Patient perspectives on the helpfulness of a community health worker program for HIV care engagement in Tanzania.

Task-shifting is a valuable approach for redistributing clinical tasks to nonprofessional health workers and relieving human resource shortages. The Community-Based HIV Services (CBHS) program is a national cohort of volunteer community health workers (CHWs) who support HIV care engagement at clinics in Tanzania. We recruited 23 patients initiating HIV care at two clinics to understand their experiences with the CBHS program. Participants completed qualitative interviews by telephone discussing the perceived helpfulness of the program, their level of connection with CHWs, and suggestions for improvement. Data were analyzed through an inductive, team-based qualitative approach. Most participants found the program to be helpful and described close, positive connections. CHWs offered education, emotional support to accept one's diagnosis and cope with stigma, and encouragement to remain engaged in HIV care. However, several participants described minimal, shallow contact with CHWs, and felt the program did not benefit their HIV care. Participants recommended increasing CHW efforts to engage people living with HIV (PLWH) in the broader community, and addressing socioeconomic barriers to care engagement. When contacts are consistent, the CBHS program is a strong resource for PLWH. To maximize the potential of the program, administrators should enhance oversight and extend new training opportunities for CHWs.

Long-Distance Travel for HIV-Related Care-Burden or Choice?: A Mixed Methods Study in Tanzania.

Decentralization of HIV care across sub-Saharan Africa has increased access to anti-retroviral therapy (ART). Although traveling for care has traditionally been viewed as a barrier, some individuals may choose to travel for care due to stigma and fear of HIV status disclosure. We sought to understand the prevalence of traveling long distances for HIV care, as well as reasons for engaging in such travel. Using a concurrent embedded mixed-methods study design, individuals receiving care at two HIV care and treatment clinics in Tanzania completed a quantitative survey (n = 196), and a sub-set of participants reporting long-distance travel for care were interviewed (n = 31). Overall 58.2% of participants (n = 114/196) reported knowing of a closer clinic than the one they chose to attend. Having experienced enacted stigma was significantly associated with traveling for care (OR 2.31, 95% CI 1.12, 4.75, p = 0.02). Reasons for clinic choice centered on three main themes: clinic familiarity, quality of care, and stigma. Traveling for care was often viewed as an enabling strategy for remaining engaged in care by helping overcome other barriers, including stigma and suboptimal quality of care.

Challenges and opportunities for improving mental health care and preventing suicide among people living with HIV: Perspectives of mental health professionals in Tanzania.

People living with HIV (PLWH) experience unique stressors that contribute to emotional distress, and PLWH are more than twice as likely to die by suicide when compared to the general population. In countries like Tanzania, there is a relatively high burden of HIV but few resources to support mental health needs. To gain a better understanding of mental health challenges experienced by PLWH in northern Tanzania and identify opportunities for intervention, we interviewed 12 mental health professionals working in the Kilimanjaro region. Thematic analysis was used to explore drivers and impacts of emotional distress, community influences on mental health, and gaps and barriers to existing mental health care. Perspectives from mental health workers highlight the compounding effects of stress related to HIV status, family conflict, finances, and other social challenges, which can lead to poor HIV treatment outcomes and suicidal ideation. Cultural beliefs and stigma surrounding both mental health and HIV limit care-seeking behavior for mental health issues. Those who do seek care often encounter barriers related to poor mental health infrastructure, including a lack of providers, limited financial resources, and little integration into other health services. There is a clear need for investment in the mental health care system, as well as interventions to improve knowledge and perceptions of mental health and comprehensively address stressors. We describe feedback on a proposed telehealth counseling intervention integrated into routine HIV services, which shows strong potential to mitigate barriers to mental health treatment, reduce suicidal ideation, and support the wellbeing of PLWH.

A scoping review of counseling interventions for suicide prevention in Africa: Few studies address this life-saving aspect of mental health treatment.

