Dietary diversity moderates household economic inequalities in the double burden of malnutrition in Tanzania.

OBJECTIVE: Improved food availability and a growing economy in Tanzania may insufficiently decrease pre-existing nutritional deficiencies and simultaneously increase overweight within the same individual, household or population, causing a double burden of malnutrition (DBM). We investigated economic inequalities in DBM at the household level, expressed as a stunted child with a mother with overweight/obesity, and the moderating role of dietary diversity in these inequalities. DESIGN: We used cross-sectional data from the 2015-2016 Tanzania Demographic and Health Survey. SETTING: A nationally representative survey. PARTICIPANTS: Totally, 2867 children (aged 6-23 months) and their mothers (aged 15-49 years). The mother-child pairs were categorised into two groups based on dietary diversity score: achieving and not achieving minimum dietary diversity. RESULTS: The prevalence of DBM was 5·6 % (sd = 0·6) and significantly varied by region (ranging from 0·6 % to 12·2 %). Significant interaction was observed between dietary diversity and household wealth index (Pfor interaction < 0·001). The prevalence of DBM monotonically increased with greater household wealth among mother-child pairs who did not achieve minimum dietary diversity (Pfor trend < 0·001; however, this association was attenuated in those who achieved minimum dietary diversity (Pfor trend = 0·16), particularly for the richest households (P = 0·44). Analysing household wealth index score as a continuous variable yielded similar results (OR (95 % CI): 2·10 (1·36, 3·25) for non-achievers of minimum dietary diversity, 1·38 (0·76, 2·54) for achievers). CONCLUSIONS: Greater household wealth was associated with higher odds of DBM in Tanzania; however, the negative impact of household economic status on DBM was mitigated by minimum dietary diversity.

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

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

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

Reducing the Antigen Prevalence Target Threshold for Stopping and Restarting Mass Drug Administration for Lymphatic Filariasis Elimination: A Model-Based Cost-effectiveness Simulation in Tanzania, India and Haiti.

BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) aims to reduce and maintain infection levels through mass drug administration (MDA), but there is evidence of ongoing transmission after MDA in areas where Culex mosquitoes are the main transmission vector, suggesting that a more stringent criterion is required for MDA decision making in these settings. METHODS: We use a transmission model to investigate how a lower prevalence threshold (<1% antigenemia [Ag] prevalence compared with <2% Ag prevalence) for MDA decision making would affect the probability of local elimination, health outcomes, the number of MDA rounds, including restarts, and program costs associated with MDA and surveys across different scenarios. To determine the cost-effectiveness of switching to a lower threshold, we simulated 65% and 80% MDA coverage of the total population for different willingness to pay per disability-adjusted life-year averted for India ($446.07), Tanzania ($389.83), and Haiti ($219.84). RESULTS: Our results suggest that with a lower Ag threshold, there is a small proportion of simulations where extra rounds are required to reach the target, but this also reduces the need to restart MDA later in the program. For 80% coverage, the lower threshold is cost-effective across all baseline prevalences for India, Tanzania, and Haiti. For 65% MDA coverage, the lower threshold is not cost-effective due to additional MDA rounds, although it increases the probability of local elimination. Valuing the benefits of elimination to align with the GPELF goals, we find that a willingness to pay per capita government expenditure of approximately $1000-$4000 for 1% increase in the probability of local elimination would be required to make a lower threshold cost-effective. CONCLUSIONS: Lower Ag thresholds for stopping MDAs generally mean a higher probability of local elimination, reducing long-term costs and health impacts. However, they may also lead to an increased number of MDA rounds required to reach the lower threshold and, therefore, increased short-term costs. Collectively, our analyses highlight that lower target Ag thresholds have the potential to assist programs in achieving lymphatic filariasis goals.

Assessment of the Surgical Oncology Case Volume Within the Public Sector in Tanzania.

