Exploring drivers of food choice among PLHIV and their families in a peri-urban Dar es Salaam, Tanzania.

BACKGROUND: A nutritious diet is critical to minimizing disease progression of human immunodeficiency virus (HIV) and maximizing treatment efficacy. In low resource settings, meeting the food preference needs of people living with the HIV (PLHIV) can be achieved with a supportive food environment when HIV status is disclosed. However, less is known about family-level strategies related to building a supportive food environment. The Diet, Environment, and Choices of positive living (DECIDE), a mixed-methods observational study conducted in peri-urban Dar es Salaam, Tanzania, explored food preferences as influenced by the personal, family, and external food domains. METHODS: We completed a qualitative analysis of data generated from 40 interviews (n = 20 PLHIV and n = 20 family members) aimed at exploring the dynamics of food choice for using a family perspective. We expanded on Turner's food environment framework and drew on Giddens' structuration theory to guide our data collection and analysis. Interviews were audio recorded, transcribed, translated from Kiswahili to English, coded, and organized into themes. RESULTS: We found PLHIV personal food preferences were influenced by organoleptic properties, medications, disease stage, and gender norms. Family members were knowledgeable about the importance of nutritious food for HIV treatment and prioritized these needs to avoid HIV-related stigma and fulfill family obligations. With high prices of nutritious foods (animal source foods, fruits), family members strategized to secure preferred foods for the PLHIV by, 1) forgoing their own food preferences; 2) reallocating food within the household; 3)making food substitutions; and 4) leveraging external networks. These strategies were increasingly employed as the disease progressed. CONCLUSION: The use of this expanded framework that included a family perspective on PLHIV food choice illuminated the various households decision-making dynamics that took place in this low resource community. Family members of PLHIV tried to buffer the limitations imposed by the external food environment, especially as the disease progressed. In the context of HIV status disclosure, integrating a family perspective into HIV nutrition interventions and programs has the potential to influence health outcomes and slow disease progression.

Exploring the mechanisms behind HIV drug resistance in sub-Saharan Africa: conceptual mapping of a complex adaptive system based on multi-disciplinary expert insights.

BACKGROUND: HIV drug resistance (HIVDR) continues to threaten the effectiveness of worldwide antiretroviral therapy (ART). Emergence and transmission of HIVDR are driven by several interconnected factors. Though much has been done to uncover factors influencing HIVDR, overall interconnectedness between these factors remains unclear and African policy makers encounter difficulties setting priorities combating HIVDR. By viewing HIVDR as a complex adaptive system, through the eyes of multi-disciplinary HIVDR experts, we aimed to make a first attempt to linking different influencing factors and gaining a deeper understanding of the complexity of the system. METHODS: We designed a detailed systems map of factors influencing HIVDR based on semi-structured interviews with 15 international HIVDR experts from or with experience in sub-Saharan Africa, from different disciplinary backgrounds and affiliated with different types of institutions. The resulting detailed system map was conceptualized into three main HIVDR feedback loops and further strengthened with literature evidence. RESULTS: Factors influencing HIVDR in sub-Saharan Africa and their interactions were sorted in five categories: biology, individual, social context, healthcare system and 'overarching'. We identified three causal loops cross-cutting these layers, which relate to three interconnected subsystems of mechanisms influencing HIVDR. The 'adherence motivation' subsystem concerns the interplay of factors influencing people living with HIV to alternate between adherence and non-adherence. The 'healthcare burden' subsystem is a reinforcing loop leading to an increase in HIVDR at local population level. The 'ART overreliance' subsystem is a balancing feedback loop leading to complacency among program managers when there is overreliance on ART with a perceived low risk to drug resistance. The three subsystems are interconnected at different levels. CONCLUSIONS: Interconnectedness of the three subsystems underlines the need to act on the entire system of factors surrounding HIVDR in sub-Saharan Africa in order to target interventions and to prevent unwanted effects on other parts of the system. The three theories that emerged while studying HIVDR as a complex adaptive system form a starting point for further qualitative and quantitative investigation.

Health priority-setting for official development assistance in low-income and middle-income countries: a Best Fit Framework Synthesis study with primary data from Ethiopia, Nigeria and Tanzania.

BACKGROUND: Decision making process for Official Development Assistance (ODA) for healthcare sector in low-income and middle-income countries involves multiple agencies, each with their unique power, priorities and funding mechanisms. This process at country level has not been well studied. METHODS: This paper developed and applied a new framework to analyze decision-making process for priority setting in Ethiopia, Nigeria, and Tanzania, and collected primary data to validate and refine the model. The framework was developed following a scoping review of published literature. Interviews were then conducted using a pre-determined interview guide developed by the research team. Transcripts were reviewed and coded based on the framework to identify what principles, players, processes, and products were considered during priority setting. Those elements were further used to identify where the potential capacity of local decision-makers could be harnessed. RESULTS: A framework was developed based on 40 articles selected from 6860 distinct search records. Twenty-one interviews were conducted in three case countries from 12 institutions. Transcripts or meeting notes were analyzed to identify common practices and specific challenges faced by each country. We found that multiple stakeholders working around one national plan was the preferred approach used for priority setting in the countries studied. CONCLUSIONS: Priority setting process can be further strengthened through better use of analytical tools, such as the one described in our study, to enhance local ownership of priority setting for ODA and improve aid effectiveness.

