Evaluation of long-lasting insecticidal net distribution through schools in Southern Tanzania.

Universal coverage with effective vector control remains the mainstay of malaria vector control in sub-Saharan Africa. Tanzania has utilized a number of mechanisms for the maintenance of long-lasting insecticidal net (LLIN) coverage over time. Schools have been identified as one potential channel for continuous distribution of LLIN. This research aims to evaluate an annual school-based LLIN distribution programme in Tanzania that began in 2013, called the School Net Programme (SNP). Following each of the first four rounds of SNP distribution, a household survey was conducted in intervention and comparison districts in Southern and Lake zones of Tanzania (N = 5083 households). Measures of ownership, access and use were compared between intervention and comparison districts. Determinants of reach were assessed in intervention districts. Population access to an LLIN increased from 63.1% (95% CI: 58.8, 67.5) to 76.5% (95% CI: 72.9, 80.0) in the intervention districts between the first and last surveys. Access also rose in the comparison districts from 51.4% (95% CI: 46.9, 55.9) to 79.8% (95% CI: 77.3, 82.0) following mass distribution and implementation of school-based distribution during the study period. LLIN use increased in intervention districts from 44.9% (95% CI: 40.5, 49.3) to 65.6% (95% CI: 59.4, 71.8) and from 57.2% (95% CI: 49.7, 64.7) to 77.4% (95% CI: 69.3, 85.5) specifically amongst primary school-aged children. Households reached by the SNP were wealthier households with children enrolled in school. The SNP in Tanzania was able to maintain population level LLIN ownership, use and access in the absence of mass distribution. The SNP successfully reached households that housed school-aged children. Alternative delivery strategies may need to be considered to reach households without children enrolled in schools that experienced fewer benefits from the programme.

Maternal mortality in Ifakara Health and Demographic Surveillance System: Spatial patterns, trends and risk factors, 2006 - 2010.

INTRODUCTION: Maternal mortality was the subject of the United Nations' fifth Millennium Development Goal which was to reduce the maternal mortality ratio by three quarters from 1990 to 2015. The Sustainable Development Goals (SDGs), target 3.1 requires participating countries to reduce their maternal mortality ratio to less than 70 deaths per 100,000 live births by 2030. Although much research has been conducted, knowing the spatial patterns and risk factors associated with maternal mortality in developing countries helps target scarce resources and intervention programmes to high risk areas for the greatest impact. METHODS: Data were analysed from a longitudinal open cohort of women aged 15 to 49 years, enrolled from 2006 to 2010. An inverse distance weighted method of interpolation was used to assess spatial patterns of maternal mortality. Cox proportional hazards regression analysis was used to identify risk factors associated with maternal mortality. RESULTS: The overall maternal mortality rate for the 36 792 study participants for the five years was 0.79 per 1000 person years. The trend declined from 90.42 in 2006 to 57.42 in 2010. Marked geographical differences were observed in maternal mortality patterns. The main causes of maternal death were eclampsia (23%), haemorrhage (22%) and abortion-related complications (10%). There was a reduced risk of 82% (HR = 0.18, 95% CI:0.05-0.74) and 78% (HR = 0.22, 95% CI:0.05-0.92) for women aged 20-29 and 30-39 years, respectively, compared with those younger than 20 years. While being married had a protective effect of 94% (HR = 0.06, 95% CI: 0.01-0.51) compared with being single, women who were widowed had an increased risk of maternal death of 913% (HR = 9.13, 95% CI: 1.02-81.94). Women who belong to poorer, poor and least poor socioeconomic quintile had 84%, 71% and 72% reduction in risk of maternal mortality respectively compared to those in the poorest category (HR = 0.16, 95% CI: 0.06-0.42; HR = 0.29, 95% CI: 0.12-0.69; HR = 0.28, 95% CI: 0.10-0.80). CONCLUSION: Maternal mortality has declined in rural southern Tanzania since 2006, with geographical differences in patterns of death. Eclampsia, haemorrhage and abortion-related complications are the three leading causes of maternal death in the region, with risk factors being younger than 20 years, being single or widowed, and having a low socioeconomic status.

Using contraceptives to delay first birth: a qualitative study of individual, community and health provider perceptions in southern Tanzania.