PURPOSE: Surgery provides vital services to diagnose, treat, and palliate patients suffering from malignancies. However, despite its importance, there is little information on the delivery of surgical oncology services in Tanzania. METHODS: Operative logbooks were reviewed at all national referral hospitals that offer surgery, all zonal referral hospitals in Mainland Tanganyika and Zanzibar, and a convenience sampling of regional referral hospitals in 2022. Cancer cases were identified by postoperative diagnosis and deidentified data were abstracted for each cancer surgery. The proportion of the procedures conducted for patients with cancer and the total number of cancer surgeries done within the public sector were calculated and compared with a previously published estimate of the surgical oncology need for the country. RESULTS: In total, 69,195 operations were reviewed at 10 hospitals, including two national referral hospitals, five zonal referral hospitals, and three regional referral hospitals. Of the cases reviewed, 4,248 (6.1%) were for the treatment of cancer. We estimate that 4,938 cancer surgeries occurred in the public sector in Tanzania accounting for operations conducted at hospitals not included in our study. Prostate, breast, head and neck, esophageal, and bladder cancers were the five most common diagnoses. Although 387 (83%) of all breast cancer procedures were done with curative intent, 506 (87%) of patients with prostate and 273 (81%) of patients with esophageal cancer underwent palliative surgery. CONCLUSION: In this comprehensive assessment of surgical oncology service delivery in Tanzania, we identified 4,248 cancer surgeries and estimate that 4,938 likely occurred in 2022. This represents only 25% of the estimated 19,726 cancer surgeries that are annually needed in Tanzania. These results highlight the need to identify strategies for increasing surgical oncology capacity in the country.

Traditionally removed mandibular central incisors and oral health-related quality of life: a cross-sectional study among adolescents in Maasai populated areas, Northern Tanzania.

BACKGROUND: The traditional removal of mandibular anterior teeth has been existing for many years in the Sub-Saharan African countries. This study aimed to assess the prevalence and sociodemographic distribution of traditionally removed mandibular central incisors (TRMCI) and its association with oral impact on daily performance (OIDP) among adolescents in Maasai populated areas in the Northern part of Tanzania. METHODS: Using a two-stage cluster sample design, with schools as the primary sampling unit, 23 out of 66 eligible rural schools were randomly selected. From each selected school, one class, expected to contain adolescents aged 12-14 years, was identified. The students from these selected classes were invited to participate in the study. A total of 989 adolescents were invited and 906 (91.6%) accepted to participate and completed both an interview and a clinical oral examination. RESULTS: Mean age was 13.4 years (12-17 years, SD 1.2) and 43.9% were males (n = 398). The participants from Longido district amounted to 47.1%. The Maasai group constituted 79.6% of the study participants. The frequency of the participants missing at least one mandibular central incisor were 18.5%. Multivariable logistic regression revealed that adolescents from Longido district were more likely to report at least one TRMCI (OR = 2.5, 95% CI 1.4-3.3). Adolescents from non-Maasai group were less likely to have atleast one TRMCI compared to adolescents from Maasai ethnic group (OR = 0.02, 95% CI 0.002-0.15). Adolescents with at least one TRMCI were more likely to report impacts on OIDP (OR = 3.3, 95% CI 1.9-5.7) than those without TRMCI. Independent of the TRMCI status, adolescents from Longido district were less likely than their counterparts to report oral impacts (OR = 0.4, 95% CI 0.2-0.6). Similarly, adolescents from non-Masaai group were more likely than their counterparts to report oral impacts (OR = 2.2, 95% CI 1.4-3.5). CONCLUSION: TRMCI is common among adolescents in the Maasai populated areas in the Northern part of Tanzania and strongly associated with the district of residence and Maasai ethnicity and has a negative impact on oral health related quality of life. There is a need for oral health education in the rural Maasai communities in Tanzania to increase awareness of the negative consequences of this practice.

Identifying neonates at risk for post-discharge mortality in Dar es Salaam, Tanzania, and Monrovia, Liberia: Derivation and internal validation of a novel risk assessment tool.