BACKGROUND: Nearly 800,000 people die by suicide each year, with 77 % occurring in low- and middle-income countries. Suicide is underestimated in many African settings due to challenges in data collection, stigma, and policies that promote silence; nonetheless, rates of suicide in Africa are consistently higher than global averages. METHODS: We conducted a scoping review of counseling interventions assessing suicide outcomes among adults in Africa using MEDLINE, Embase, PsycINFO, African Index Medicus, CABI Global Health, and Proquest databases. Study screening and data extraction was informed by the JBI Manual for Evidence Synthesis. RESULTS: Of 2438 abstracts reviewed, 33 studies met criteria for full-text review and 13 were included in the analysis. Interventions served several populations, including people living with HIV, out of school youth, university students, and women undergoing obstetric fistula repair. There was a near-equal split in individual versus group counseling modalities and the use of professional versus lay counselors. The majority of interventions had primary outcomes focused on other mental health or social variables with a secondary focus on suicide. Mechanisms of change for suicide prevention were poorly articulated. LIMITATIONS: The review was limited to English-language studies conducted after 2001 and excluded qualitative studies and those with fewer than 10 participants. CONCLUSIONS: There is a clear paucity of research in this area, particularly in the lack of randomized clinical trials and studies with suicide prevention as their primary outcome. Researchers should seek to develop or adapt evidence-based, culturally-resonant interventions to reduce the burden of suicide on the African continent.

Brief Report: Task-Shifting "Gold Standard" Clinical Assessment and Safety Planning for Suicide Risk Among People Living With HIV: A Feasibility and Fidelity Evaluation in Tanzania.

BACKGROUND: Suicide is a leading cause of death among people living with HIV (PLWH) worldwide, with suicide deaths occurring twice as frequently among PLWH than among the general public. In Tanzania, resources for mental health care are sorely lacking, with 55 psychiatrists and psychologists providing treatment for 60 million people. In light of this shortage, nonspecialists play a crucial role. The objective of this study was to assess feasibility of implementing task-shifted screening, assessment, and safety planning for suicide risk among PLWH. SETTING: Two adult HIV clinics in Kilimanjaro, Tanzania. METHODS: Registered professional nurses in the HIV clinics were trained to administer brief screening of suicidal ideation in the past month. Patients experiencing suicidal ideation were referred to bachelor's-level counselors for further assessment and safety planning, supervised by specialist providers who reviewed audio recordings for quality assurance. RESULTS: During 180 days of implementation, nurses screened patients attending 2745 HIV appointments. Sixty-one (2.2%) endorsed suicidal ideation and were linked to further assessment and safety planning. We cross-checked screening with clinic attendance logs on 7 random days and found high fidelity to screening (206 of 228 screened, 90%). Quality assurance ratings demonstrated key assessment pieces were consistently completed (mean = 9.3/10 possible), with "Good" to "Excellent" counseling skills (mean = 23.7/28) and "Good" to "Excellent" quality (mean = 17.1/20), including appropriate referral for higher levels of care. CONCLUSIONS: Brief screening can be implemented and paired with task-shifted counseling to facilitate high-quality assessment of suicide risk. This model shows excellent potential to extend mental health services for PLWH in low-resource settings.

Healthcare provider perspective on barriers and facilitators in the care of pediatric injury patients at a tertiary hospital in Northern Tanzania: A qualitative study.

Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). The recovery of injured children in LMICs is often impeded by barriers in accessing and receiving timely and quality care at healthcare facilities. The purpose of this study was to identify the barriers and the facilitators in pediatric injury care at Kilimanjaro Christian Medical Center (KCMC), a tertiary zonal referral hospital in Northern Tanzania. In this study, focus group discussions (FGDs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the barriers and facilitators in pediatric injury care. Five FGDs were completed from February 2021 to July 2021. Participants (n = 30) were healthcare providers from the emergency department, burn ward, surgical ward, and pediatric ward. De-identified transcripts were analyzed with team-based, applied thematic analysis using qualitative memo writing and consensus discussions. Our study found barriers that impeded pediatric injury care were: lack of pediatric-specific injury training and care guidelines, lack of appropriate pediatric-specific equipment, staffing shortages, lack of specialist care, and complexity of cases due to pre-hospital delays in patients presenting for care due to cultural and financial barriers. Facilitators that improved pediatric injury care were: team cooperation and commitment, strong priority and triage processes, benefits of a tertiary care facility, and flexibility of healthcare providers to provide specialized care if needed. The data highlights barriers and facilitators that could inform interventions to improve the care of pediatric injury patients in Northern Tanzania such as: increasing specialized provider training in pediatric injury management, the development of pediatric injury care guidelines, and improving access to pediatric-specific technologies and equipment.