BACKGROUND: Young adolescents and unmarried women in low and middle income countries face challenges in accessing family planning services. One factor likely to limit contraceptive use is the attitude and opinion of local stakeholders such as community leaders and health workers. Much of the existing evidence on this topic focuses on women who have already started childbearing. Using primary qualitative data, we explored individual, community and health provider's perceptions about using modern contraceptives to delay the first birth in a high fertility setting. METHODS: A descriptive qualitative study was conducted in Tandahimba district in southern Tanzania between December 2014 and March 2015. We conducted 8 focus group discussions with men and women and 25 in-depth interviews (18 with women, 4 with family planning service providers and 3 with district-level staff). Participants were purposively sampled. Data transcripts were managed and coded using Nvivo 11 software and we employed a thematic framework analysis. RESULTS: Three main themes emerged about using modern contraceptives to delay first birth: (1) the social and biological status of the woman (2) the type of contraceptive and (3) non-alignment among national policies for adolescents. Use of modern contraceptives to delay first birth was widely acceptable for women who were students, young, unmarried and women in unstable marriage. But long-acting reversible methods such as implants and intrauterine devices were perceived as inappropriate methods for delaying first birth, partly because of fears around delayed return to fecundity, discontinuation once woman's marital status changes and permanently limiting future fertility. The support for use of modern contraceptives to delay a first pregnancy was not unanimous. A small number of participants from both rural and urban areas did not approve the use of contraceptive methods before the birth of a first baby at all, not even for students. There was lack of clarity and consistency on the definition of 'young' and that had direct implications for access, autonomy in decision-making, confidentiality and consent for young people. CONCLUSIONS: Women who wish to delay their first birth face challenges related to restrictions by age and method imposed by stakeholders in accessing and provision of modern contraceptives. There is a need for a clearly communicated policy on minimum age and appropriate method choice for delayers of first birth.

Effectiveness and equity of the Tanzania National Voucher Scheme for mosquito nets over 10 years of implementation.

BACKGROUND: The Tanzania National Voucher Scheme (TNVS) was a public private partnership managed by the Ministry of Health that provided pregnant women and infants with highly subsidized (long-lasting) insecticide-treated nets between 2004 and 2014. It was implemented in the context of the National Insecticide Treated Nets (NATNETS) Programme and was the main keep up strategy for vulnerable populations. CASE DESCRIPTION: The programme design was adjusted considerably over time to incorporate new evidence, shifting public health policies, and changing donor priorities. Three TNVS models can be distinguished: (1) the fixed discount; (2) the fixed top-up; (3) the hybrid voucher model. The changes improved equity and effectiveness, but also had a profound effect on how the programme was managed and implemented. RESULTS: The TNVS reached the majority of beneficiaries with vouchers, and significantly increased household ownership and use of LLINs. While two mass distribution campaigns implemented between 2009 and 2011 achieved universal coverage and equity, the TNVS ensured continuous protection of the vulnerable populations before, during and after the campaigns. The TNVS stimulated and maintained a large national retail network which managed the LLIN supply chain. DISCUSSION AND LESSONS LEARNED: The effectiveness of the TNVS was a function of several interdependent factors, including the supply chain of vouchers through the public health system; the supply chain of nets in the commercial sector; the demand for nets from voucher recipients; management and risk mitigation measures; and the influence of global and donor objectives. CONCLUSION: The TNVS was a highly innovative and globally influential programme, which stimulated the thinking around effectively and equitably distributing ITNs, and contributed directly to the evolution of global policy. It was a fundamental component of the NATNETS programme which protected a malaria-vulnerable population for over a decade.

Can school-based distribution be used to maintain coverage of long-lasting insecticide treated bed nets: evidence from a large scale programme in southern Tanzania?