Are out-of-school adolescents at higher risk of adverse health outcomes? Evidence from 9 diverse settings in sub-Saharan Africa.

OBJECTIVES: We analysed mutually comparable surveys on adolescent attitudes and behaviours from nine sites in seven sub-Saharan African countries, to determine the relationship between school enrolment and adolescent health outcomes. METHODS: Data from the Africa Research, Implementation Science, and Education Network cross-sectional adolescent health surveys were used to examine the associations of current school enrolment, self-reported general health and four major adolescent health domains: (i) sexual and reproductive health; (ii) nutrition and non-communicable diseases; (iii) mental health, violence and injury; and (iv) healthcare utilisation. We used multivariable Poisson regression models to calculate relative risk ratios with 95% confidence intervals (CI), controlling for demographic and socio-economic characteristics. We assessed heterogeneity by gender and study site. RESULTS: Across 7829 adolescents aged 10-19, 70.5% were in school at the time of interview. In-school adolescents were 14.3% more likely (95% CI: 6-22) to report that their life is going well; 51.2% less likely (95% CI: 45-67) to report ever having had sexual intercourse; 32.6% more likely (95% CI: 9-61) to report unmet need for health care; and 30.1% less likely (95% CI: 15-43) to report having visited a traditional healer. School enrolment was not significantly associated with malnutrition, low mood, violence or injury. Substantial heterogeneity was identified between genders for sexual and reproductive health, and in-school adolescents were particularly less likely to report adverse health outcomes in settings with high average school enrolment. CONCLUSIONS: School enrolment is strongly associated with sexual and reproductive health and healthcare utilisation outcomes across nine sites in sub-Saharan Africa. Keeping adolescents in school may improve key health outcomes, something that can be explored through future longitudinal, mixed-methods, and (quasi-)experimental studies.

OBJECTIFS: Nous avons analysé des enquêtes mutuellement comparables sur les attitudes et les comportements d'adolescents dans neuf sites dans sept pays d'Afrique subsaharienne, afin de déterminer la relation entre la scolarisation et les résultats de la santé des adolescents. MÉTHODES: Des données provenant d'enquêtes transversales sur la santé des adolescents menées par le Réseau Africain de Recherche, d'Implémentation, de Science et d'Education ont été utilisées pour examiner les associations existant entre la scolarisation, l'état de santé général autodéclaré et les quatre principaux domaines de la santé des adolescents: (i) santé sexuelle et reproductive ; (ii) nutrition et maladies non transmissibles; (iii) santé mentale, violence et blessures et (iv) utilisation des soins de santé. Nous avons utilisé des modèles de régression multivariée de Poisson pour calculer les rapports de risque relatifs avec des intervalles de confiance (IC) à 95%, en tenant compte des caractéristiques démographiques et socioéconomiques. Nous avons évalué l'hétérogénéité par sexe et par site d'étude. RÉSULTATS: Sur 7.829 adolescents âgés de 10 à 19 ans, 70,5% étaient à l'école au moment de l'enquête. Les adolescents scolarisés étaient 14,3% (IC95%: 6-22) plus susceptibles de déclarer que leur vie se passait bien, 51,2% (IC95%: 45-67) moins susceptibles de déclarer avoir déjà eu des rapports sexuels, 32,6% (IC95%: 39-91) plus susceptibles de signaler un besoin de soins de santé non satisfait et 30,1% (IC95%: 15-43) moins susceptibles de déclarer avoir rendu visite à un guérisseur traditionnel. La scolarisation n'était pas associée de manière significative à la malnutrition, à la mauvaise humeur, à la violence ou aux blessures. Une hétérogénéité substantielle a été identifiée entre les sexes pour la santé sexuelle et reproductive, et les adolescents scolarisés étaient particulièrement moins susceptibles de faire état de résultats défavorables pour la santé dans les milieux où la moyenne de scolarisation était élevée. CONCLUSIONS: La scolarisation est fortement associée aux résultats en matière de santé sexuelle et reproductive et d'utilisation des soins de santé dans neuf sites en Afrique subsaharienne. Garder les adolescents à l'école peut améliorer les principaux résultats de santé, ce qui peut être exploré dans le cadre de futures études longitudinales.

Design and field methods of the ARISE Network Adolescent Health Study.

The ARISE Network Adolescent Health Study is an exploratory, community-based survey of 8075 adolescents aged 10-19 in 9 communities in 7 countries: Burkina Faso, Eswatini, Ethiopia, Ghana, Nigeria, Tanzania and Uganda. Communities were selected opportunistically and existing population cohorts maintained by health and demographic surveillance systems (HDSSs). The study is intended to serve as a first round of data collection for African adolescent cohorts, with the overarching goal of generating community-based data on health-related behaviours and associated risk factors in adolescents, to identify disease burdens and health intervention opportunities. Household-based sampling frames were used in each community to randomly select eligible adolescents (aged 10-19 years). Data were collected between July 2015 and December 2017. Consenting participants completed face-to-face interviews with trained research assistants using a standardised questionnaire, which covered physical activity, cigarette and tobacco use, substance and drug use, mental health, sexual behaviours and practices, sexually transmitted infections, pregnancy, food security and food diversity, teeth cleaning and hand washing, feelings and friendship, school and home activities, physical attacks and injuries, health care, health status assessment and life satisfaction, as well as media and cell phone use and socio-demographic and economic background characteristics. Results from this multi-community study serve to identify major adolescent health risks and disease burdens, as well as opportunities for interventions and improvements through policy changes.

