to a provider of their gender. This paper, therefore, assesses the gender-based distribution of the United Republic of Tanzania's health workforce cadres. METHODS: This is a secondary analysis of data collected in a cross-sectional health facility survey on health system strengthening in the United Republic of Tanzania in 2008. During the survey, 88 health facilities, selected randomly from 8 regions, yielded 815 health workers (HWs) eligible for the current analysis. While Chi-square was used for testing associations in the bivariate analysis, multivariate analysis was conducted using logistic regression to assess the relationship between gender and each of the cadres involved in the analysis. RESULTS: The mean age of the HWs was 39.7, ranging from 15 to 63 years. Overall, 75% of the HWs were women. The proportion of women among maternal and child health aides or medical attendants (MCHA/MA), nurses and midwives was 86%, 86% and 91%, respectively, while their proportion among clinical officers (COs) and medical doctors (MDs) was 28% and 21%, respectively. Multivariate analysis revealed that the odds ratio (OR) and 95% confidence interval (CI) that a HW was a female (baseline category is "male") for each cadre was: MCHA/MA, OR = 3.70, 95% CI 2.16-6.33; nurse, OR = 5.61, 95% CI 3.22-9.78; midwife, OR = 2.74, 95% CI 1.44-5.20; CO, OR = 0.08, 95% CI 0.04-0.17 and MD, OR = 0.04, 95% CI 0.02-0.09. CONCLUSION: The distribution of the United Republic of Tanzania's health cadres is dramatically gender-skewed, a reflection of gender inequality in health career choices. MCHA/MA, nursing and midwifery cadres are large and female-dominant, whereas COs and MDs are fewer in absolute numbers and male-dominant. While a need for more staff is necessary for an effective delivery of quality health services, adequate representation of women in highly trained cadres is imperative to enhance responses to some gender-specific roles and needs.