Many sub-Saharan African countries have achieved substantial gains in insecticide treated bednet coverage since 2005. The Tanzania National Malaria Control Programme identified school-based net distribution as one potential 'keep-up' strategy for the purpose of maintaining long-lasting insecticidal net (LLIN) coverage after a nationwide mass campaign in 2011. The School Net Programme (SNP) was implemented in three regions of southern Tanzania and distributed one LLIN to each enrolled child attending schools in primary grades (standards) 1, 3, 5 and 7, and secondary grades (forms) 2 and 4 in 2013 and again with slightly modified eligibility criteria in 2014 and 2015. Household surveys in the programme area as well as in a control area were conducted after each of the SNP distributions to measure ownership and use of long-lasting insecticide treated nets. Ownership of at least one LLIN after the first distribution was 76.1% (95% CI 70.8-80.7) in the intervention area and 78.6% (95% CI 74.4-82.3) in the control area. After the second distribution, ownership of at least one LLIN had dropped significantly in the control area to 65.4% (95% CI 59.5-71.0) in 2015 (P < 0.001), while coverage in the intervention area was maintained at 79.3% (95% CI 75.4 × 82.6). Ownership of at least one LLIN in intervention area remained stable following the second round of net distribution. During the same period LLIN ownership, especially of enough nets to ensure all household member access, fell significantly in the control area. These results demonstrate that the SNP may be sufficient to maintain stable LLIN coverage following a mass distribution of LLINs.

Delaying first birth: an analysis of household survey data from rural Southern Tanzania.

BACKGROUND: Currently, family planning metrics derived from nationally-representative household surveys such as the Demographic and Health Surveys (DHS) categorise women into those desiring to space or limit (permanently stop) births, or according to their age in the case of young women. This conceptualisation potentially ignores a large and growing group of young women who desire to delay a first birth. This study uses household survey data to investigate the characteristics and needs for family planning of women who want to delay their first birth. METHODS: The research was conducted in two rural districts in southern Tanzania (Tandahimba and Newala), and nested within the Expanded Quality Management Using Information Power (EQUIP) study. Data were collected as part of a repeated cross sectional household survey conducted between September 2013 and April 2014. The socio-demographic characteristics, including parity, contraceptive practices and fertility intentions of 2128 women aged 13-49 were analysed. The association between women's life stages of reproduction (delayers of first birth, spacers of subsequent pregnancies and limiters of future birth) and selected contraceptive outcomes (current use, unmet need and demand for modern contraceptives) was assessed using the point estimates and 95% confidence intervals for each indicator, adjusted for the survey design. RESULTS: Overall, four percent of women surveyed were categorised as 'delayers of first birth', i.e. sexually active but not started childbearing. Among this group, the majority were younger than 20 years old (82%) and unmarried (88%). Fifty-nine percent were currently using a modern method of contraception and injectables dominated their contraceptive use. Unmet need for contraception was higher among delayers (41%; 95% CI 32-51) and limiters (41%; 95% CI 35-47) compared to spacers (19%; 95% CI 17-22). CONCLUSIONS: Delayers of first birth have very high unmet needs for modern contraceptives and they should be routinely and separately categorised and measured within nationally-representative surveys such as Demographic and Health Survey and Multiple Indicator Cluster surveys. Acknowledging their unique needs could help catalyse a programmatic response.

Variations in disability and quality of life with age and sex between eight lower income and middle-income countries: data from the INDEPTH WHO-SAGE collaboration.

BACKGROUND: Disability and quality of life are key outcomes for older people. Little is known about how these measures vary with age and gender across lower income and middle-income countries; such information is necessary to tailor health and social care policy to promote healthy ageing and minimise disability. METHODS: We analysed data from participants aged 50 years and over from health and demographic surveillance system sites of the International Network for the Demographic Evaluation of Populations and their Health Network in Ghana, Kenya, Tanzania, South Africa, Vietnam, India, Indonesia and Bangladesh, using an abbreviated version of the WHO Study on global AGEing survey instrument. We used the eight-item WHO Quality of Life (WHOQoL) tool to measure quality of life and theWHO Disability Assessment Schedule, version 2 (WHODAS-II) tool to measure disability. We collected selected health status measures via the survey instrument and collected demographic and socioeconomic data from linked surveillance site information. We performed regression analyses to quantify differences between countries in the relationship between age, gender and both quality of life and disability, and we used anchoring vignettes to account for differences in interpretation of disability severity. RESULTS: We included 43 935 individuals in the analysis. Mean age was 63.7 years (SD 9.7) and 24 434 (55.6%) were women. In unadjusted analyses across all countries, WHOQoL scores worsened by 0.13 points (95% CI 0.12 to 0.14) per year increase in age and WHODAS scores worsened by 0.60 points (95% CI 0.57 to 0.64). WHODAS-II and WHOQoL scores varied markedly between countries, as did the gradient of scores with increasing age. In regression analyses, differences were not fully explained by age, socioeconomic status, marital status, education or health factors. Differences in disability scores between countries were not explained by differences in anchoring vignette responses. CONCLUSIONS: The relationship between age, sex and both disability and quality of life varies between countries. The findings may guide tailoring of interventions to individual country needs, although these associations require further study.