L'étude ARISE du réseau sur la santé des adolescents est une étude exploratoire de surveillance basée sur la communauté portant sur 8.075 adolescents âgés de 10 à 19 ans dans 9 communautés de 7 pays: Burkina Faso, Eswatini, Ethiopie, Ghana, Nigéria, Tanzanie et Ouganda. Les communautés ont été sélectionnés de manière opportuniste et les cohortes de population existantes maintenues par des systèmes de surveillance de la santé et démographique (SSSD). L'étude est destinée à servir comme premier cycle de collecte de données pour les cohortes d'adolescents africains, dans le but primordial de générer des données communautaires sur les comportements liés à la santé et les facteurs de risque associés chez les adolescents, afin d'identifier la charge de morbidité et les opportunités d'intervention en matière de santé. Des cadres d'échantillonnage basés sur le ménage ont été utilisés dans chaque communauté pour sélectionner au hasard les adolescents admissibles (âgés de 10-19 ans). Les données ont été collectées entre juillet 2015 et décembre 2017. Les participants consentants ont participé à des entretiens de face à face avec des assistants de recherche formés, à l'aide d'un questionnaire standardisé couvrant l'activité physique, l'usage de la cigarette ou la consommation de tabac, l'usage de drogues et autres substances, la santé mentale, les comportements et pratiques sexuels, les infections sexuellement transmissibles, la grossesse, la sécurité et la diversité alimentaire, le nettoyage des dents et le lavage des mains, les sentiments et les amitiés, les activités scolaires et à domicile, les attaques et les blessures physiques, les soins de santé, l'évaluation de l'état de santé et la satisfaction à l'égard de la vie, l'utilisation des médias et du téléphone portable ainsi que les caractéristiques sociodémographiques et économiques. Les résultats de cette étude portant sur plusieurs communautés permettent d'identifier les principaux risques pour la santé des adolescents et les charges de morbidité, ainsi que les opportunités d'interventions et d'amélioration par le biais de changements de politiques.

The age of opportunity: prevalence of key risk factors among adolescents 10-19 years of age in nine communities in sub-Saharan Africa.

OBJECTIVE: To measure health-related behaviours and risk factors among sub-Saharan African adolescents. METHODS: Cross-sectional study in nine communities in Burkina Faso, Ethiopia, Eswatini, Ghana, Nigeria, Tanzania and Uganda between 2015 and 2017. Community-representative samples of males and females 10-19 years of age were selected. All communities used a uniform questionnaire that was adapted from the WHO Global School-based Student Health Survey. Weighted prevalence estimates and 95% confidence intervals were calculated for each indicator and stratified by age and sex using SAS version 9.4. All prevalence estimates were pooled across communities through random-effects meta-analyses in Stata version 14. RESULTS: A total of 8075 adolescents participated in the study. We observed a high prevalence of inadequate fruit consumption (57-63%) and low physical activity (82-90%); a moderate prevalence of inadequate vegetable consumption (21-31%), unprotected last sex (38-45%), age at first sex <15 years (21-28%) and bullying and physical fighting (12-35%); and a low prevalence of mental health risk factors (1-11%) and alcohol and substance use risk factors (0-6%). We observed a moderate to high prevalence of daily soft drink consumption (21-31%) for all adolescents. Among sexually active adolescents 15-19 years, 37% of females reported ever being pregnant and 8% of males reported to have ever made someone pregnant. Bullying (23%) and physical fighting (35%) were more common among younger male adolescents . The prevalence of low mood was generally higher among older (15-19 years) than younger adolescents (10-14 years). The proportion of adolescents reporting alcohol, drug or cigarette use was very small, with the exception of khat use in Ethiopia. CONCLUSION: Overall, diet and physical activity, violence, sexual and reproductive health, and depression are important risk factors for these sub-Saharan African communities. These findings suggest that more evidence is needed including novel efforts for the collection of sensitive information, as well as a need to move towards community-tailored interventions to reach adolescent populations with varying needs.