Family caregiver perspectives on strengths and challenges in the care of pediatric injury patients at a tertiary referral hospital in Northern Tanzania.

BACKGROUND: Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). It is important that injured children get quality care in order to improve their outcomes. Injured children are nearly always accompanied by family member caregivers invested in their outcome, and who will be responsible for their recovery and rehabilitation after discharge. OBJECTIVE: The purpose of this study was to identify family member caregiver perspectives on strengths and challenges in pediatric injury care throughout hospitalization at a tertiary hospital in Northern Tanzania. METHODS: This study was conducted at a zonal referral hospital in Northern Tanzania. Qualitative semi-structured in-depth interviews (IDIs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the strengths and challenges in pediatric injury care. IDIs were completed from November 2020 to October 2021 with 30 family member caregivers of admitted pediatric injured patients. De-identified transcripts were synthesized in memos and analyzed through a team-based, thematic approach informed by applied thematic analysis. RESULTS: Strengths and challenges were identified throughout the hospital experience, including emergency medicine department (EMD) care, inpatient wards care, and discharge. Across the three phases, strengths were identified such as how quickly patients were evaluated and treated, professionalism and communication between healthcare providers, attentive nursing care, frequent re-evaluation of a patient's condition, and open discussion with caregivers about readiness for discharge. Challenges identified related to lack of communication with caregivers, perceived inability of caregivers to ask questions, healthcare providers speaking in English during rounds with lack of interpretation into the caregivers' preferred language, and being sent home without instructions for rehabilitation, ongoing care, or guidance for follow-up. CONCLUSION: Caregiver perspectives highlighted strengths and challenges throughout the hospital experience that could lead to interventions to improve the care of pediatric injury patients in Northern Tanzania. These interventions include prioritizing communication with caregivers about patient status and care plan, ensuring all direct communication is in the caregivers' preferred language, and standardizing instructions regarding discharge and follow-up.

Protocol for a pilot randomized controlled trial of a telehealth-delivered counseling intervention to reduce suicidality and improve HIV care engagement in Tanzania.

OBJECTIVE: Suicidal ideation is strikingly common among people living with HIV (PLWH) worldwide, leading to higher burden of disease, poor HIV care engagement, and loss of life. In low- and middle-income countries such as Tanzania, mental health resources are scarce, requiring innovative strategies for treatment. We describe the protocol for a clinical trial of a three-session telehealth counseling intervention to reduce suicidality and improve HIV care engagement in Tanzania. METHODS: In a pilot randomized controlled trial, we will assess the feasibility, acceptability, and potential efficacy of a new telehealth intervention, termed "IDEAS for Hope". A total of 60 PLWH will be enrolled from two HIV clinics in the Kilimanjaro region and connected to telehealth counsellors based at a large regional hospital. Participants will be ≥18 years old and speak either Kiswahili or English. Patient screening will occur during routine HIV clinical care to identify PLWH experiencing suicidal ideation. Baseline surveys will be administered upon enrollment and participants will be randomized 1:1 to receive either IDEAS for Hope or the comparison condition, a brief safety planning session. All participants will receive an additional referral for psychiatric treatment. Follow-up assessment will occur at three months. IDEAS for Hope is informed by a Motivational Interviewing-enhanced safety planning intervention (MI-SafeCope) and our formative work in Tanzania. The model consists of Four Pillars: living healthy with HIV, managing HIV stigma, seeking social support, and meeting basic needs. Together, these mechanisms serve as a foundation for developing a sense of safety and hope for the future. Outcome measures will include intervention feasibility, acceptability, participant suicidality, and HIV care engagement. SIGNIFICANCE: Innovative, telehealth-based counseling represents a promising treatment for suicidality among PLWH in low-resource settings. Results from this pilot trial will inform intervention refinement and parameter estimates for a future clinical trial powered to evaluate effectiveness.