Trends in socioeconomic disparities in a rapid under-five mortality transition: a longitudinal study in the United Republic of Tanzania.

OBJECTIVE: To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011. METHODS: We used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. We estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models. FINDINGS: The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births (95% confidence interval, CI: 119.3-147.4) in 2000 to 66.2 (95% CI: 59.0-74.3) in 2011 and in Rufiji from 118.4 deaths per 1000 live births (95% CI: 107.1-130.7) in 2000 to 76.2 (95% CI: 66.7-86.9) in 2011. Combining both sites, in 2000-2001, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 1.08-1.92) higher than for children of mothers who had received education beyond primary school and in 2010-2011, the HR was 1.18 (95% CI: 0.90-1.55). In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 (95% CI: 0.99-1.47) in 2000-2001 to 1.48 (95% CI: 1.15-1.89) in 2010-2011, while in Ifakara, disparities narrowed from 1.30 (95% CI: 1.09-1.55) to 1.15 (95% CI: 0.95-1.39) in the same period. CONCLUSION: While childhood survival has improved, mortality disparities still persist, suggesting a need for policies and programmes that both reduce child mortality and address socioeconomic disparities.

Health & Demographic Surveillance System Profile: The Ifakara Rural and Urban Health and Demographic Surveillance System (Ifakara HDSS).

The Ifakara Rural HDSS (125,000 people) was set up in 1996 for a trial of the effectiveness of social marketing of bed nets on morbidity and mortality of children aged under 5 years, whereas the Ifakara Urban HDSS (45,000 people) since 2007 has provided demographic indicators for a typical small urban centre setting. Jointly they form the Ifakara HDSS (IHDSS), located in the Kilombero valley in south-east Tanzania. Socio-demographic data are collected twice a year. Current malaria work focuses on phase IV studies for antimalarials and on determinants of fine-scale variation of pathogen transmission risk, to inform malaria elimination strategies. The IHDSS is also used to describe the epidemiology and health system aspects of maternal, neonatal and child health and for intervention trials at individual and health systems levels. More recently, IHDSS researchers have studied epidemiology, health-seeking and national programme effectiveness for chronic health problems of adults and older people, including for HIV, tuberculosis and non-communicable diseases. A focus on understanding vulnerability and designing methods to enhance equity in access to services are cross-cutting themes in our work. Unrestricted access to core IHDSS data is in preparation, through INDEPTH iSHARE [www.indepth-ishare.org] and the IHI data portal [http://data.ihi.or.tz/index.php/catalog/central].

The effect of mother's age and other related factors on neonatal survival associated with first and second birth in rural, Tanzania: evidence from Ifakara health and demographic surveillance system in rural Tanzania.

BACKGROUND: With a view to improve neonatal survival, data on birth outcomes are critical for planning maternal and child health care services. We present information on neonatal survival from Ifakara Health and Demographic Surveillance System (HDSS) in Tanzania, regarding the influence of mother's age and other related factors on neonatal survival of first and second births. METHODS: The study conducted analysis using longitudinal health and demographic data collected from Ifakara HDSS in parts of Kilombero and Ulanga districts in Morogoro region. The analysis included first and second live births that occurred within six years (2004-2009) and the unit of observation was a live birth. A logistic regression model was used to assess the influence of socio-demographic factors on neonates' survival. RESULTS: A total of 18,139 first and second live births were analyzed. We found neonatal mortality rate of 32 per 1000 live births (95% CI: 29/1000-34/1000). Results from logistic regression model indicated increase in risk of neonatal mortality among neonates those born to young mothers aged 13-19 years compared with those whose mother's aged 20-34 years (aOR = 1.64, 95% CI = 1.34-2.02). We also found that neonates in second birth order were more likely to die than those in first birth order (aOR = 1.85: 95% CI = 1.52-2.26). The risk of neonatal mortality among offspring of women who had a partner co-resident was 18% times lower as compared with offspring of mothers without a partner co-resident in the household (aOR = 0.82: 95% CI = 0.66-0.98). Short birth interval (<33 months) was associated with increased risk of neonatal mortality (aOR = 1.50, 95% CI =1.16-1.96) compared with long birth interval (> = 33 months). Male born neonates were found to have an increased risk (aOR = 1.34, 95% CI =1.13- 1.58) of neonatal mortality as compared to their female counterparts. CONCLUSIONS: Delaying the age at first birth may be a valuable strategy to promote and improve neonatal health and survival. Moreover, birth order, birth interval, mother's partner co-residence and sex of the neonate appeared as important markers for neonatal survival.