OBJECTIF: Mesurer les comportements liés à la santé et les facteurs de risque chez les adolescents africains subsahariens. MÉTHODES: Etude transversale dans neuf communautés au Burkina Faso, en Ethiopie, à Eswatini, au Ghana, au Nigéria, en Tanzanie et en Ouganda entre 2015 et 2017. Des échantillons représentatifs de la communauté composés d'hommes et de femmes âgés de 10 à 19 ans ont été sélectionnés. Toutes les communautés ont utilisé un questionnaire uniforme adapté de l'Enquête Mondiale sur la Santé des Elèves de l'OMS. Les estimations de prévalence pondérée et les intervalles de confiance à 95% ont été calculés pour chaque indicateur et stratifiées par âge et sexe à l'aide de la version 9.4 de SAS. Toutes les estimations de prévalence ont été poolées dans les communautés via des méta-analyses à effets aléatoires dans Stata, version 14. RÉSULTATS: 8.075 adolescents ont participé à l'étude. Nous avons observé une prévalence élevée de consommation insuffisante de fruits (57-63%) et de faible activité physique (82-90%); une prévalence modérée de consommation insuffisante de légumes (21-31%), du dernier rapport sexuel non protégé (38-45%), du premier rapport sexuel à moins de 15 ans (21-28%) et de l'intimidation et des combats physiques (12-35%), une faible prévalence de facteurs de risque pour la santé mentale (1-11%) et de facteurs de risque pour la consommation d'alcool et de substances (0-6%). Nous avons observé une prévalence modérée à élevée de consommation quotidienne de boissons gazeuses (21-31%) chez tous les adolescents. Parmi les adolescents sexuellement actifs âgées de 15 à 19 ans, 37,0% des femmes ont déclaré avoir déjà été enceintes et 8,0% des hommes ont rapporté avoir déjà enceinté une femme. L'intimidation (23%) et les combats physiques étaient plus fréquents chez les adolescents plus jeunes (35%). La prévalence de la mauvaise humeur était généralement plus élevée chez les adolescents d'âge plus élevé (de 15 à 19 ans) que chez les plus jeunes (de 10 à 14 ans). La proportion d'adolescents déclarant avoir consommé de l'alcool, des drogues ou des cigarettes était très faible, à l'exception de la consommation de khat en Ethiopie. CONCLUSION: Dans l'ensemble, le régime alimentaire et l'activité physique, la violence, la santé sexuelle et reproductive et la dépression sont des facteurs de risque importants pour ces communautés d'Afrique subsaharienne. Ces résultats suggèrent que davantage de données sont nécessaires, notamment de nouveaux efforts pour la collecte d'informations sensibles, ainsi que la nécessité de passer à des interventions adaptées aux communautés pour atteindre les populations adolescentes avec des besoins variés.

Men's roles in care seeking for maternal and newborn health: a qualitative study applying the three delays model to male involvement in Morogoro Region, Tanzania.

BACKGROUND: Increasing the utilization of facility-based care for women and newborns in low-resource settings can reduce maternal and newborn morbidity and mortality. Men influence whether women and newborns receive care because they often control financial resources and household decisions. This influence can have negative effects if men misjudge or ignore danger signs or are unwilling or unable to pay for care. Men can also positively affect their families' health by helping plan for delivery, supplementing women's knowledge about danger signs, and supporting the use of facility-based care. Because of these positive implications, researchers have called for increased male involvement in maternal and newborn health. However, data gathered directly from men to inform programs are lacking. METHODS: This study draws on in-depth interviews with 27 men in Morogoro Region, Tanzania whose partners delivered in the previous 14 months. Debriefings took place throughout data collection. Interview transcripts were analyzed inductively to identify relevant themes and devise an analysis questionnaire, subsequently applied deductively to all transcripts. RESULTS: Study findings add a partner-focused dimension to the three delays model of maternal care seeking. Men in the study often, though not universally, described facilitating access to care for women and newborns at each point along this care-seeking continuum (deciding to seek care, reaching a facility, and receiving care). Specifically, men reported taking ownership of their role as decision makers and described themselves as supportive of facility-based care. Men described arranging transport and accompanying their partners to facilities, especially for non-routine care. Men also discussed purchasing supplies and medications, acting as patient advocates, and registering complaints about health services. In addition, men described barriers to their involvement including a lack of knowledge, the need to focus on income-generating activities, the cost of care, and policies limiting male involvement at facilities. CONCLUSION: Men can leverage their influence over household resources and decision making to facilitate care seeking and navigate challenges accessing care for women and newborns. Examining these findings from men and understanding the barriers they face can help inform interventions that encourage men to be positively and proactively involved in maternal and newborn health.

Integrating Community Health Worker Roles to Improve Facility Delivery Utilization in Tanzania: Evidence from an Interrupted Time Series Analysis.

OBJECTIVES: Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania. METHODS: A 36-month time series data set (2014-2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility. RESULTS: There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals, from an average of 202-234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001). CONCLUSIONS FOR PRACTICE: Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care.

Validity of an FFQ to measure nutrient and food intakes in Tanzania.

OBJECTIVE: FFQ are often used to estimate food and nutrient intakes to rank individuals by their level of intake. We evaluated the relative validity of a semi-quantitative FFQ created for use in Tanzania by comparing it with two 24 h diet recalls. DESIGN: We measured relative validity of the FFQ with deattenuated energy-adjusted rank correlations for nutrients, deattenuated rank correlations for food groups, and performed a cross-classification analysis of energy-adjusted nutrient quartiles using percentage of agreement and Bland-Altman analysis. SETTING: Interviews were conducted in 2014 in participants' homes in Ukonga, Dar es Salaam, Tanzania. SUBJECTS: We surveyed 317 adults aged 40 years or older from the general public. RESULTS: Deattenuated energy-adjusted rank correlation coefficients of nutrients ranged from -0·03 for riboflavin to 0·41 for percentage of energy from carbohydrates, with a median correlation of 0·21. Coefficients for food groups ranged from 0·00 for root vegetables to 0·51 for alcohol, with a median of 0·35. Relative to the average of the two 24 h diet recalls, the FFQ overestimated energy intake and intakes of all nutrients and food groups, other than tea, with ratios among nutrients ranging from 1·34 for SFA to 7·08 for vitamin A; and among food groups from 0·92 for tea to 9·00 for fruit. The percentage of participants classified into the same nutrient intake quartile ranged from 23 % for SFA to 32 % for both niacin and pantothenic acid, with a median of 28 %. CONCLUSIONS: The FFQ performed moderately well in urban Tanzanian adults.