INTRODUCTION: The immediate period after hospital discharge carries a large burden of childhood mortality in sub-Saharan Africa. Our objective was to derive and internally validate a risk assessment tool to identify neonates discharged from the neonatal ward at risk for 60-day post-discharge mortality. METHODS: We conducted a prospective observational cohort study of neonates discharged from Muhimbili National Hospital in Dar es Salaam, Tanzania, and John F Kennedy Medical Centre in Monrovia, Liberia. Research staff called caregivers to ascertain vital status up to 60 days after discharge. We conducted multivariable logistic regression analyses with best subset selection to identify socioeconomic, demographic, clinical, and anthropometric factors associated with post-discharge mortality. We used adjusted log coefficients to assign points to each variable and internally validated our tool with bootstrap validation with 500 repetitions. RESULTS: There were 2344 neonates discharged and 2310 (98.5%) had post-discharge outcomes available. The median (IQR) age at discharge was 8 (4, 15) days; 1238 (53.6%) were male. In total, 71 (3.1%) died during follow-up (26.8% within 7 days of discharge). Leaving against medical advice (adjusted OR [aOR] 5.62, 95% CI 2.40 to 12.10) and diagnosis of meconium aspiration (aOR 6.98, 95% CI 1.69 to 21.70) conferred the greatest risk for post-discharge mortality. The risk assessment tool included nine variables (total possible score=63) and had an optimism corrected area under the receiver operating characteristic curve of 0.77 (95% CI 0.75 to 0.80). A score of ≥6 was most optimal (sensitivity 68.3% [95% CI 64.8% to 71.5%], specificity 72.1% [95% CI 71.5% to 72.7%]). CONCLUSIONS: A small number of factors predicted all-cause, 60-day mortality after discharge from neonatal wards in Tanzania and Liberia. After external validation, this risk assessment tool may facilitate clinical decision making for eligibility for discharge and the direction of resources to follow-up high risk neonates.

Rudi Kundini, Pamoja Kundini (RKPK): study protocol for a hybrid type 1 randomized effectiveness-implementation trial using data science and economic incentive strategies to strengthen the continuity of care among people living with HIV in Tanzania.

BACKGROUND: Economic incentives can improve clinical outcomes among in-care people living with HIV (PLHIV), but evidence is limited for their effectiveness among out-of-care PLHIV or those at risk of disengagement. We propose a type 1 hybrid effectiveness-implementation study to advance global knowledge about the use of economic incentives to strengthen the continuity of HIV care and accelerate global goals for HIV epidemic control. METHODS: The Rudi Kundini, Pamoja Kundini study will evaluate two implementation models of an economic incentive strategy for supporting two groups of PLHIV in Tanzania. Phase 1 of the study consists of a two-arm, cluster randomized trial across 32 health facilities to assess the effectiveness of a home visit plus one-time economic incentive on the proportion of out-of-care PLHIV with viral load suppression (< 1000 copies/ml) 6 months after enrollment (n = 640). Phase 2 is an individual 1:1 randomized controlled trial designed to determine the effectiveness of a short-term counseling and economic incentive program offered to in-care PLHIV who are predicted through machine learning to be at risk of disengaging from care on the outcome of viral load suppression at 12 months (n = 692). The program includes up to three incentives conditional upon visit attendance coupled with adapted counselling sessions for this population of PLHIV. Consistent with a hybrid effectiveness-implementation study design, phase 3 is a mixed methods evaluation to explore barriers and facilitators to strategy implementation in phases 1 and 2. Results will be used to guide optimization and scale-up of the incentive strategies, if effective, to the larger population of Tanzanian PLHIV who struggle with continuity of HIV care. DISCUSSION: Innovative strategies that recognize the dynamic process of lifelong retention in HIV care are urgently needed. Strategies such as conditional economic incentives are a simple and effective method for improving many health outcomes, including those on the HIV continuum. If coupled with other supportive services such as home visits (phase 1) or with tailored counselling (phase 2), economic incentives have the potential to strengthen engagement among the subpopulation of PLHIV who struggle with retention in care and could help to close the gap towards reaching global "95-95-95" goals for ending the AIDS epidemic. TRIAL REGISTRATION: Phase 1: ClinicalTrials.gov, NCT05248100 , registered 2/21/2022. Phase 2: ClinicalTrials.gov, NCT05373095 , registered 5/13/2022.

Economic vulnerabilities, mental health, and coping strategies among Tanzanian youth during COVID-19.

