Misperception of peer beliefs reinforces inequitable gender norms among Tanzanian men.

Gender role ideology, i.e. beliefs about how genders should behave, is shaped by social learning. Accordingly, if perceptions about the beliefs of others are inaccurate this may impact trajectories of cultural change. Consistent with this premise, recent studies report evidence of a tendency to overestimate peer support for inequitable gender norms, especially among men, and that correcting apparent 'norm misperception' promotes transitions to relatively egalitarian beliefs. However, supporting evidence largely relies on self-report measures vulnerable to social desirability bias. Consequently, observed patterns may reflect researcher measurement error rather than participant misperception. Addressing this shortcoming, we examine men's gender role ideology using both conventional self-reported and a novel wife-reported measure of men's beliefs in an urbanising community in Tanzania. We confirm that participants overestimate peer support for gender inequity. However, the latter measure, which we argue more accurately captures men's true beliefs, implies that this tendency is relatively modest in magnitude and scope. Overestimation was most pronounced among men holding relatively inequitable beliefs, consistent with misperception of peer beliefs reinforcing inequitable norms. Furthermore, older and poorly educated men overestimated peer support for gender inequity the most, suggesting that outdated and limited social information contribute to norm misperception in this context.

He for she? Variation and exaggeration in men's support for women's empowerment in northern Tanzania.

Achieving gender equality fundamentally requires a transfer of power from men to women. Yet data on men's support for women's empowerment (WE) remains scant and limited by reliance on self-report methodologies. Here, we examine men's support for WE as a sexual conflict trait, both via direct surveys (n = 590) and indirectly by asking men's wives (n = 317) to speculate on their husband's views. Data come from a semi-urban community in Mwanza, Tanzania. Consistent with reduced resource competition and increased exposure to relatively egalitarian gender norms, higher socioeconomic status predicted greater support for WE. However, potential demographic indicators of sexual conflict (high fertility, polygyny, large spousal age gap) were largely unrelated to men's support for WE. Contrasting self- and wife-reported measures suggests that men frequently exaggerate their support for women in self-reported attitudes. Discrepancies were especially pronounced among men claiming the highest support for WE, but smallest among men who held a professional occupation and whose wife participated in wage labour, indicating that these factors predict genuine support for WE. We discuss the implications of these results for our understanding of both individual variation and patriarchal gender norms, emphasising the benefits of greater exchange between the evolutionary human sciences and global health research on these themes.

Sharing the Load: How Do Coresident Children Influence the Allocation of Work and Schooling in Northwestern Tanzania?

Economic and evolutionary models of parental investment often predict education biases toward earlier-born children, resulting from either household resource dilution or parental preference. Previous research, however, has not always found these predicted biases-perhaps because in societies where children work, older children are more efficient at household tasks and substitute for younger children, whose time can then be allocated to school. The role of labor substitution in determining children's schooling remains uncertain, however, because few studies have simultaneously considered intrahousehold variation in both children's education and work. Here, we investigate the influence of coresident children on education, work, and leisure in northwestern Tanzania, using detailed time use data collected from multiple children per household (n = 1,273). We find that age order (relative age, compared with coresident children) within the household is associated with children's time allocation, but these patterns differ by gender. Relatively young girls do less work, have more leisure time, and have greater odds of school enrollment than older girls. We suggest that this results from labor substitution: older girls are more efficient workers, freeing younger girls' time for education and leisure. Conversely, relatively older boys have the highest odds of school enrollment among coresident boys, possibly reflecting traditional norms regarding household work allocation and age hierarchies. Gender is also important in household work allocation: boys who coreside with more girls do fewer household chores. We conclude that considering children as both producers and consumers is critical to understanding intrahousehold variation in children's schooling and work.

Changes in rapid HIV treatment initiation after national "treat all" policy adoption in 6 sub-Saharan African countries: Regression discontinuity analysis.