Stigma, Facility Constraints, and Personal Disbelief: Why Women Disengage from HIV Care During and After Pregnancy in Morogoro Region, Tanzania.

Millions of children are living with HIV in sub-Saharan Africa, and the primary mode of these childhood infections is mother-to-child transmission. While existing interventions can virtually eliminate such transmission, in low- and middle-income settings, only 63 % of pregnant women living with HIV accessed medicines necessary to prevent transmission. In Tanzania, HIV prevalence among pregnant women is 3.2 %. Understanding why HIV-positive women disengage from care during and after pregnancy can inform efforts to reduce the impact of HIV on mothers and young children. Informed by the tenets of Grounded Theory, we conducted qualitative interviews with 40 seropositive postpartum women who had disengaged from care to prevent mother-to-child transmission (PMTCT). Nearly all women described antiretroviral treatment (ART) as ultimately beneficial but effectively inaccessible given concerns related to stigma. Many women also described how their feelings of health and vitality coupled with concerns about side effects underscored a desire to forgo ART until they deemed it immediately necessary. Relatively fewer women described not knowing or forgetting that they needed to continue their treatment regimens. We present a theory of PMTCT disengagement outlining primary and ancillary barriers. This study is among the first to examine disengagement by interviewing women who had actually discontinued care. We urge that a combination of intervention approaches such as mother-to-mother support groups, electronic medical records with same-day tracing, task shifting, and mobile technology be adapted, implemented, and evaluated within the Tanzanian setting.

Equally able, but unequally accepted: Gender differentials and experiences of community health volunteers promoting maternal, newborn, and child health in Morogoro Region, Tanzania.

BACKGROUND: Despite emerging qualitative evidence of gendered community health worker (CHW) experience, few quantitative studies examine CHW gender differentials. The launch of a maternal, newborn, and child health (MNCH) CHW cadre in Morogoro Region, Tanzania enlisting both males and females as CHWs, provides an opportunity to examine potential gender differences in CHW knowledge, health promotion activities and client acceptability. METHODS: All CHWs who received training from the Integrated MNCH Program between December 2012 and July 2013 in five districts were surveyed and information on health promotion activities undertaken drawn from their registers. CHW socio-demographic characteristics, knowledge, and health promotion activities were analyzed through bi- and multivariate analyses. Composite scores generated across ten knowledge domains were used in ordered logistic regression models to estimate relationships between knowledge scores and predictor variables. Thematic analysis was also undertaken on 60 purposively sampled semi-structured interviews with CHWs, their supervisors, community leaders, and health committee members in 12 villages from three districts. RESULTS: Of all CHWs trained, 97% were interviewed (n = 228): 55% male and 45% female. No significant differences were observed in knowledge by gender after controlling for age, education, date of training, marital status, and assets. Differences in number of home visits and community health education meetings were also not significant by gender. With regards to acceptability, women were more likely to disclose pregnancies earlier to female CHWs, than male CHWs. Men were more comfortable discussing sexual and reproductive concerns with male, than female CHWs. In some cases, CHW home visits were viewed as potentially being for ulterior or adulterous motives, so trust by families had to be built. Respondents reported that working as female-male pairs helped to address some of these dynamics. CONCLUSIONS: Male and female CHWs in this study have largely similar knowledge and health promotion outputs, but challenges in acceptance of CHW counseling for reproductive health and home visits by unaccompanied CHWs varied by gender. Programs that pair male and female CHWs may potentially overcome gender issues in CHW acceptance, especially if they change gender norms rather than solely accommodate gender preferences.

Determinants of postnatal care use at health facilities in rural Tanzania: multilevel analysis of a household survey.

BACKGROUND: Postnatal care (PNC) for the mother and infant is a neglected area, even for women who give birth in a health facility. Currently, there is very little evidence on the determinants of use of postnatal care from health facilities in Tanzania. METHODS: This study examined the role of individual and community-level variables on the use of postnatal health services, defined as a check up from a heath facility within 42 days of delivery, using multilevel logistic regression analysis. We analyzed data of 1931 women, who had delivered in the preceding 2-14 months, from a two-stage household survey in 4 rural districts of Morogoro region, Tanzania. Individual level explanatory variables included i) Socio-demographic factors: age, birth order, education, and wealth, ii) Factors related to pregnancy: frequency of antenatal visits, history of complications, mode of delivery, place of delivery care, and counseling received. Community level variables included community levels of family planning, health service utilization, trust, poverty and education, and distance to health facility. RESULTS: Less than one in four women in Morogoro reported having visited a health facility for postnatal care. Individual-level attributes positively associated with postnatal care use were women's education of primary level or higher [Odds Ratio (OR) 1.37, 95 % Confidence Interval (CI) 1.04-1.81], having had a caesarean section or forceps delivery (2.95, 1.8-4.81), and being counseled by a community health worker to go for postnatal care at a health facility (2.3, 1.36-3.89). Other positive associations included those recommended HIV testing for baby (1.94, 1.19-3.15), and whose partners tested for HIV (1.41, 1.07-1.86). High community levels of postpartum family planning usage (2.48, 1.15-5.37) and high level of trust in health system (1.77, 1.12-2.79) were two significant community-level predictors. Lower postnatal care use was associated with having delivered at a hospital (0.5, 0.33-0.76), health center (0.57, 0.38-0.85), or dispensary (0.48, 0.33-0.69), and having had severe swelling of face and legs during pregnancy (0.65, 0.43-0.97). CONCLUSIONS: In the context of low postnatal care use in a rural setting, programs should direct efforts towards reaching women who do not avail themselves of postnatal care as identified in our study.