BACKGROUND: The COVID-19 pandemic has exacerbated struggles for youth living in poor households. Youth in rural Tanzania are particularly vulnerable given widespread poverty, lack of formal sector employment opportunities, and health risks. We examine influences of the pandemic on economic insecurity and mental health and explore the coping strategies employed by youth and their households. METHODS: We conducted mixed-method data collection with youth (N = 760 quantitative and N = 44 qualitative interviews) and households (n = 542) via mobile phone among a sub-set of a cohort from an on-going longitudinal sample in two rural regions in Tanzania. In addition to phone interviews, we collected data bi-weekly via SMS messaging. We present mixed-methods, descriptive analysis of the outcomes and longitudinally compare quantitative outcomes pre- and post-COVID-19, within the same individuals. RESULTS: Adverse economic impacts were most salient, and to cope, youth engaged in more labor and domestic chores. Compared to prior the COVID-19 pandemic, youth reported spending more time caring for elderly or sick household members and gathering firewood or nuts. CONCLUSIONS: These findings underscore the potential opportunity to promote policies and programs which address risks youth face. Recommended measures include expansion and adaptation of social protection policies, strengthened food and nutrition surveillance and referral systems, and scaling up community-based mental health programming.

Epidemiology of alcohol use and alcohol use disorders among people living with HIV on antiretroviral therapy in Northwest Tanzania: implications for ART adherence and case management.

Alcohol use disorders (AUD) among people living with HIV (PLHIV) are associated with poor health outcomes. This cross-sectional study examined current alcohol use and AUD among 300 PLHIV on ART at four HIV care centres in Northwest Tanzania. Participants' data were collected using questionnaires. Alcohol use was assessed using Alcohol Use Disorders Identification Test (AUDIT). Logistic regression was used to examine associations between each outcome (current drinking and AUD) and sociodemographic and clinical factors. Association between alcohol use and ART adherence was also studied. The median age of participants was 43 years (IQR 19-71) and 41.3% were male. Twenty-two (7.3%) participants failed to take ART at least once in the last seven days. The prevalence of current drinking was 29.3% (95% CI 24.2-34.8%) and that of AUD was 11.3% (8.2%-15.5%). Males had higher odds of alcohol use (OR 3.03, 95% CI 1.79-5.14) and AUD (3.89, 1.76-8.60). Alcohol use was associated with ART non-adherence (OR = 2.78, 1.10-7.04). There was a trend towards an association between AUD and non-adherence (OR = 2.91, 0.92-9.21). Alcohol use and AUD were common among PLHIV and showed evidence of associations with ART non-adherence. Screening patients for alcohol use and AUD in HIV clinics may increase ART adherence.

Neonatal mortality and video assessment of resuscitation in four district hospitals in Pemba, Tanzania.

BACKGROUND: We aimed to assess risk factors for neonatal mortality, quality of neonatal resuscitation (NR) on videos and identify potential areas for improvement. METHODS: This prospective cohort study included women in childbirth and their newborns at four district hospitals in Pemba, Tanzania. Videos were analysed for quality-of-care. Questionnaires on quality-of-care indicators were answered by health workers (HW) and women. Risk factors for neonatal mortality were analysed in a binomial logistic regression model. RESULTS: 1440 newborns were enrolled. 34 newborns died within the neonatal period (23.6 per 1000 live births). Ninety neonatal resuscitations were performed, 20 cases on video. Positive pressure ventilation (PPV) was inadequate in 15 cases (75%). Half (10/20) did not have PPV initiated within the first minute, and in one case (5.0%), no PPV was performed. PPV was not sustained in 16/20 (80%) newborns. Of the 20 videos analysed, death occurred in 10 newborns: 8 after resuscitation attempts and two within the first 24 h. Most of HW 49/56 (87.5%) had received training in NR. CONCLUSIONS: Video analysis of NR revealed significant deviations from guidelines despite 87.5% of HW being trained in NR. Videos provided direct evidence of gaps in the quality of care and areas for future education, particularly effective PPV. IMPACT: Neonatal mortality in Pemba is 23.6 per 1000 livebirths, with more than 90% occurring in the first 24 h of life. Video assessment of neonatal resuscitation revealed deviations from guidelines and can add to understanding challenges and aid intervention design. The present study using video assessment of neonatal resuscitation is the first one performed at secondary-level hospitals where many of the world's births are conducted. Almost 90% of the health workers had received training in neonatal resuscitation, and the paper can aid intervention design by understanding the actual challenges in neonatal resuscitation.

Bayesian multilevel modelling of the association between socio-economic status and stunting among under-five-year children in Tanzania.