BACKGROUND: Most countries have formally adopted the World Health Organization's 2015 recommendation of universal HIV treatment ("treat all"). However, there are few rigorous assessments of the real-world impact of treat all policies on antiretroviral treatment (ART) uptake across different contexts. METHODS AND FINDINGS: We used longitudinal data for 814,603 patients enrolling in HIV care between 1 January 2004 and 10 July 2018 in 6 countries participating in the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium: Burundi (N = 11,176), Kenya (N = 179,941), Malawi (N = 84,558), Rwanda (N = 17,396), Uganda (N = 96,286), and Zambia (N = 425,246). Using a quasi-experimental regression discontinuity design, we assessed the change in the proportion initiating ART within 30 days of enrollment in HIV care (rapid ART initiation) after country-level adoption of the treat all policy. A modified Poisson model was used to identify factors associated with failure to initiate ART rapidly under treat all. In each of the 6 countries, over 60% of included patients were female, and median age at enrollment ranged from 32 to 36 years. In all countries studied, national adoption of treat all was associated with large increases in rapid ART initiation. Significant increases in rapid ART initiation immediately after treat all policy adoption were observed in Rwanda, from 44.4% to 78.9% of patients (34.5 percentage points [pp], 95% CI 27.2 to 41.7; p < 0.001), Kenya (25.7 pp, 95% CI 21.8 to 29.5; p < 0.001), Burundi (17.7 pp, 95% CI 6.5 to 28.9; p = 0.002), and Malawi (12.5 pp, 95% CI 7.5 to 17.5; p < 0.001), while no immediate increase was observed in Zambia (0.4 pp, 95% CI -2.9 to 3.8; p = 0.804) and Uganda (-4.2 pp, 95% CI -9.0 to 0.7; p = 0.090). The rate of rapid ART initiation accelerated sharply following treat all policy adoption in Malawi, Uganda, and Zambia; slowed in Kenya; and did not change in Rwanda and Burundi. In post hoc analyses restricted to patients enrolling under treat all, young adults (16-24 years) and men were at increased risk of not rapidly initiating ART (compared to older patients and women, respectively). However, rapid ART initiation following enrollment increased for all groups as more time elapsed since treat all policy adoption. Study limitations include incomplete data on potential ART eligibility criteria, such as clinical status, pregnancy, and enrollment CD4 count, which precluded the assessment of rapid ART initiation specifically among patients known to be eligible for ART before treat all. CONCLUSIONS: Our analysis indicates that adoption of treat all policies had a strong effect on increasing rates of rapid ART initiation, and that these increases followed different trajectories across the 6 countries. Young adults and men still require additional attention to further improve rapid ART initiation.

Parent-offspring conflict unlikely to explain 'child marriage' in northwestern Tanzania.

Approximately 40% of women in sub-Saharan Africa marry before their eighteenth birthday1. Within the international development sector, this phenomenon is referred to as 'child marriage', widely equated to forced marriage, and recognized as damaging to multiple dimensions of female well-being1,2. An escalating global campaign to end early marriage typically assumes that its high prevalence is driven by a conflict of interests between parents and daughters, with parents coercing daughters to marry early for the parents' economic benefit3. However, a parent-offspring conflict model of early marriage has not been explicitly tested. Here we present a study of marriage transitions in rural Tanzania, where marriage before or just after 18 years of age is normative. Consistent with parental coercion, we find that bridewealth transfers are highest for younger brides. However, autonomy in partner choice is very common at all ages, relationships between age at marriage and female well-being are largely equivocal, and women who marry early achieve relatively higher reproductive success. We conclude that, in contexts in which adolescents have autonomy in marriage choices and in which marriage promotes economic and social security, early marriage may be better understood as serving the strategic interests of both parents and daughters.

From policy to practice: exploring the implementation of antiretroviral therapy access and retention policies between 2013 and 2016 in six sub-Saharan African countries.

BACKGROUND: Understanding the implementation of 2013 World Health Organization (WHO) consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection at the facility level provides important lessons for the roll-out of future HIV policies. METHODS: A national policy review was conducted in six sub-Saharan African countries to map the inclusion of the 2013 WHO HIV treatment recommendations. Twenty indicators of policy adoption were selected to measure ART access (n = 12) and retention (n = 8). Two sequential cross-sectional surveys were conducted in facilities between 2013/2015 (round 1) and 2015/2016 (round 2) from ten health and demographic surveillance sites in Kenya, Malawi, South Africa, Tanzania, Uganda and Zimbabwe. Using standardised questionnaires, facility managers were interviewed. Descriptive analyses were used to assess the change in the proportion of facilities that implemented these policy indicators between rounds. RESULTS: Although, expansion of ART access was explicitly stated in all countries' policies, most lacked policies that enhanced retention. Overall, 145 facilities were included in both rounds. The proportion of facilities that initiated ART at CD4 counts of 500 or less cells/µL increased between round 1 and 2 from 12 to 68%, and facilities initiating patients on 2013 WHO recommended ART regimen increased from 42 to 87%. There were no changes in the proportion of facilities reporting stock-outs of first-line ART in the past year (18 to 11%) nor in the provision of three-month supply of ART (43 to 38%). None of the facilities provided community-based ART delivery. CONCLUSION: The increase in ART initiation CD4 threshold in most countries, and substantial improvements made in the provision of WHO recommended first-line ART regimens demonstrates that rapid adoption of WHO recommendations is possible. However, improved logistics and resources and/or changes in policy are required to further minimise ART stock-outs and allow lay cadres to dispense ART in the community. Increased efforts are needed to offer longer durations between clinic visits, a strategy purported to improve retention. These changes will be important as countries move to implement the revised 2015 WHO guidelines to initiate all HIV positive people onto ART regardless of their immune status.