Initial experiences and innovations in supervising community health workers for maternal, newborn, and child health in Morogoro region, Tanzania.

BACKGROUND: Supervision is meant to improve the performance and motivation of community health workers (CHWs). However, most evidence on supervision relates to facility health workers. The Integrated Maternal, Newborn, and Child Health (MNCH) Program in Morogoro region, Tanzania, implemented a CHW pilot with a cascade supervision model where facility health workers were trained in supportive supervision for volunteer CHWs, supported by regional and district staff, and with village leaders to further support CHWs. We examine the initial experiences of CHWs, their supervisors, and village leaders to understand the strengths and challenges of such a supervision model for CHWs. METHODS: Quantitative and qualitative data were collected concurrently from CHWs, supervisors, and village leaders. A survey was administered to 228 (96%) of the CHWs in the Integrated MNCH Program and semi-structured interviews were conducted with 15 CHWs, 8 supervisors, and 15 village leaders purposefully sampled to represent different actor perspectives from health centre catchment villages in Morogoro region. Descriptive statistics analysed the frequency and content of CHW supervision, while thematic content analysis explored CHW, supervisor, and village leader experiences with CHW supervision. RESULTS: CHWs meet with their facility-based supervisors an average of 1.2 times per month. CHWs value supervision and appreciate the sense of legitimacy that arises when supervisors visit them in their village. Village leaders and district staff are engaged and committed to supporting CHWs. Despite these successes, facility-based supervisors visit CHWs in their village an average of only once every 2.8 months, CHWs and supervisors still see supervision primarily as an opportunity to check reports, and meetings with district staff are infrequent and not well scheduled. CONCLUSIONS: Supervision of CHWs could be strengthened by streamlining supervision protocols to focus less on report checking and more on problem solving and skills development. Facility health workers, while important for technical oversight, may not be the best mentors for certain tasks such as community relationship-building. We suggest further exploring CHW supervision innovations, such as an enhanced role for community actors, who may be more suitable to support CHWs engaged primarily in health promotion than scarce and over-worked facility health workers.

Motivation and satisfaction among community health workers in Morogoro Region, Tanzania: nuanced needs and varied ambitions.

BACKGROUND: In 2012, the Ministry of Health and Social Welfare (MOHSW), Tanzania, approved national guidelines and training materials for community health workers (CHWs) in integrated maternal, newborn and child health (Integrated MNCH), with CHWs trained and deployed across five districts of Morogoro Region soon after. To inform future scale up, this study assessed motivation and satisfaction among these CHWs. METHODS: A survey of all CHWs trained by the Integrated MNCH Programme was conducted in the last quarter of 2013. Motivation and satisfaction were assessed using a five-point Likert scale with 29 and 27 items based on a literature review and discussions with CHW programme stakeholders. Exploratory factor analysis was conducted to identify motivation and satisfaction determinants. RESULTS: Out of 238 eligible CHWs, 96 % were included in the study. Findings showed that respondents were motivated to become CHWs due to altruism (work on MNCH, desire to serve God, work hard) and intrinsic needs (help community, improve health, pride) than due to external stimuli (monetary incentives, skill utilization, community respect or hope for employment). CHWs were satisfied by relationships with health workers and communities, job aids and the capacity to provide services. CHWs were dissatisfied with the lack of transportation, communication devices and financial incentives for carrying out their tasks. Factors influencing motivation and satisfaction did not differ across CHW socio-demographic characteristics. Nonetheless, older and less educated CHWs were more likely to be motivated by altruism, intrinsic needs and skill utilization, community respect and hope for employment. Less educated CHWs were more satisfied with service and quality factors and more wealthy CHWs satisfied with job aids. CONCLUSION AND RECOMMENDATIONS: A combination of financial and non-financial incentives is required to support motivation and satisfaction among CHWs. Although CHWs joined mainly due to their altruistic nature, they became discontented with the lack of monetary compensation, transportation and communication support received. With the planned rollout of the national CHW cadre, improved understanding of CHWs as a heterogeneous group with nuanced needs and varied ambitions is vital for ensuring sustainability.

Profile, knowledge, and work patterns of a cadre of maternal, newborn, and child health CHWs focusing on preventive and promotive services in Morogoro Region, Tanzania.

