From trauma to transmission: exploring the intersection of adversity, substance use, and HIV risk in women's life histories.

BACKGROUND: At increased risk for poor health outcomes, physical and/or sexual violence, and onward transmission of HIV, women who use drugs and are living with HIV (WWUDHIV) are vulnerable and in need of services. Understanding the role of trauma across their life history may offer insights into HIV and drug use prevention and opportunities for intervention. We explored trauma and drug use among WWUDHIV in Dar es Salaam, Tanzania. METHODS: We conducted in-depth interviews with 30 WWUDHIV from January-March 2019. Interviewers used semi-structured interview guides and asked questions about the life history as related to drug use. Interviews were audio recorded, transcribed, translated, coded, and life histories charted. We utilized content analysis. RESULTS: Participants described death of family members as traumatic catalysts for drug use. Sexual partners early in their life history were often the point of introduction to drugs and source of HIV acquisition. Death of partners was present across many life histories and was a traumatic event negatively influencing life trajectories, including start of sex work for survival or to support drug use. Sex work in-turn often led to traumatic events including sexual and/or physical violence. HIV diagnosis for many participants followed the start of drug use, frequently occurred during pregnancy or severe illness and was described by most participants as a trauma. Despite this, particularly during pregnancy, HIV diagnosis was a turning point for some participant's desire to engage in drug use treatment. Traumatic events were often cumulative and regularly described as catalysts for poor mental health that could lead to new or increased drug use for coping. CONCLUSIONS: These findings suggest trauma is common in the life history of WWUDHIV and has negative impacts on drug use and HIV vulnerability. Our life history charting highlights the cumulative and cyclical nature of trauma and drug use in this population. This study allows for better understanding of trauma, drug use, and HIV prevention, which offers opportunities for intervention among a group with limited access to services: during adolescence for orphaned youth, following the death of a child or partner, and when vulnerable women engage with the health system (HIV diagnosis, pregnancy, illness).

Prevalence and predictors of depressive and anxiety symptoms in a sample of women who use drugs in Tanzania: the key role of drug use stigma.

BACKGROUND: Globally, women who use drugs face multiple health vulnerabilities, including poor mental health. Little is known about the mental health burden among women who use drugs in sub-Saharan Africa. This cross-sectional study examined the prevalence and predictors of depressive and anxiety symptoms among a sample of women who use drugs in Dar es Salaam, Tanzania. METHODS: We administered a cross-sectional survey to a non-random sample of 200 women who use drugs in Dar es Salaam between November 2018 and March 2019. We used descriptive statistics to characterize the study sample and fitted separate logistic regression models to assess depressive and anxiety symptoms and their predictors. RESULTS: The percentages of women reporting depressive and anxiety symptoms were 67.5% and 43.7%, respectively. Internalized drug use stigma (AOR = 1.34, 95% CI: 1.03-1.75) and prior attempts to stop heroin use (AOR = 2.99, 95% CI: 1.28-7.00) were associated with depressive symptoms. Enacted drug use stigma from health workers (AOR = 2.02, 95% CI: 1.34-3.04) and anticipated drug use stigma from family (AOR = 1.49, 95% CI: 1.02-2.16) were associated with anxiety symptoms. CONCLUSIONS: Depressive and anxiety symptoms were high among our study sample, with higher reports of symptoms of depression than anxiety. Drug use stigma was a key factor that contributed to elevated symptoms of depression and anxiety.

Knowledge, Implementation, and Gaps of Gender-Based Violence Management Guidelines among Health Care Workers.

(1) Background: Gender-based violence (GBV) is widespread globally and has a myriad of adverse effects but is vastly under-reported. Health care workers are among the first responders in GBV. The objective of this study was to assess the knowledge of health workers with regard to GBV and related management guidelines and implementation. (2) Methods: The study employed a descriptive, sequential mix-method study, beginning with the quantitative part, followed by the qualitative component. Qualitative analysis was conducted using a content framework approach. (3) Results: More than two-thirds (71.79%) of health workers were found to be generally knowledgeable about gender-based violence; however, only 36.9% had good knowledge about gender-based violence management guidelines for gender-based violence and the mean value for all the items was less than 3 which indicates poor knowledge of the management guideline. Additionally, only 36.8% found the gender-based violence management guidelines useful and practical in clinical care for gender-based violence cases. (4) Conclusions: The finding of this study revealed that knowledge of gender-based violence management guideline was not adequate among health workers and rarely used during management of GBV cases. This calls for continuous training and specific refresher courses, including on-site practical sessions, professionals' mentorship, and supervision.