Physical activity and associated factors from a cross-sectional survey among adults in northern Tanzania.

BACKGROUND: Insufficient physical activity (PA) is a major contributing factor in the growing problem of non-communicable diseases (NCDs) in urban and rural Sub-Saharan Africa. This study aimed to determine PA and associated factors among adults in Northern Tanzania. METHODS: We analyzed secondary data from a cross-sectional serological survey nested within the Magu health and demographic sentinel surveillance population in Magu District Northwestern Tanzania. All resident adults aged 15 years and older were invited to participate in the study, and physical activity data were analyzed for 5663 participants. Data were analyzed using Stata version 13.0. We used logistic regression to obtain odds ratios and 95% confidence intervals (CI) for risk factors associated with differences in PA. RESULTS: In this mainly rural population, 96% reported sufficient PA, with a higher proportion in males (97.3%) compared to females (94.8%). In males the odds of sufficient PA were lower in rural areas compared to urban areas (OR = 0.19; P < 0.001; 95% CI = 0.08-0.42), while in females the odds of sufficient PA were higher in rural areas compared to urban areas (OR = 2.27; P < 0.001; 95%CI = 1.59-3.24). Leisure-related activity was low compared to work-related and transport-related activity. Farmers had a higher odds of sufficient PA than those in professional jobs in both males (OR = 9.75; P < 0.001; 95% CI = 3.68-5.82) and females (OR = 2.83; P = 0.021; 95% CI = 1.17-6.86). CONCLUSION: The prevalence of PA in this population was high. However, there is need for PA programs to maintain the high level of compliance during and following the transition to a more urban-based culture.

The Incidence Patterns Model to Estimate the Distribution of New HIV Infections in Sub-Saharan Africa: Development and Validation of a Mathematical Model.

BACKGROUND: Programmatic planning in HIV requires estimates of the distribution of new HIV infections according to identifiable characteristics of individuals. In sub-Saharan Africa, robust routine data sources and historical epidemiological observations are available to inform and validate such estimates. METHODS AND FINDINGS: We developed a predictive model, the Incidence Patterns Model (IPM), representing populations according to factors that have been demonstrated to be strongly associated with HIV acquisition risk: gender, marital/sexual activity status, geographic location, "key populations" based on risk behaviours (sex work, injecting drug use, and male-to-male sex), HIV and ART status within married or cohabiting unions, and circumcision status. The IPM estimates the distribution of new infections acquired by group based on these factors within a Bayesian framework accounting for regional prior information on demographic and epidemiological characteristics from trials or observational studies. We validated and trained the model against direct observations of HIV incidence by group in seven rounds of cohort data from four studies ("sites") conducted in Manicaland, Zimbabwe; Rakai, Uganda; Karonga, Malawi; and Kisesa, Tanzania. The IPM performed well, with the projections' credible intervals for the proportion of new infections per group overlapping the data's confidence intervals for all groups in all rounds of data. In terms of geographical distribution, the projections' credible intervals overlapped the confidence intervals for four out of seven rounds, which were used as proxies for administrative divisions in a country. We assessed model performance after internal training (within one site) and external training (between sites) by comparing mean posterior log-likelihoods and used the best model to estimate the distribution of HIV incidence in six countries (Gabon, Kenya, Malawi, Rwanda, Swaziland, and Zambia) in the region. We subsequently inferred the potential contribution of each group to transmission using a simple model that builds on the results from the IPM and makes further assumptions about sexual mixing patterns and transmission rates. In all countries except Swaziland, individuals in unions were the single group contributing to the largest proportion of new infections acquired (39%-77%), followed by never married women and men. Female sex workers accounted for a large proportion of new infections (5%-16%) compared to their population size. Individuals in unions were also the single largest contributor to the proportion of infections transmitted (35%-62%), followed by key populations and previously married men and women. Swaziland exhibited different incidence patterns, with never married men and women accounting for over 65% of new infections acquired and also contributing to a large proportion of infections transmitted (up to 56%). Between- and within-country variations indicated different incidence patterns in specific settings. CONCLUSIONS: It is possible to reliably predict the distribution of new HIV infections acquired using data routinely available in many countries in the sub-Saharan African region with a single relatively simple mathematical model. This tool would complement more specific analyses to guide resource allocation, data collection, and programme planning.