BACKGROUND: Stunting is associated with socioeconomic status (SES) which is multidimensional. This study aimed to compare different SES indices in predicting stunting. METHODS: This was the secondary data analysis using Tanzania Demographics and Health Surveys (TDHS). The study used 7492, 6668, and 8790 under-five-year children from TDHS 2004/5, 2010, and 2015/16, respectively. The Household Wealth Index (HWI); Water and Sanitation, Assets, Maternal education and Income (WAMI); Wealth Assets, Education, and Occupation (WEO); and the Multidimensional Poverty Index (MPI) indices were compared. The summated scores, principal component analysis (PCA), and random forest (RF) approaches were used to construct indices. The Bayesian and maximum likelihood multilevel generalized linear mixed models (MGLMM) were constructed to determine the association between each SES index and stunting. RESULTS: The study revealed that 42.3%, 38.4%, and 32.4% of the studied under-five-year children were stunted in 2004/5, 2010, and 2015/16, respectively. Compared to other indicators of SES, the MPI had a better prediction of stunting for the TDHS 2004/5 and 2015/16, while the WAMI had a better prediction in 2010. For each score increase in WAMI, the odds of stunting were 64% [BPOR = 0.36; 95% CCI 0.3, 0.4] lower in 2010, while for each score increase in MPI there was 1 [BPOR = 1.1; 95% CCI 1.1, 1.2] times higher odds of stunting in 2015/16. CONCLUSION: The MPI and WAMI under PCA were the best measures of SES that predict stunting. Because MPI was the best predictor of stunting for two surveys (TDHS 2004/5 and 2015/16), studies dealing with stunting should use MPI as a proxy measure of SES. Use of BE-MGLMM in modelling stunting is encouraged. Strengthened availability of items forming MPI is inevitable for child growth potentials. Further studies should investigate the determinants of stunting using Bayesian spatial models to take into account spatial heterogeneity.

Climate distress, climate-sensitive risk factors, and mental health among Tanzanian youth: a cross-sectional study.

BACKGROUND: Climate change threatens youth mental health through multiple mechanisms, yet empirical studies typically focus on single pathways. We explored feelings of distress over climate change among Tanzanian youth, considering associations with climate change awareness and climate-sensitive risk factors, and assessed how these factors relate to mental health. METHODS: Tanzanian youth (aged 18-23 years) from a cluster randomised controlled trial in Mbeya and Iringa regions of Tanzania were interviewed between Jan 25, and March 3, 2021, and included in this cross-sectional study. A threshold of at least 10 on the ten-item Centre for Epidemiological Studies Depression Scale was used to classify symptom severity indicative of depression. Regardless of climate change awareness, respondents were asked about their feelings of distress on climate change using inclusive language (changing weather patterns or changing seasons). We estimated rate differences in climate change distress (slight or moderate or extreme vs none) by youth characteristics, extent of climate awareness, and climate-sensitive livelihoods (eg, agriculture, tending livestock) and climate-sensitive living conditions (eg, food or water insecurity), using generalised linear models. We compared depression prevalence by extent of climate change distress and climate-sensitive living conditions. FINDINGS: Among 2053 youth (1123 [55%] were male and 930 [45%] were female) included in this analysis, 946 (46%) had reported any distress about climate change. Distress was higher among female, more educated, more religious, older youth, and those working in extreme temperatures. Adjusting for climate awareness-a factor strongly associated with climate distress-helped to explain some of these associations. Depression was 23 percentage points (95% CI 17-28) higher among youth who had severe water insecurity than those who did not. Similarly, youth who had severe food insecurity had 23 percentage points higher depression (95% CI 17-28) compared with those who did not. Those reporting climate change distress also had worse mental health-extremely distressed youth had 18 percentage points (95% CI 6-30) higher depression than those reporting none. INTERPRETATION: Living in conditions worsened by climate change and feeling distressed over climate change have mental health implications among young people from low-resource settings, indicating that climate change can impact youth mental health through multiple pathways. FUNDING: Erasmus Trustfonds, Centre for Global Health Inequalities Research, UK's Foreign, Commonwealth, and Development Office, Oak Foundation, UNICEF, UK's Department of International Development, the Swedish Development Cooperation Agency, Irish Aid.