Prevalence and factors associated with potential substance use disorders among police officers in urban Tanzania: a cross-sectional study.

BACKGROUND: Substance Use Disorders (SUDs) among Police Officers has been a concern to many professionals in the field of health, research and criminal justice since their work is subjected to higher levels of stress and hence more likely to use alcohol or tobacco as a coping mechanism. However, little is known about SUDs among Police Officers in Tanzania. Therefore, we assessed the prevalence and factors associated with SUDs among Police Officers in urban Tanzania. MATERIALS AND METHODS: A cross-sectional study was conducted between April and October 2019 among Police Officers in Dar es Salaam. Multistage cluster sampling technique was used to recruit study participants. The WHO-Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) version 3.0 was used to measure potential SUDs. Bivariate and multivariate analyses were performed to establish associations between potential SUDs and predictors of interest, and an alpha of 5% was used in sample size calculation. RESULTS: A total of 497 participants were enrolled, of these, 76.6% (376/491) were males, the median age (years) and IQR was 37.0 (30.0, 47.0). The prevalence of past three months use of alcohol and tobacco were 31.3% and 6.3%, respectively. About 13.3% (62/468) and 6.2% (29/468) of Police Officers met criteria for potential Alcohol Use Disorder (AUD) and potential Tobacco Use Disorder (TUD) respectively. In adjusted analysis, participants with depression had about two times increased odds for potential AUD (aOR: 2.27, 95% CI; 1.12 - 4.58, p = 0.023) than those with no depression. Potential AUD and depression were associated with about eight times (aOR: 8.03, 95% CI; 3.52 - 18.28, p < 0.01) and more than twice (aOR: 2.63, 95% CI; 1.12 - 6.15, p = 0.026) higher odds for potential TUD respectively. CONCLUSION: Substance use and potential substance use disorders particularly AUD and TUD are common among Police Officers in urban Tanzania. Depression was found to be an important factor for potential AUD and TUD among Police Officers and, a significant co-occurrence of potential AUD with potential TUD was observed. Findings from this study call for interventions, for example, the need to routinize the brief motivational interview services for alcohol and tobacco use among Police Officers.

HIV testing and associated factors among female sex workers in Tanzania: approaching the first 90% target?

Use of HIV testing services among FSW in sub-Saharan Africa (SSA) is below the desired UNAIDS target of 90%. We estimated the prevalence and factors associated with HIV testing among FSW in Dar es Salaam, Tanzania. A respondent-driven sampling method was used to recruit FSW aged 18. Modified Poisson regression models were used to determine factors associated with recent HIV testing. Of 958 surveyed FSW (median age 26 years), 85.4% (95% CI: 82.3, 88.1) reported to have ever been tested for HIV and 65.3% (95% CI: 61.2, 69.3) tested in the past 12 months. Condom use on the last day worked (prevalence ratio (PR) = 1.17; 95% CI: 0.99, 1.38), no or low self-perceived risk of HIV acquisition (PR = 1.16; 95% CI: 1.02, 1.32), having never felt stigmatized as a sex worker (PR = 1.18; 95% CI: 1.04, 1.33), and having been in contact with a peer educator (PR = 1.33; 95% CI: 1.18, 1.49) during the past year preceding the survey were associated with recent HIV testing. Interventions aiming to mitigate stigma due to sex work, improve health education to address risk perception as a barrier to HIV testing, and scaling up peer educator's engagement should be given priority.

Why local concepts matter: Using cultural expressions of distress to explore the construct validity of research instruments to measure mental health problems among Congolese women in Nyarugusu refugee camp.

There is considerable variation in the presentation of mental health problems across cultural contexts. Most screening and assessment tools do not capture local idioms and culturally specific presentations of distress, thus introducing measurement error and overlooking meaningful variation in mental health. Before applying screening and assessment tools in a particular context, a qualitative exploration of locally salient idioms and expression of distress can help assess whether existing measures are appropriate in a specific context as well as what adaptations may improve their construct validity. We aimed to employ a mixed-methods approach to describe and measure cultural concepts of distress among female Congolese survivors of intimate partner violence in Nyarugusu refugee camp, Tanzania. This sequential study used data from 55 qualitative (free-listing and in-depth) interviews followed by 311 quantitative interviews that included assessments of symptoms of common mental disorder to explore whether the symptom constellations were consistent across these methodologies. Results from thematic analysis of qualitative data and exploratory factor analysis of quantitative data converged on three concepts of distress: huzuni (deep sadness), msongo wa mawazo (stress, too many thoughts), and hofu (fear). The psychometric properties of these constructs were comparable to those of the three original common mental disorders measured by the quantitative symptom assessment tools-anxiety, depression, and post-traumatic stress disorder-adding weight to the appropriateness of using these tools in this specific setting. This mixed-methods approach presents an innovative additional method for assessing the local "cultural fit" of globally used tools for measuring mental health in cross-cultural research.