Health & Demographic Surveillance System Profile: The Magu Health and Demographic Surveillance System (Magu HDSS).

The Magu Health and Demographic Surveillance System (Magu HDSS) is part of Kisesa OpenCohort HIV Study located in a rural area of North-Western Tanzania. Since its establishment in 1994, information on pregnancies, births, marriages, migrations and deaths have been monitored and updated between one and three times a year by trained fieldworkers. Other research activities implemented in the cohort include: sero surveys which have been conducted every 2-3 years to collect socioeconomic data, HIV sero status and health knowledge attitude and behaviour in adults aged 15 years or more living in the area; verbal autopsy (VA) interviews conducted to establish cause of death in all deaths encountered in the area; Llnking data collected at health facilities to community-based data; monitoring voluntary counselling and testing (VCT); and assessing uptake of antiretroviral treatment (ART). In addition, within the community, qualitative studies have been conducted to address issues linked to HIV stigma, the perception of ART access and adherence.In 2014, the population was over 35 000 individuals. Magu HDSS has contributed to Tanzanian estimates of fertility and mortality, and is a member of the INDEPTH network. Demographic data for Magu HDSS are available via the INDEPTH Network's Sharing and Accessing Repository (iSHARE) and applications to access HDSS data for collaborative analysis are encouraged.

Updates to the spectrum model to estimate key HIV indicators for adults and children.

BACKGROUND: The Spectrum program is used to estimate key HIV indicators for national programmes. The purpose of the study is to describe the key updates made to Spectrum in the last 2 years to produce the version used in the 2013 global estimates of HIV/AIDS. METHODS: The United Nations Programme on HIV/AIDS (UNAIDS) Reference Group on Estimates, Models and Projections regularly reviews new data and information needs and recommends updates to the methodology and assumptions used in Spectrum. The latest data from surveys, census and special studies are used to estimate key parameter values for countries and regions. RESULTS: Country-specific life tables prepared by the United National Population Division (UNPD) have been incorporated into Spectrum's demographic projections replacing the model life tables used previously. This update includes revised estimates of non-AIDS life expectancy. Incidence among all adults 15-49 years generated from curve fitting to surveillance and survey data is now split by age using incidence rate ratios derived from Analysing Longitudinal Population-based HIV/AIDS data on Africa Network data for generalized epidemics. Methods for estimating the number of AIDS orphans have been updated to include the changing effects of PMTCT and antiretroviral therapy programmes. Procedures for estimating the number of adults eligible for treatment have been updated to reflect the 2013 WHO guidelines. Program data on AIDS mortality has been used to estimate prevalence trends in Argentina, Brazil and Mexico for the 2013 estimates. CONCLUSION: Spectrum was updated for the 2013 round of HIV estimates in order to support national programmes with improved methods and data to estimating national indicators.

Socio-economic change and parent-child relationships: implications for parental control and HIV prevention among young people in rural North Western Tanzania.

This paper examines how socio-economic changes in Tanzania have impacted on parent-child relationships, in particular parental behavioural control over their children and parental influence on young people's sexual behaviour. Data came from participant observation, focus group discussions and in-depth interviews with young people (14-24 years) and their parents. Socio-economic changes (education, changes in values, material needs provision) affected parent-young person relationships. Young people contributed to the economic needs of their families and parents receiving or expecting more support from their children exercised less behavioural control (in sexual and non-sexual matters of their children). Parents and young people spent less time together than in earlier generations. Parents reported that they thought their children were more knowledgeable about sexual and reproductive health than they were. As young people received more education and contributed more to their families' economic well being. they emerged as decision-makers in their own right and parental influence waned. Policy interventions addressing sexual and reproductive health among young people should consider family influence on young people as well as the influence of young people on their families and parental authority. Families, and particularly parents, should be supported to respond to the emerging challenges and changes in their families and the wider society.