Validation of a culturally sensitive, Swahili-translated instrument to assess suicide risk among adults living with HIV in Tanzania.

In Tanzania, there are high rates of suicidal thoughts and behavior among people living with HIV (PLWH), yet few instruments exist for effective screening and referral. To address this gap, we developed and validated Swahili translations of the Columbia Suicide Severity Rating Scale (C-SSRS) Screen Version and two accompanying scales assessing self-efficacy to avoid suicidal action and reasons for living. We administered a structured survey to 80 PLWH attending two HIV clinics in Moshi, Tanzania. Factor analysis of the items revealed four subscales: suicide intensity, self-efficacy to avoid suicide, fear and social concern about suicide, and family and spirituality deterrents to suicide. The area under the receiver operating curve showed only suicide intensity, and fear and social concern met the prespecified cutoff of ≥0.7 in accurately identifying patients with a plan and intent to act on suicidal thoughts. This study provides early evidence that brief screening of intensity of suicidality in the past month, assessed by the C-SSRS Screen Version, is a strong, resource-efficient strategy for identifying suicide risk in the Tanzanian setting. Patients who report little fear of dying and low concern about social perceptions of suicide may also be at increased risk.

A cohort of pediatric injury patients from a hospital-based trauma registry in Northern Tanzania.

Introduction: Pediatric injuries in low- and middle-income countries are a leading cause of morbidity and mortality worldwide. Implementing hospital-based trauma registries can reduce the knowledge gap in both hospital care and patient outcomes and lead to quality improvement initiatives. The goal of this study was to create a pediatric trauma registry to provide insight into the epidemiology, outcomes, and factors associated with poor outcomes in injured children. Methods: This was a prospective observational study in which a pediatric trauma registry was implemented at a large zonal referral hospital in Northern Tanzania. Data included demographics, hospital-based care, and outcomes including morbidity and mortality. Data were input into REDCap© and analyzed using ANOVA and Chi-squared tests in SAS(Version 9.4)©. Results: 365 patients were enrolled in the registry from November 2020 to October 2021. The majority were males (n=240, 65.8%). Most were children 0-5 years (41.7%, n=152), 34.5% (n=126) were 6-11 years, and 23.8% (n=87) were 12-17 years. The leading causes of pediatric injuries were falls (n=137, 37.5%) and road traffic injuries (n=125, 34.5%). The mortality rate was 8.2% (n=30). Of the in-hospital deaths, 43.3% were children with burn injuries who also had a higher odds of mortality than children with other injuries (OR 8.72, p<0.001). The factors associated with in-hospital mortality and morbidity were vital sign abnormalities, burn severity, abnormal Glasgow Coma Score, and ICU admission. Conclusion: The mortality rate of injured children in our cohort was high, especially in children with burn injuries. In order to reduce morbidity and mortality, interventions should be prioritized that focus on pediatric injured patients that present with abnormal vital signs, altered mental status, and severe burns. These findings highlight the need for health system capacity building to improve outcomes of pediatric injury patients in Northern Tanzania.

Three delays model applied to pediatric injury care seeking in Northern Tanzania: A mixed methods study.