Testing for Drug-Related Infectious Diseases and Determinants among People Who Use Drugs in a Low-Resource Setting: A Respondent-Driven Cross-Sectional Survey.

(1) Background: There is a dearth of data on the levels and determinants of testing for drug-related infectious diseases among people who use drugs (PWUD). We assessed the proportions and determinants of testing for drug-related infectious diseases to inform ongoing interventions for PWUD. (2) Methods: A cross-sectional study involving 599 PWUD was conducted in Dar es Salaam and Tanga between January and February 2019. Data were collected through a researcher-administered questionnaire using handheld tablets. Logistic regression models were used to identify independent testing determinants for drug-related infectious diseases. (3) Results: A majority (98.0%) of participants were males, with a mean age of 36.8 (SD = 7.8) years. 75.0%, 40.6%, 38.6%, and 8.2% reported having ever tested for HIV, tuberculosis (TB), sexually transmitted infections (STIs), and viral hepatitis, respectively. The likelihood of HIV testing was higher among those living with someone (AOR = 2.18, 95% CI: 1.09-4.68) compared with those who were homeless and perceived treatment was appropriate (AOR = 2.18, 95% CI: 1.05-4.46), but was lower among those who experienced mild to moderate (AOR = 0.44, 95% CI: 0.21-0.95) and severe internalized stigma (AOR = 0.44, 95% CI: 0.22-0.94) compared with those reporting no internalized stigma, and among those who experienced financial difficulties resulting from spending on health care services (AOR = 0.60, 95% CI: 0.40-0.89). Perception of treatment appropriateness (AOR = 2.29, 96% CI: 1.10-5.06) and severe enacted stigma (AOR = 1.90, 95% CI: 1.06-3.42) were associated with increased odds of TB testing. The odds of STIs testing increased among those who were married (AOR = 2.31, 95% CI: 1.45-3.72) compared with those who were single and those who had experienced mild (AOR = 2.39, 95% CI: 1.28-4.53) or severe (AOR = 6.20, 95% CI: 1.99-23.83) sexual violence, compared with those who had not experienced sexual violence. However, the odds decreased among those who had been remanded in the past month (AOR = 0.64, 95% CI: 0.43-0.95) compared with those who were not remanded and among those who had financial difficulties resulting from spending on health care services (AOR = 0.66, 95% CI: 0.47-0.94). The likelihood of testing for viral hepatitis testing increased among those who had heard about the comprehensive HIV intervention package (CHIP) (AOR = 2.59, 95% CI: 1.40-4.94); however, it decreased among those who had financial difficulties resulting from spending on health care services (AOR = 0.48, 95% CI: 0.24-0.92). (4) Conclusions: Except for HIV, PWUD had undergone limited testing for drug-related infectious diseases. The study findings highlight some factors influencing testing for the selected infectious diseases investigated, which should be targeted for tailored interventions to improve diagnosis and treatment.

Acceptability of multiple modalities of pre-exposure prophylaxis (PrEP) among female sex workers in Tanzania: a mixed-methods study.