Socioecological systems analysis of potential factors for cholera outbreaks and assessment of health system's readiness to detect and respond in Ilemela and Nkasi districts, Tanzania.

BACKGROUND: Cholera outbreaks are a recurrent issue in Tanzania, with Ilemela and Nkasi districts being particulary affected. The objective of this study was to conduct a socio-ecological system (SES) analysis of cholera outbreaks in these districts, identifying potential factors and assessing the preparedness for cholera prevention and control. METHODS: A cross-sectional study was carried out in Ilemela and Nkasi districts of Mwanza and Rukwa regions, respectively in Tanzania between September and October 2021. A SES framework analysis was applied to identify potential factors associated with cholera outbreaks and assess the readiness of the districts to cholera prevention and control. RESULTS: Ilemela is characterised by urban and peri-urban ecosystems while Nkasi is mainly rural. Cholera was reported to disproportionately affect people living along the shores of Lake Victoria in Ilemela and Lake Tanganyika in Nkasi, particularly fishermen and women involved infish trading. The main potential factors identified for cholera outbreaks included defecation in the shallow ends and along the edges of lakes, open defecation, bathing/swimming in contaminated waters and improper waste disposal. The preparedness of both districts for cholera prevention and response was found to be inadequate due to limited laboratory capacity, insufficient human resources, and budget constraints. CONCLUSION: People of Ilemela and Nkasi districts remain at significant risk of recurrent cholera outbreaks and the capacity of the districts to detect the disease is limited. Urgent preventive measures, such as conducting considerable community awareness campaigns on personal hygiene and environmental sanitation are needed to alleviate the disease burden and reduce future cholera outbreaks.

Costing of HIV services, Uganda and United Republic of Tanzania.

Objective: To evaluate resource allocation and costs associated with delivery of human immunodeficiency virus (HIV) services in Uganda and the United Republic of Tanzania. Methods: We used time-driven activity-based costing to determine the resources consumed and costs of providing five HIV services in Uganda and the United Republic of Tanzania: antiretroviral therapy (ART); HIV testing and counselling; prevention of mother-to-child transmission; voluntary male medical circumcision; and pre-exposure prophylaxis. Findings: Country-based teams undertook time-driven activity-based costing with 1119 adults in Uganda and 886 adults in the United Republic of Tanzania. In Uganda, service delivery costs ranged from 8.18 United States dollars (US$) per visit for HIV testing and counselling to US$ 43.43 for ART (for clients in whom HIV was suppressed). In the United Republic of Tanzania, these costs ranged from US$ 3.67 per visit for HIV testing and counselling to US$ 28.00 for voluntary male medical circumcision. In both countries, consumables were the main cost driver, accounting for more than 60% of expenditure. Process maps showed that in both countries, registration, measurement of vital signs, consultation and medication dispensing were the steps that occurred most frequently for ART clients. Conclusion: Establishing a rigorous, longitudinal system for tracking investments in HIV services that includes thousands of clients and numerous facilities is achievable in different settings with a high HIV burden. Consistent engagement of implementation partners and standardized training and data collection instruments proved essential for the success of these exercises.

Assessment of knowledge, attitude, and practice of dog owners to rabies disease in Kahama town council, Shinyanga region, Tanzania.

BACKGROUND: Rabies is a fatal zoonotic disease of significant public health importance. Domestic dogs are the main reservoir and transmitter of this disease, particularly in developing countries. Community awareness about rabies is one of the key components of prevention. This study describes the knowledge, attitudes, and practices about rabies disease among dog owners at Kahama town council, Shinyanga Region, Tanzania. METHODOLOGY: This was a cross sectional community-based study which was done in May 2021. Structured questionnaires were administered to collect the data among 422 dog owners. The information collected included demographic characteristics of the dog owners, as well as their knowledge, attitude and practice towards rabies. Data were analyzed using SPSS statistical software version 20. RESULTS: Out of 422 respondents, 421 (99.76%) knew that rabies can be transmitted by dogs, 384 (91%) knew that rabies can be prevented by vaccination of dogs, 269 (63.74%) knew the symptoms and signs, and 379 (89.81%) believed that it was necessary to vaccinate all owned dogs, but 227 (53.79%) had not vaccinated their dogs. Education level (p = 0.006) and occupation (p = 0.002) were significantly associated with a positive attitude, whereby those with a higher level of education and farmers were more likely to have a positive attitude. Also there was statistically significant association between gender (p = 0.038), marital status (p < 0.001) occupation (p < 0.001), education level (p = 0.006) and the practices of the respondents in the community whereby majority of male, unmarried dog owner who are farmer with primary education level had lower practice score. CONCLUSION: This study concludes that respondents had good knowledge, a relatively good attitude, and poor practice towards rabies prevention and control. Rabies awareness with an emphasis on the importance of vaccination as well as vaccination campaigns should, therefore, be intensified, especially among the least educated dog owners.