Parental control and monitoring of young people's sexual behaviour in rural North-Western Tanzania: implications for sexual and reproductive health interventions.

BACKGROUND: Parenting through control and monitoring has been found to have an effect on young people's sexual behaviour. There is a dearth of literature from sub-Saharan Africa on this subject. This paper examines parental control and monitoring and the implications of this on young people's sexual decision making in a rural setting in North-Western Tanzania. METHODS: This study employed an ethnographic research design. Data collection involved 17 focus group discussions and 46 in-depth interviews conducted with young people aged 14-24 years and parents/carers of young people within this age-group. Thematic analysis was conducted with the aid of NVIVO 7 software. RESULTS: Parents were motivated to control and monitor their children's behaviour for reasons such as social respectability and protecting them from undesirable sexual and reproductive health (SRH) outcomes. Parental control and monitoring varied by family structure, gender, schooling status, a young person's contribution to the economic running of the family and previous experience of a SRH outcome such as unplanned pregnancy. Children from single parent families reported that they received less control compared to those from both parent families. While a father's presence in the family seemed important in controlling the activities of young people, a mother's did not have a similar effect. Girls especially those still schooling received more supervision compared to boys. Young women who had already had unplanned pregnancy were not supervised as closely as those who hadn't. Parents employed various techniques to control and monitor their children's sexual activities. CONCLUSIONS: Despite parents making efforts to control and monitor their young people's sexual behaviour, they are faced with several challenges (e.g. little time spent with their children) which make it difficult for them to effectively monitor them. There is a need for interventions such as parenting skills building that might enable parents to improve their relationships with children. This would equip parents with the appropriate skills for positive guidance and monitoring of their children and avoid inappropriate parenting behaviour. As much as parents focus their attention on their school going daughters, there is a need to also remember the out-of-school young people as they are also vulnerable to adverse SRH outcomes.

Secretive females or swaggering males? An assessment of the quality of sexual partnership reporting in rural Tanzania.

In population-based surveys on sexual behaviour, men consistently report higher numbers of sexual partners than women, which may be associated with male exaggeration or female under-reporting or with issues related to sampling, such as exclusion of female sex workers. This paper presents an analysis of data collected in the context of a longitudinal study in rural Tanzania, where a sexual partnership module was applied to all participating men and women in the study population. Since the study design included all men and women of reproductive ages and did not involve sampling, these data provide a unique opportunity to compare the consistency of aggregate measures of sexual behaviour between men and women living in the same villages. The analysis shows that non-marital partnerships were common amongst single people of both sexes--around 70% of unmarried men and women report at least one sexual partner in the last year. However, 40% of married men also report having non-marital partners, but only 3% of married women did so. Single women reported about half as many multiple partnerships in the last year as men. Under-reporting of non-marital partnerships was much more common among single women than among married women and men. Furthermore, women were more likely to report longer duration partnerships and partnership with urban men or more educated men than with others. If a woman reports multiple partners, biological data indicate that she is at high risk of contracting HIV. For men, however, there is only a weak association between number of partnerships and the risk of HIV, and it cannot be excluded that men, especially single men, exaggerate the number of sexual partners.

Health service use and household expenditure during terminal illness due to AIDS in rural Tanzania.

Most knowledge about health seeking behaviour during terminal illness among people with HIV/AIDS in Africa is derived from health facility based studies. This study uses data from a longitudinal community study in a rural area in north-west Tanzania, where interviews were conducted on health seeking behaviour and expenditure with relatives who lost an adult family member in recent months. HIV status and verbal autopsy were used to assess if service use differed by cause of death. During terminal illness, people with HIV/AIDS made extensive use of both traditional and modern health services, and more so than people who died from other causes. The main factor associated with this difference was the longer duration of illness. Expenses associated with HIV/AIDS terminal illness were higher than for other causes of death, largely because of the longer duration of illness. The direct medical costs were about 1.5 times higher than the funeral costs and the sum of the medical and funeral costs exceeded the estimated annual household income per capita in this population. In conclusion, the rapid increase in numbers of terminally ill adults as a result of HIV/AIDS is likely to lead to an increased burden on all layers of the health system and household resources, in part because of the relatively long duration of HIV/AIDS terminal illness. However, almost half of all HIV/AIDS deaths in this rural population were not admitted to hospitals during their terminal illness and only a small proportion died in hospitals. If more effective treatment becomes available, a further increase in health service use and direct medical costs to households and community is likely.