OBJECTIVES: Modalities of pre-exposure prophylaxis (PrEP) for HIV prevention offer options to women at high risk including female sex workers (FSW). This study aimed to explore FSW's acceptability and preferences for oral pills, long-acting (LA) injectable and vaginal ring PrEP. DESIGN: Sequential, explanatory, mixed methods. SETTING: Iringa, Tanzania. PARTICIPANTS: FSW aged above 18 were recruited from sex work venues using time-location sampling (n=496); HIV-uninfected (n=293) were included in this analysis. Subsequently, survey participants were recruited for in-depth interviews (n=10) and two focus group discussions (n=20). PRIMARY OUTCOME MEASURES: (1) Acceptability of PrEP (Do you personally think it would be worth it to you to take ART if it could prevent HIV?: yes/no) and (2) preference for LA injectable versus oral pills (If you personally were going to take ART to prevent HIV infection, would you prefer to take it in the form of a daily pill or an injection once every 3 months? Injection/pill). RESULTS: Participants were (92%) unaware of PrEP but 58% thought it would be worth it to personally take PrEP. Acceptability of PrEP was significantly associated with higher social cohesion (aOR 2.12; 95% CI 1.29 to 3.50) and STI symptoms in the past 6 months (aOR 2.52; 95% CI 1.38 to 4.62). Most (88%) preferred LA vs oral PrEP. Qualitative findings revealed generally positive reactions to all types of PrEP, and they were viewed as a welcome backup to condoms. Participants had concerns about pills (burden of daily use, stigma from clients), and the vaginal ring (fear of client noticing and becoming suspicious, fear of infertility) and overall preferred LA-PrEP (less frequent use, easy to hide, belief in higher efficacy). CONCLUSIONS: Offering multiple formulations of PrEP within the context of community-driven HIV prevention interventions among FSW may facilitate increased uptake and adherence. LA injectable PrEP may be a particularly preferred formulation among FSW. TRIAL REGISTRATION NUMBER: NCT02281578.

Housing instability and violence among women who use drugs in Dar es Salaam, Tanzania.

BACKGROUND: Women who use heroin and other drugs (WWUD) are a key population with elevated risk of physical and sexual violence perpetrated by intimate partners and non-partners. While housing instability has been shown to be associated with violence in high-income settings, this is an underexplored topic in sub-Saharan Africa. In this research, we aimed to assess the relationship between housing instability and various forms of violence within a sample of WWUD in Dar es Salaam. METHODS: This analysis uses data from a parent study from 2018. A total of 200 WWUD were recruited through respondent-driven sampling methods and administered a survey. Two multivariable logistic regression models were built to assess the relationship between housing instability and physical violence (Model 1) and housing instability and sexual violence (Model 2) while controlling for a number of sociodemographic characteristics. RESULTS: Approximately 35% of participants were classified as housing unstable. More than half of participants (62%) reported experiencing physical violence in the past 12 months, and more than a third (36%) reported sexual violence in the same time period. Housing instability was found to be independently associated with both physical and sexual violence victimization in the past year when adjusting for covariates (Model 1 adjusted odds ratio [AOR]: 2.40, 95% CI 1.22-4.46; Model 2 AOR: 1.93. 95% CI 1.02-3.67). CONCLUSION: To our knowledge, this is the first study to document a significant association between housing instability and violence among WWUD communities in sub-Saharan Africa. This analysis adds to the growing body of literature on the relationship between stable housing and livelihood and health outcomes across differing populations. The cyclical nature of housing instability and violence may be disrupted through housing programming that provides safety, security, and stability for WWUD.

Examining implementation of an intervention to reduce psychological distress and intimate partner violence in a refugee camp setting.

An integrated approach to reduce intimate partner violence and improve mental health in humanitarian settings requires coordination across health and protection services. We developed and tested the Nguvu intervention, which combined evidence-based interventions for psychological distress and intimate partner violence among Congolese refugee women in Nyarugusu refugee camp (Tanzania). We conducted 29 semi-structured interviews with Nguvu participants and stakeholders to explore the relevance, acceptability, feasibility, and impact of this intervention. Participants reported that the intervention aligned with needs and filled a gap in programming, yet further adaptations may improve the fit of the intervention. The Nguvu intervention was acceptable to participants, including group discussion of sensitive topics. Confidentiality was highly regarded among staff and participants, which improved safety and acceptability. It was feasible to train non-specialist refugee workers to deliver the intervention with adequate supervision. Facilitators noted contextual challenges that made it difficult to implement the intervention: limited infrastructure, competing priorities, and population mobility. The intervention was perceived to improve awareness of the association between violence and mental health, reduce self-blame, and build skills to improve wellbeing. Recommended adaptations reveal promising, yet challenging future directions for addressing social determinants of mental health and implementing multi-sectoral programmes in complex humanitarian settings.

Socio-cognitive factors influencing access to HIV prevention services among people who inject drugs in Dar es Salaam, Tanzania: An integrated bio-behavioural survey.