BACKGROUND: Despite impressive decreases in under-five mortality, progress in reducing maternal and neonatal mortality in Tanzania has been slow. We present an evaluation of a cadre of maternal, newborn, and child health community health worker (MNCH CHW) focused on preventive and promotive services during the antenatal and postpartum periods in Morogoro Region, Tanzania. Study findings review the effect of several critical design elements on knowledge, time allocation, service delivery, satisfaction, and motivation. METHODS: A quantitative survey on service delivery and knowledge was administered to 228 (of 238 trained) MNCH CHWs. Results are compared against surveys administered to (1) providers in nine health centers (n = 88) and (2) CHWs (n = 53) identified in the same districts prior to the program's start. Service delivery outputs were measured by register data and through a time motion study conducted among a sub-sample of 33 randomly selected MNCH CHWs. RESULTS: Ninety-seven percent of MNCH CHWs (n = 228) were interviewed: 55% male, 58% married, and 52% with secondary school education or higher. MNCH CHWs when compared to earlier CHWs were more likely to be unmarried, younger, and more educated. Mean MNCH CHW knowledge scores were <50% for 8 of 10 MNCH domains assessed and comparable to those observed for health center providers but lower than those for earlier CHWs. MNCH CHWs reported covering a mean of 186 households and were observed to provide MNCH services for 5 h weekly. Attendance of monthly facility-based supervision meetings was nearly universal and focused largely on registers, yet data quality assessments highlighted inconsistencies. Despite program plans to provide financial incentives and bicycles for transport, only 56% of CHWs had received financial incentives and none received bicycles. CONCLUSIONS: Initial rollout of MNCH CHWs yields important insights into addressing program challenges. The social profile of CHWs was not significantly associated with knowledge or service delivery, suggesting a broader range of community members could be recruited as CHWs. MNCH CHW time spent on service delivery was limited but comparable to the financial incentives received. Service delivery registers need to be simplified to reduce inconsistencies and yet expanded to include indicators on the timing of antenatal and postpartum visits.

"Every method seems to have its problems"- Perspectives on side effects of hormonal contraceptives in Morogoro Region, Tanzania.

BACKGROUND: Family planning has been shown to be an effective intervention for promoting maternal, newborn and child health. Despite family planning's multiple benefits, women's experiences of - or concerns related to - side effects present a formidable barrier to the sustained use of contraceptives, particularly in the postpartum period. This paper presents perspectives of postpartum, rural, Tanzanian women, their partners, public opinion leaders and community and health facility providers related to side effects associated with contraceptive use. METHODS: Qualitative interviews were conducted with postpartum women (n = 34), their partners (n = 23), community leaders (n = 12) and health providers based in both facilities (n = 12) and communities (n = 19) across Morogoro Region, Tanzania. Following data collection, digitally recorded data were transcribed, translated and coded using thematic analysis. RESULTS: Respondents described family planning positively due to the health and economic benefits associated with limiting and spacing births. However, side effects were consistently cited as a reason that women and their partners choose to forgo family planning altogether, discontinue methods, switch methods or use methods in an intermittent (and ineffective) manner. Respondents detailed side effects including excessive menstrual bleeding, missed menses, weight gain and fatigue. Women, their partners and community leaders also described concerns that contraceptives could induce sterility in women, or harm breastfeeding children via contamination of breast milk. Use of family planning during the postpartum period was viewed as particularly detrimental to a newborn's health in the first months of life. CONCLUSIONS: To meet Tanzania's national target of increasing contraceptive use from 34 to 60 % by 2015, appropriate counseling and dialogue on contraceptive side effects that speaks to pressing concerns outlined by women, their partners, communities and service providers are needed.

Why are primary school children overweight and obese? A cross sectional study undertaken in Kinondoni district, Dar-es-salaam.

BACKGROUND: The world is experiencing an alarming increase in prevalence of childhood obesity. Despite this trend little is known about determinants of childhood obesity in Tanzania. A cross sectional study determined the prevalence and factors associated with overweight and obesity in 1722 children aged 7-14 years (10.9 ± 1.74) attending primary schools in Dar es Salaam. METHODS: Six public and four private schools were systemically selected from a total of 227 primary schools. Anthropometric measurements (weight and height) were collected using a standard protocol and Body Mass Index (BMI) was calculated. Interviews collected demographic characteristics and lifestyle factors. Multiple logistic regression test was used to assess the influence of independent variables on overweight and obesity while controlling for confounding factors. The level of significance was set at α = 5 %. RESULTS: Of 1, 722 children 10.2 % were overweight and 4.5 % were obese. Overweight and obesity was higher in boys (14.9 %) than girls (14.5 %), higher in children attending private schools (27.7 %) than public schools (5.9 %). Children who walked to and from school were less likely to be overweight or obese than those who used vehicles (AOR = 0.5; 95%CI: 0.3-0.6; p < 0.001). Those who used private cars or school buses were more likely to be overweight or obese than those who used public transport (AOR = 2.9; 95%CI: 0.2-0.7; p < 0.05). Computer/video game use were associated with increased risk of overweight and obesity (AOR = 1.6; 95%CI: 1.1-2.3; p = 0.03). Lunch provided by schools was associated with increased risk of overweight or obese (AOR = 6.4, 95 % CI = 4.2-9.6, p < 0.001). CONCLUSIONS: The findings of this study identified a number of behavioural and dietary factors that are related to overweight and obesity. Parents and teachers should encourage children to be physically active by limiting screen time and promoting active transport to and from school to promote health and reduce obesity. Ministry of education needs to formulate/enforce policies that encourage physical activities for school children and regulate quality of foods provided to children at schools.

Program synergies and social relations: implications of integrating HIV testing and counselling into maternal health care on care seeking.