Assessment of Required Patient Travel to Receive Interventional Radiology Services in the Resource-Limited Setting of Tanzania.

This study aimed to evaluate the geographic patient profile of a country's first interventional radiology (IR) service in sub-Saharan Africa. From October 2018 to August 2022, travel time (1,339 patients) and home region (1,184 patients) were recorded from 1,434 patients who underwent IR procedures at Tanzania's largest referral center. Distances traveled by road were calculated from the administrative capital of each region using a web mapping platform (google.com/maps). The effect of various factors on distance and time traveled were assessed. Patients from all 31 regions in Tanzania underwent IR procedures. The mean and maximum calculated distance traveled by patients were 241.6 km and 1,387 km, respectively (Sk2 = 1.66); 25.0% of patients traveled for over 6 hours for their procedure. Patients traveled furthest for genitourinary procedures (mean = 293.4 km) and least for angioplasty and stent placement (mean = 123.9 km) (P < .001). To increase population access and reduce travel times, geographic data should be used to decentralize services.

Malaria elimination in Zanzibar: where next?

In 2018, Zanzibar developed a national malaria strategic plan IV (2018-2023) to guide elimination of malaria by 2023. We assessed progress in the implementation of malaria activities as part of the end-term review of the strategic plan. The review was done between August and October 2022 following the WHO guideline to assess progress made towards malaria elimination, effectiveness of the health systems in delivering malaria case management; and malaria financing. A desk review examined available malaria data, annual work plans and implementation reports for evidence of implemented malaria activities. This was complemented by field visits to selected health facilities and communities by external experts, and interviews with health management teams and inhabitants to authenticate desk review findings. A steady increase in the annual parasite incidence (API) was observed in Zanzibar, from 2.7 (2017) to 3.6 (2021) cases per 1,000 population with marked heterogeneity between areas. However, about 68% of the detected malaria cases were imported into Zanzibar. Malaria case follow-up and investigation increased from <70% in 2017 to 94% and 96% respectively, in 2021. The review noted a 3.7-fold increase of the health allocation in the country's budget, from 31.7 million USD (2017/18) to 117.3 million USD (2022/23) but malaria allocation remained low (<1%). The varying transmission levels in the islands suggest a need for strategic re-orientation of the elimination attempts from a national-wide to a sub-national agenda. We recommend increasing malaria allocation from the health budget to ensure sustainability of malaria elimination interventions.

Healthcare utilization and catastrophic health expenditure in rural Tanzania: does voluntary health insurance matter?

BACKGROUND: Over 150 million people, mostly from low and middle-income countries (LMICs) suffer from catastrophic health expenditure (CHE) every year because of high out-of-pocket (OOP) payments. In Tanzania, OOP payments account for about a quarter of the total health expenditure. This paper compares healthcare utilization and the incidence of CHE among improved Community Health Fund (iCHF) members and non-members in central Tanzania. METHODS: A survey was conducted in 722 households in Bahi and Chamwino districts in Dodoma region. CHE was defined as a household health expenditure exceeding 40% of total non-food expenditure (capacity to pay). Concentration index (CI) and logistic regression were used to assess the socioeconomic inequalities in the distribution of healthcare utilization and the association between CHE and iCHF enrollment status, respectively. RESULTS: 50% of the members and 29% of the non-members utilized outpatient care in the previous month, while 19% (members) and 15% (non-members) utilized inpatient care in the previous twelve months. The degree of inequality for utilization of inpatient care was higher (insured, CI = 0.38; noninsured CI = 0.29) than for outpatient care (insured, CI = 0.09; noninsured CI = 0.16). Overall, 15% of the households experienced CHE, however, when disaggregated by enrollment status, the incidence of CHE was 13% and 15% among members and non-members, respectively. The odds of iCHF-members incurring CHE were 0.4 times less compared to non-members (OR = 0.41, 95%CI: 0.27-0.63). The key determinants of CHE were iCHF enrollment status, health status, socioeconomic status, chronic illness, and the utilization of inpatient and outpatient care. CONCLUSION: The utilization of healthcare services was higher while the incidence of CHE was lower among households enrolled in the iCHF insurance scheme relative to those not enrolled. More studies are needed to establish the reasons for the relatively high incidence of CHE among iCHF members and the low degree of healthcare utilization among households with low socioeconomic status.