INTRODUCTION: People who inject drugs (PWID) in Sub-Saharan Africa have limited access to comprehensive HIV services. While it is important to inform programming, knowledge about factors influencing access to comprehensive HIV services is scarce. We assessed the proportions of PWID with access to HIV prevention services and associated socio-cognitive factors in Tanzania. METHODS: A cross-sectional survey was conducted among PWID between October and December 2017 in Dar es Salaam, Tanzania. Data on access to HIV prevention services, demographics and selected socio-cognitive factors were collected through structured face-to-face interviews. Weighted descriptive and forward selection multivariable logistics regression analyses were done to assess independent associations between HIV prevention services and predictors of interest. The results were two tailed and a p-value of less than 0.05 was considered statistically significant. RESULTS: The study included 611 PWID (males: 94.4%) with a median age of 34 years (Interquartile Range (IQR), 29-38). A large majority of participants reported to have access to condoms (87.8%), sterile needles/syringes (72.8%) and ever tested for HIV (66.0%). About half (52.0%) reported to have used condoms in the past one month and about a third (28.5%) accessed a peer educator. The odds of testing for HIV decreased among participants who perceived their HIV risk to be high (aOR = 0.29; 95%CI: 0.17-0.49) and those experienced sexual violence (aOR = 0.60; 95%CI 0.37-0.98). However, the odds of testing for HIV increased among participants with secondary level of education (aOR = 2.16; 95%CI: 1.06-5.55), and those who reported having correct comprehensive HIV knowledge (CCHK) (aOR = 1.63; 95%CI 1.12-2.41). The odds of access to condoms increased among females (aOR = 2.23; 95%CI: 1.04-5.02) but decreased among participants with secondary level of education (aOR = 0.41; 95%CI: 0.19-0.84), an income of >TZS 200,000 (aOR = 0.39; 95%CI: 0.23-0.66) and those who perceived their HIV risk to be high (aOR = 0.13; 95%CI: 0.03-0.36). The odds of access to peer educators was higher among participants with primary (aOR = 1.61; 95%CI: 1.01-2.26), and secondary (aOR = 2.71; 95%CI: 1.39-5.33) levels of education. The odds of access to sterile needle and syringe decreased among participants who perceived their HIV risk to be high (aOR = 0.11;95%CI 0.05-0.22), and low-medium (aOR = 0.25;95%CI 0.11-0.52) but increased among those with primary level of education (aOR = 1.72;95%CI 1.06-2.78). CONCLUSION: Access to condom, HIV testing, sterile needles and syringes were relatively high among PWID. However, condom use and access to peer educators was relatively low. HIV knowledge and risk perception, gender, education, and sexual violence influenced access to HIV prevention services. There is an urgent need to address the identified socio-cognitive factors and scale up all aspects of HIV prevention services to fast-track attainment of the 2025 UNAIDS goals and ending the HIV epidemic.

Acceptability and perceptions of HIV oral self-testing across settings: A comparative qualitative study among Dominican and Tanzanian female sex workers.

Rapid oral HIV self-tests (HIVST) have potential to increase the proportion of people who know their HIV status, especially among stigmatised populations. This study was embedded in two cohorts of female sex workers (FSW) in the Dominican Republic (DR) and Tanzania. Qualitative interviews with 40 FSW were conducted to explore perceived acceptability of HIVST. Interviews were analysed using inductive and deductive thematic coding. Emergent themes were organised by socio-ecological framework levels. FSW in both settings responded positively to the ease of use of HIVST but questioned test accuracy due to the use of saliva rather than blood. FSW in the DR had a more cautious response, while women in Tanzania had favourable perceptions expressing eagerness to use it. At the individual level, themes shaping participants' interest included autonomy, HIV risk perception, and emotional well-being for those with reactive test results, and self-efficacy. At the interpersonal level, privacy, confidentiality, sex work and HIV stigma and social support were salient. Structural level themes focused on health systems including linkages to HIV treatment, provider roles, and access (cost, travel, distribution). Understanding FSW's perceptions and acceptability of HIVST is essential to its integration into health systems and programmes using a community-driven approach.

"She is the one who knows": A qualitative exploration of oral and injectable PrEP as part of a community empowerment approach to HIV prevention among female sex workers in the Dominican Republic and Tanzania.