Pediatric injuries are a leading cause of morbidity and mortality in low-and middle-income countries. Timely presentation to care is key for favorable outcomes. The goal of this study was to identify and examine delays that children experience between injury and receiving definitive care at a zonal referral hospital in Northern Tanzania. Between November 2020 and October 2021, we enrolled 348 pediatric trauma patients, collecting quantitative data on referral and timing information. In-depth interviews (IDIs) to explain and explore delays to care were completed with a sub-set of 30 family members. Data were analyzed according to the Three Delays Model. 81.0% (n = 290) of pediatric injury patients sought care at an intermediary facility before reaching the referral hospital. Time from injury to presentation at the referral hospital was 10.2 hours [IQR 4.8, 26.5] if patients presented first to clinics, 8.0 hours [IQR 3.9, 40.0] if patients presented first to district/regional hospitals, and 1.4 hours [IQR 0.7, 3.5] if patients presented directly to the referral hospital. In-hospital mortality was 8.2% (n = 30); 86.7% (n = 26) of these children sought care at an intermediary facility prior to reaching the referral hospital. IDIs revealed themes related to each delay. For decision to seek care (Delay 1), delays included emergency recognition, applying first aid, and anticipated challenges. For reaching definitive care (Delay 2), delays included caregiver rationale for using intermediary facilities, the complex referral system, logistical challenges, and intermediary facility delays. For receiving definitive care (Delay 3), wait time and delays due to treatment cost existed at the referral hospital. Factors throughout the healthcare system contribute to delays in receipt of definitive care for pediatric injuries. To minimize delays and improve patient outcomes, interventions are needed to improve caregiver and healthcare worker education, streamline the current trauma healthcare system, and improve quality of care in the hospital setting.

The Role of Community Health Workers in HIV Care Engagement: A Qualitative Study of Stakeholder Perspectives in Tanzania.

ABSTRACT: Suboptimal retention in HIV care is a major driver of the global epidemic, including in sub-Saharan Africa. In Tanzania, the national Community-Based HIV Services program integrates volunteer community health workers (CHWs) to support patient care engagement and reduce the burden placed on HIV clinic nurses; however, few studies have assessed the value of CHWs supporting HIV care. Qualitative interviews were conducted with 48 administrators, nurses, CHWs, and patients to explore strengths and limitations of the Community-Based HIV Services program. Stakeholders believed CHWs are uniquely positioned to establish trust and provide patient support. Patients who had frequent contact with CHWs described them as valued sources of education and encouragement, but fewer than half of the patients interviewed had ever met with a CHW. Clinic nurses described feeling disconnected from CHWs, and stakeholders highlighted the need for financial, logistical, and educational support to rejuvenate the program and effectively address care engagement challenges.

Assessing the Influence of Community Health Worker Support on Early Antiretroviral Therapy Adherence, Anticipated Stigma, and Mental Health Among People Living with HIV in Tanzania.

In many low- and middle-income countries, community health workers (CHWs) support multiple aspects of HIV care, including patient education and counseling, adherence support, and re-engaging patients lost to care. In Tanzania, the Community-Based HIV Services program is a nationwide cohort of CHWs supporting HIV care engagement. We enrolled a prospective cohort study of 80 people initiating HIV care at two Tanzanian clinics and conducted baseline and 3-month follow-up assessments to examine the potential influence of CHW support and other factors on patient early self-reported medication adherence, depression, anxiety, attitudes about medication, and HIV stigma. The vast majority of participants reported maintaining strong antiretroviral therapy (ART) adherence during the study and endorsed beliefs that ART is beneficial for them. However, there was high occurrence of likely depression and anxiety disorders in the study sample. Patient contact with CHWs at the clinic was unexpectedly low; fewer than two-thirds of participants were informed about the CHW program and fewer than one-third ever met with a CHW. Among participants who met with a CHW, there was mixed feedback about the helpfulness of the program, and contact with a CHW did not improve medication adherence at 3-month follow-up. Male participants, those with likely depression, and those who lived further from the clinic were significantly more likely to experience adherence challenges. The study findings indicate that CHWs are currently underutilized to provide patient support and may not be producing observable benefits to patients in this setting, representing a missed opportunity to address patient challenges, including depression and anxiety.