The contribution of reduction in malaria as a cause of rapid decline of under-five mortality: evidence from the Rufiji Health and Demographic Surveillance System (HDSS) in rural Tanzania.

BACKGROUND: Under-five mortality has been declining rapidly in a number of sub-Saharan African settings. Malaria-related mortality is known to be a major component of childhood causes of death and malaria remains a major focus of health interventions. The paper explored the contribution of malaria relative to other specific causes of under-five deaths to these trends. METHODS: This paper uses longitudinal demographic surveillance data to examine trends and causes of death of under-five mortality in Rufiji, whose population has been followed for over nine years (1999-2007). Causes of death, determined by the verbal autopsy technique, are analysed with Arriaga's decomposition method to assess the contribution of declining malaria-related mortality relative to other causes of death as explaining a rapid decline in overall childhood mortality. RESULTS: Over the 1999-2007 period, under-five mortality rate in Rufiji declined by 54.3%, from 33.3 to 15.2 per 1,000 person-years. If this trend is sustained, Rufiji will be a locality that achieves MDG4 target. Although hypotrophy at birth remained the leading cause of death for neonates, malaria remains as the leading cause of death for post-neonates followed by pneumonia. However, declines in malaria death rates accounted for 49.9% of the observed under-five mortality decline while all perinatal causes accounted for only 19.9%. CONCLUSION: To achieve MDG 4 in malaria endemic settings, health programmes should continue efforts to reduce malaria mortality and more efforts are also needed to improve newborn survival.

Child mortality patterns in rural Tanzania: an observational study on the impact of malaria control interventions.

BACKGROUND: Between 1997 and 2009, a number of key malaria control interventions were implemented in the Kilombero and Ulanga Districts in south central Tanzania to increase insecticide-treated nets (ITN) coverage and improve access to effective malaria treatment. In this study we estimated the contribution of these interventions to observed decreases in child mortality. METHODS: The local Health and Demographic Surveillance Site (HDSS) provided monthly estimates of child mortality rates (age 1 to 5 years) expressed as cases per 1000 person-years (c/1000py) between 1997 and 2009. We conducted a time series analysis of child mortality rates and explored the contribution of rainfall and household food security. We used Poisson regression with linear and segmented effects to explore the impact of malaria control interventions on mortality. RESULTS: Child mortality rates decreased by 42.5% from 14.6 c/1000py in 1997 to 8.4 c/1000py in 2009. Analyses revealed the complexity of child mortality patterns and a strong association with rainfall and food security. All malaria control interventions were associated with decreases in child mortality, accounting for the effect of rainfall and food security. CONCLUSIONS: Reaching the fourth Millenium Development Goal will require the contribution of many health interventions, as well as more general improvements in socio-environmental and nutritional conditions. Distinguishing between the effects of these multiple factors is difficult and represents a major challenge in assessing the effect of routine interventions. However, this study suggests that credible estimates can be obtained when high-quality data on the most important factors are available over a sufficiently long time period.

Design, implementation and evaluation of a national campaign to deliver 18 million free long-lasting insecticidal nets to uncovered sleeping spaces in Tanzania.