Despite documented interest among female sex workers (FSW), uptake of oral pre-exposure prophylaxis (PrEP) for HIV prevention has been low. Recent trials and regulatory approval of long-acting injectable (LAI) PrEP offer new hope for the potential of this biomedical intervention. We examined FSW's PrEP-related interest and preferences regarding both oral and LAI PrEP situating these dynamics within their specific social and occupational realities. We conducted this work using qualitative methods across two distinct contexts by conducting 40 in-depth interviews with FSW in Tanzania and the Dominican Republic. Textual data was coded using iterative thematic content analysis. Analytic summaries were developed and reviewed to identify recurring themes. We systematically organized themes within each country and then compared across settings. Women in both settings expressed strong interest in PrEP seeing it as an important option to protect themselves in their work. Most participants preferred LAI PrEP due to expectations of reduced stigma and concerns about daily pill adherence and side effects. Occupational factors such as alcohol use, overnight dates with clients, and fear of violence from clients were identified as barriers to daily oral PrEP. LAI PrEP was seen as having the potential to reduce stress related to oral PrEP. Women who preferred pills discussed fear of needles, skepticism about the injections, and others relayed that taking a daily pill would not be challenging for them. There was a pre-dominant sentiment that women know best whether they are better suited for oral or LAI PrEP. Participants stressed the importance of FSW understanding both options to ensure informed decision-making around PrEP and described community-led peer education as key to delivering trusted information. Community empowerment approaches led by FSW which address structural and psychosocial constraints and promote safe work environments may facilitate equitable access and uptake of PrEP among FSW across settings.

Multilevel Determinants of Integrated Service Delivery for Intimate Partner Violence and Mental Health in Humanitarian Settings.

Inter-agency guidelines recommend that survivors of intimate partner violence in humanitarian settings receive multisectoral services consistent with a survivor-centered approach. Providing integrated services across sectors is challenging, and aspirations often fall short in practice. In this study, we explore factors that influence the implementation of a multisectoral, integrated intervention intended to reduce psychological distress and intimate partner violence in Nyarugusu Refugee Camp, Tanzania. We analyzed data from a desk review of donor, legal, and policy documents; a gender-based violence services mapping conducted through 15 interviews and 6 focus group discussions; and a qualitative process evaluation with 29 stakeholders involved in the implementation of the integrated psychosocial program. We identified the challenges of implementing a multisectoral, integrated intervention for refugee survivors of intimate partner violence at the structural, inter-institutional, intra-institutional, and in social and interpersonal levels. Key determinants of successful implementation included the legal context, financing, inter-agency coordination, engagement and ownership, and the ability to manage competing priorities. Implementing a multisectoral, integrated response for survivors of intimate partner violence is complex and influenced by interrelated factors from policy and financing to institutional and stakeholder engagement. Further investment in identifying strategies to overcome the existing challenges of implementing multisectoral approaches that align with global guidelines is needed to effectively address the burden of intimate partner violence in humanitarian settings.

Cultural adaptation of a scalable psychological intervention for Burundian refugee adolescents in Tanzania: a qualitative study.

BACKGROUND: There is an urgent need for evidence-based, scalable, psychological interventions to improve the mental health of adolescents affected by adversity in low-resource settings. Early Adolescents Skills for Emotions (EASE) was developed by the WHO as a brief, transdiagnostic, group intervention for early adolescents exhibiting internalising problems, delivered by trained and supervised lay providers. This study describes the cultural adaptation of EASE for Burundian adolescents living in Mtendeli refugee camps in Tanzania. METHODS: A phased approach to adaptation of the EASE intervention and its implementation, was adopted and comprised of: (1) a desk review to synthesize existing research on mental health issues in conflict-affected Burundian communities, (2) a rapid qualitative assessment involving free listing and key informant interviews with multiple stakeholders, (3) cognitive interviews with end users, and (4) a two-part adaptation workshop involving the implementing partner staff, members of the refugee community and mental health experts. We applied the Bernal framework to systematically document and track adaptations across eight dimensions of the intervention. RESULTS: Problems associated with worry, stress, sadness, shame and fear were identified as amongst the most critical mental health concerns, alongside a range of experiences of different forms of violence (such as gender-based violence, violence when fleeing from their homes) and associated problems. Problems associated with violence that included past experiences of fleeing as well as ongoing problems of gender-based violence in the camp. The most significant adaptations that were required included providing options for low literacy of participants, safety planning to address the high prevalence of sexual violence, simplification of strategies for the benefit of the end users and of lay facilitators, and implementation changes to consider involvement of refugee incentive workers. A majority of changes were across dimensions of language, people, metaphors, content, methods and context, while there were fewer changes regarding the goals and concepts of EASE. CONCLUSIONS: The approach to adaptation of a psychological intervention suggested both minor and major required changes. Adaptations based on the findings of this study are anticipated to enhance relevance and acceptability of the EASE intervention and its delivery for camp-residing Burundian refugees in Tanzania.