Health needs assessment for the double burden of malnutrition: a community-based study on nutrition facilitators and barriers in rural Tanzania.

OBJECTIVE: The aim of this study is to explore nutrition-related health needs, the perceptions and beliefs regarding the double burden of malnutrition, as well as barriers and facilitators in accessing nutritious food among the local population in rural Tanzania. DESIGN: A qualitative study design using semi-structured individual interviews and focus-group discussions (FGD) was used. Basic socio-demographic information was obtained from all participants. SETTING: The study was conducted in four villages within the catchment area of the Shirati KMT Hospital in Rorya district, in north-western Tanzania. PARTICIPANTS: Men and women in the reproductive age as well as Community Health Workers (CHW) were included. RESULTS: In total, we performed fourteen interviews (N 41), consisting of four FGD, one dual and nine individual interviews. The three most significant topics that were identified are the large knowledge gap concerning overweight and obesity as a health problem, changing weather patterns and its implications on food supply and the socio-cultural drivers including gender roles and household dynamics. CONCLUSION: Environmental and socio-cultural factors play a crucial role in the determinants for DBM, which underlines the importance of understanding the local context and the nutrition practices and beliefs of the communities. Future nutritional interventions should aim towards more inclusion of men in project implementation as well as support of women empowerment. CHW could play a key role in facilitating some of the suggested interventions, including nutritional counselling and increasing awareness on the drivers of the double burden of malnutrition.

Cultural adaption and validation of the Explanatory Model Interview Catalogue-Community Stigma Scale in the assessment of public stigma related to schistosomiasis in lakeshore areas of Mwanza region, Tanzania.

BACKGROUND: Previous qualitative studies on attitudes towards schistosomiasis demonstrated inconclusive results on the extent of stigma towards schistosomiasis in endemic communities around the world. The Explanatory Model Interview Catalogue-Community Stigma Scale (EMIC-CSS) has been used and validated for the assessment of public stigma across numerous countries in various health conditions. This study tested the performance of the scale in the context of stigma related to schistosomiasis in twelve communities in the three districts of Magu, Nyamagana and Ilemela in Mwanza region, Tanzania. METHODOLOGY/PRINCIPAL FINDINGS: The 15-item-version of the EMC-CSS was first translated to Kiswahili language. The translation was discussed within the research team to retain the meaning of the items and implement cultural adaptations. Validation of the adapted EMIC-CSS scale was conducted following the framework of Herdman and Fox- Rushby. A pilot study with 41 participants from two communities provided the basis for testing the performance of each item and assessing the semantic and operational equivalence of the scales. In addition, eight qualitative focus group discussions (FGDs) were conducted to evaluate the conceptional equivalence of the EMIC-CSS. Finally, the performance of the adjusted scale was tested on 200 participants with a 50:50 male-female ratio from ten communities. The mean score of the EMIC-CSS M = 8.35 (SD = 6.63) shows clear indications for public stigma towards schistosomiasis. The EMIC-CSS demonstrated a good internal consistency with Cronbach's alpha α = .857 and no floor and ceiling effects. CONCLUSION/SIGNIFICANCE: The results demonstrate that the EMIC-CSS is a useful instrument in assessing public stigma towards schistosomiasis and allow a clear recommendation of the EMIC-CSS for schistosomiasis in the Tanzanian culture. However, future studies are additionally recommended to address specific aspects and forms of the disease and how they contribute to the development of stigma towards schistosomiasis.