BACKGROUND: Women and children in sub-Saharan Africa bear a disproportionate burden of HIV/AIDS. Integration of HIV with maternal and child services aims to reduce the impact of HIV/AIDS. To assess the potential gains and risks of such integration, this paper considers pregnant women's and providers' perceptions about the effects of integrated HIV testing and counselling on care seeking by pregnant women during antenatal care in Tanzania. METHODS: From a larger evaluation of an integrated maternal and newborn health care program in Morogoro, Tanzania, this analysis included a subset of information from 203 observations of antenatal care and interviews with 57 providers and 190 pregnant women from 18 public health centers in rural and peri-urban settings. Qualitative data were analyzed manually and with Atlas.ti using a framework approach, and quantitative data of respondents' demographic information were analyzed with Stata 12.0. RESULTS: Perceptions of integrating HIV testing with routine antenatal care from women and health providers were generally positive. Respondents felt that integration increased coverage of HIV testing, particularly among difficult-to-reach populations, and improved convenience, efficiency, and confidentiality for women while reducing stigma. Pregnant women believed that early detection of HIV protected their own health and that of their children. Despite these positive views, challenges remained. Providers and women perceived opt out HIV testing and counselling during antenatal services to be compulsory. A sense of powerlessness and anxiety pervaded some women's responses, reflecting the unequal relations, lack of supportive communications and breaches in confidentiality between women and providers. Lastly, stigma surrounding HIV was reported to lead some women to discontinue services or seek care through other access points in the health system. CONCLUSION: While providers and pregnant women view program synergies from integrating HIV services into antenatal care positively, lack of supportive provider-patient relationships, lack of trust resulting from harsh treatment or breaches in confidentiality, and stigma still inhibit women's care seeking. As countries continue rollout of Option B+, social relations between patients and providers must be understood and addressed to ensure that integrated delivery of HIV counselling and services encourages women's care seeking in order to improve maternal and child health.

Supply-side dimensions and dynamics of integrating HIV testing and counselling into routine antenatal care: a facility assessment from Morogoro Region, Tanzania.

BACKGROUND: Integration of HIV into RMNCH (reproductive, maternal, newborn and child health) services is an important process addressing the disproportionate burden of HIV among mothers and children in sub-Saharan Africa. We assess the structural inputs and processes of care that support HIV testing and counselling in routine antenatal care to understand supply-side dynamics critical to scaling up further integration of HIV into RMNCH services prior to recent changes in HIV policy in Tanzania. METHODS: This study, as a part of a maternal and newborn health program evaluation in Morogoro Region, Tanzania, drew from an assessment of health centers with 18 facility checklists, 65 quantitative and 57 qualitative provider interviews, and 203 antenatal care observations. Descriptive analyses were performed with quantitative data using Stata 12.0, and qualitative data were analyzed thematically with data managed by Atlas.ti. RESULTS: Limitations in structural inputs, such as infrastructure, supplies, and staffing, constrain the potential for integration of HIV testing and counselling into routine antenatal care services. While assessment of infrastructure, including waiting areas, appeared adequate, long queues and small rooms made private and confidential HIV testing and counselling difficult for individual women. Unreliable stocks of HIV test kits, essential medicines, and infection prevention equipment also had implications for provider-patient relationships, with reported decreases in women's care seeking at health centers. In addition, low staffing levels were reported to increase workloads and lower motivation for health workers. Despite adequate knowledge of counselling messages, antenatal counselling sessions were brief with incomplete messages conveyed to pregnant women. In addition, coping mechanisms, such as scheduling of clinical activities on different days, limited service availability. CONCLUSION: Antenatal care is a strategic entry point for the delivery of critical tests and counselling messages and the framing of patient-provider relations, which together underpin care seeking for the remaining continuum of care. Supply-side deficiencies in structural inputs and processes of delivering HIV testing and counselling during antenatal care indicate critical shortcomings in the quality of care provided. These must be addressed if integrating HIV testing and counselling into antenatal care is to result in improved maternal and newborn health outcomes.

High prevalence of self-reported sexually transmitted infections among older adults in Tanzania: results from a list experiment in a population-representative survey.

PURPOSE: Self-report of sensitive or stigmatized health states is often subject to social desirability and interviewer biases. To reduce such biases, we estimated the rate of sexually transmitted infections (STIs) using a list experiment. METHODS: This population-representative study was nested within the Dar es Salaam Urban Cohort Study, a Health and Demographic Surveillance System (HDSS) in the Ukonga ward of Dar es Salaam, Tanzania. Men and women aged ≥40years were randomly assigned to receive a list of either four control items (i.e., the control group) or four control items plus an additional item on having had a disease through sexual contacts in the past 12months (i.e., the treatment group). We calculated the mean difference in the total number of items to which respondents answered "yes" in the treatment versus control group and compared this prevalence estimate to the one measured by the direct question. RESULTS: A total of 2310 adults aged ≥40years were enrolled in the study: 32% were male and 48% were aged 40-49years. The estimated prevalence of having STIs in the past 12months was 17.8% (95% confidence interval [CI] 12.3-23.3) in the list experiment, almost 10 times higher than the estimated prevalence of 1.8% (95%CI 1.3-2.4) based on the direct question (P < .001). STI prevalence remained high after adjusting for age, the number of lifetime sex partners, alcohol consumption and smoking in multivariate linear regression (15.6%; 95% CI 7.3-23.9). CONCLUSIONS: We found a substantially higher prevalence of STIs among older adults in urban Tanzania when we based our estimation on a list experiment rather than a direct question in a population-representative survey. List experiments should be considered to elimnate social desirability and interviewer biases in surveys of sensitive or stigmatized health states. The very high prevalence of STIs highlights the need for improved access to STI screening, prevention and treatment for older adults in urban Africa.