Improving mental health in low-resource settings: A feasibility randomized controlled trial of a transdiagnostic psychological intervention among Burundian refugee adolescents and their caregivers.

There is a paucity of evidence regarding interventions that can improve the mental health of adversity-affected young adolescents living in low-resource settings. We evaluated the feasibility, acceptability, relevance, and safety of the World Health Organization's Early Adolescent Skills for Emotions (EASE) intervention among Burundian refugee adolescents and their caregivers in Tanzania. This study consisted of a feasibility cluster randomized controlled trial (cRCT) and a process evaluation. The feasibility cRCT included 82 young adolescents and their 64 caregivers, with two clusters randomized to EASE and two to an enhanced control condition. EASE was delivered by adult refugees without prior training in mental health. The process evaluation consisted of 36 semi-structured qualitative interviews with key stakeholders, including adolescents, caregivers, and facilitators. EASE participants and facilitators gave positive feedback about its format, accessibility, and content. Trained non-specialist refugee facilitators were able to deliver EASE with high fidelity. The research protocol functioned well in terms of balanced randomization, limited loss to follow-up, and psychometrically promising measures, but discordance was observed between the short screener and psychological distress symptom checklist. This formative study suggests the potential of EASE in targeting psychological distress among displaced young adolescents and lays the groundwork for a future definitive trial.

Knowledge, Experience and Perception of Gender-Based Violence Health Services: A Mixed Methods Study on Adolescent Girls and Young Women in Tanzania.

Many adolescent girls and young women (AGYW) experience gender-based violence (GBV) in Tanzania and only few seek GBV health services following violence. The objectives of our study are (1) to evaluate knowledge of gender-based violence among AGYW, (2) to explore their perceptions of and experiences with GBV health service quality and (3) to evaluate access to comprehensive GBV services. This study employed an explanatory, sequential mixed methods design in two districts of Dar es Salaam, Tanzania (Kinondoni and Temeke). A quantitative cross-sectional survey among AGYW (n = 403) between 15-24 years old was performed to assess their knowledge of GBV as well as perceptions of and experiences with GBV health services. The quantitative data was complemented by 20 semi-structured in-depth interviews with participants. Out of 403 study participants, more than three quarters (77.9%) had moderate to good knowledge of how GBV is defined and what constitutes gender-based violence. However, few participants (30.7%, n = 124) demonstrated knowledge of GBV health services offered at local health facilities. For example, only 10.7% (n = 43) of participants reported knowledge of forensic evidence collection. Additionally, of 374 participants (93% of total participants) who reported to have received GBV education sessions, only 66% accessed GBV health services (n = 247) and about half of these (52.7%, n = 130) were satisfied with these services. The study indicated that-despite good knowledge about what constituted GBV-knowledge about the roles and availability of GBV health services was limited and utilization of GBV health services remained low. Coordinated actions need to be strengthened to reach AGYW who remain unaware of GBV health services offered at health facilities by improving GBV service quality, bettering interventions aimed at reducing GBV among AGYW in Tanzania, and scaling-up integrated service models, such as GBV one-stop centers.

Depression, suicidality and associated risk factors among police officers in urban Tanzania: a cross-sectional study.

BACKGROUND: The WHO has classified depression as a disease of public concern. Police officers are a particular subpopulation group that is at an increased risk for mental health problems. This study examined the prevalence of depression, suicidality and associated risk factors among police officers in urban Tanzania. AIMS: The aim of this study was to examine the prevalence of depression, suicidality and associated risk factors among police officers in Tanzania. METHODS: A cross-sectional study was conducted between April 2019 and October 2020 among 550 participants in Dar es Salaam recruited using a multistage cluster sampling technique. The Patient Health Questionnaire-9 was used to screen for depression and suicidality. The Interpersonal Support Evaluation List-12 tool was used to measure perceived social support. Descriptive statistics were summarised using frequencies and percentages. Bivariate and multivariate analyses were used to establish associations between predictors of interest, depression and suicidality. RESULTS: There were 497 participants in the study. Of these, 76.6% (376 of 491) were men, and the median (IQR) age was 37.0 (17) years. Around 19.8% (96 of 486) of the police officers screened positive for depression and 15.4% (75 of 413) for suicidality. A significant proportion was either moderately (29 of 96, 30.2%) or severely depressed (8 of 75, 10.7 %). Of those who experienced suicidal thoughts, 10.7% (8 of 75) reported having daily suicidal thoughts. Perceiving low social support was associated with an increased risk of reporting depression (adjusted OR (aOR): 28.04, 95% CI: 8.42 to 93.37, p<0.001) and suicidality (aOR: 10.85, 95% CI: 3.56 to 33.08, p<0.001) as compared with those with high perceived social support. CONCLUSION: The magnitude of depression and suicidality among police officers in urban Tanzania is alarmingly high. The study findings indicate the need for routine screening for depression and suicidality among police officers and design appropriate mental health responsive services in this population.

Family planning use and correlates among female sex workers in a community empowerment HIV prevention intervention in Iringa, Tanzania: a case for tailored programming.

BACKGROUND: Female sex workers in sub-Saharan Africa face high unmet need for family planning and higher risk for unintended pregnancy. Community empowerment HIV prevention approaches have the potential to increase family planning uptake and present an opportunity to integrate HIV, reproductive health, and contraception. This article describes family planning use and pregnancy among female sex workers in Iringa, Tanzania and evaluates whether engagement in a community empowerment HIV prevention program is associated with contraceptive use. METHODS: This study consists of secondary analysis from a two-community randomized controlled trial following a longitudinal cohort over 18 months. We implemented a year-long community empowerment intervention consisting of 1) a community-led drop-in-center; 2) venue-based peer education, condom distribution, and HIV testing; 3) peer service navigation; 4) sensitivity trainings for providers and police; and 5) text messages to promote engagement. Additionally, monthly seminars were held at the drop-in-center, one of which focused on family planning. Modified Poisson regression models were used to estimate the association between program exposure and family planning use in the intervention arm. (Trials Registration NCT02281578, Nov 2, 2014.) RESULTS: Among the 339 participants with follow-up data on family planning, 60% reported current family planning use; 6% reported dual use of modern contraception and condoms; over 90% had living children; and 85% sought antenatal care at their most recent pregnancy. Among the 185 participants in the intervention arm, the adjusted relative risk (aRR) of family planning use among female sex workers who reported ever attending the Shikamana drop-in-center and among female sex workers who reported attending a family planning-related workshop was respectively 26% (aRR 1.26 [95% Confidence Interval (CI): 1.02-1.56]) and 36% (aRR 1.36 [95%CI: 1.13-1.64) higher than among those who had not attended. CONCLUSION: There is a clear need for family planning among this population. General program exposure and exposure to a family planning workshop were associated with higher family planning use, which suggests that community empowerment models have potential to increase family planning uptake for this vulnerable group.

Evaluation of an integrated intervention to reduce psychological distress and intimate partner violence in refugees: Results from the Nguvu cluster randomized feasibility trial.

INTRODUCTION: The complex relationship between intimate partner violence and psychological distress warrants an integrated intervention approach. In this study we examined the relevance, acceptability, and feasibility of evaluating a multi-sectoral integrated violence- and mental health-focused intervention (Nguvu). METHODS: We enrolled 311 Congolese refugee women from Nyarugusu refugee camp in Tanzania with past-year intimate partner violence and elevated psychological distress in a feasibility cluster randomized trial. Women were recruited from local women's groups that were randomized to the Nguvu intervention or usual care. Participants from women's groups randomized to Nguvu received 8 weekly sessions delivered by lay refugee incentive workers. Psychological distress, intimate partner violence, other wellbeing, and process indicators were assessed at baseline and 9-weeks post-enrollment to evaluate relevance, acceptability, and feasibility of implementing and evaluating Nguvu in refugee contexts. RESULTS: We found that Nguvu was relevant to the needs of refugee women affected by intimate partner violence. We found reductions in some indicators of psychological distress, but did not identify sizeable changes in partner violence over time. Overall, we found that Nguvu was acceptable and feasible. However, challenges to the research protocol included baseline imbalances between study conditions, differential intervention completion related to intimate partner violence histories, differences between Nguvu groups and facilitators, and some indication that Nguvu may be less beneficial for participants with more severe intimate partner violence profiles. CONCLUSIONS: We found evidence supporting the relevance of Nguvu to refugee women affected by partner violence and psychological distress and moderate evidence supporting the acceptability and feasibility of evaluating and implementing this intervention in a complex refugee setting. A definitive cluster randomized trial requires further adaptations for recruitment and eligibility screening, randomization, and retention. TRIAL REGISTRATION: ISRCTN65771265, June 27, 2016.