BACKGROUND: Since 2004, the Tanzanian National Voucher Scheme has increased availability and accessibility of insecticide-treated nets (ITNs) to pregnant women and infants by subsidizing the cost of nets purchased. From 2008 to 2010, a mass distribution campaign delivered nine million long-lasting insecticidal nets (LLINs) free-of-charge to children under-five years of age in Tanzania mainland. In 2010 and 2011, a Universal Coverage Campaign (UCC) led by the Ministry of Health and Social Welfare (MoHSW) was implemented to cover all sleeping spaces not yet reached through previous initiatives. METHODS: The UCC was coordinated through a unit within the National Malaria Control Programme. Partners were contracted by the MoHSW to implement different activities in collaboration with local government authorities. Volunteers registered the number of uncovered sleeping spaces in every household in the country. On this basis, LLINs were ordered and delivered to village level, where they were issued over a three-day period in each zone (three regions). Household surveys were conducted in seven districts immediately after the campaign to assess net ownership and use. RESULTS: The UCC was chiefly financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria with important contributions from the US President's Malaria Initiative. A total of 18.2 million LLINs were delivered at an average cost of USD 5.30 per LLIN. Overall, 83% of the expenses were used for LLIN procurement and delivery and 17% for campaign associated activities. Preliminary results of the latest Tanzania HIV Malaria Indicator Survey (2011-12) show that household ownership of at least one ITN increased to 91.5%. ITN use, among children under-five years of age, improved to 72.7% after the campaign. ITN ownership and use data post-campaign indicated high equity across wealth quintiles. CONCLUSION: Close collaboration among the MoHSW, donors, contracted partners, local government authorities and volunteers made it possible to carry out one of the largest LLIN distribution campaigns conducted in Africa to date. Through the strong increase of ITN use, the recent activities of the national ITN programme will likely result in further decline in child mortality rates in Tanzania, helping to achieve Millennium Development Goals 4 and 6.

Evolving strategies, opportunistic implementation: HIV risk reduction in Tanzania in the context of an incentive-based HIV prevention intervention.

BACKGROUND: Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic. The shortcomings of BCC interventions are partly due to barriers arising from structural or economic constraints. Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection. METHODS: In 2009/2010 we conducted 216 in-depth interviews with a subset of study participants enrolled in the RESPECT study - an HIV prevention trial in Tanzania that used cash awards to incentivize safer sexual behaviors. We analyzed community diaries to understand how the study was perceived in the community. We drew on these data to enhance our understanding of how the intervention influenced strategies for risk reduction. RESULTS: We found that certain situations provide increased leverage for sexual negotiation, and these situations facilitated opportunistic implementation of risk reduction strategies. Opportunities enabled by the RESPECT intervention included leveraging conditional cash awards, but participants also emphasized the importance of exploiting new health status knowledge from regular STI testing. Risk reduction strategies included condom use within partnerships and/or with other partners, and an unexpected emphasis on temporary abstinence. CONCLUSIONS: Our results highlight the importance of increasing opportunities for implementing risk reduction strategies. We found that an incentive-based intervention could be effective in part by creating such opportunities, particularly among groups such as women with limited sexual agency. The results provide new evidence that expanding regular testing of STIs is another important mechanism for providing opportunities for negotiating behavior change, beyond the direct benefits of testing. Exploiting the latent demand for STI testing should receive renewed attention as part of innovative new combination interventions for HIV prevention.

Survival of neonates in rural Southern Tanzania: does place of delivery or continuum of care matter?

BACKGROUND: The concept of continuum of care has recently been highlighted as a core principle of maternal, newborn and child health initiatives, and as a means to save lives. However, evidence has consistently revealed that access to care during and post delivery (intra and postpartum) remains a challenge in the continuum of care framework. In places where skilled delivery assistance is exclusively available in health facilities, access to health facilities is critical to the survival of the mother and her newborn. However, little is known about the association of place of delivery and survival of neonates. This paper uses longitudinal data generated in a Health and Demographic Surveillance System in rural Southern Tanzania to assess associations of neonatal mortality and place of delivery. METHODS: Three cohorts of singleton births (born 2005, 2006 and 2007) were each followed up from birth to 28 days. Place of birth was classified as either "health facility" or "community". Neonatal mortality rates were produced for each year and by place of birth. Poisson regression was used to estimate crude relative risks of neonatal death by place of birth. Adjusted ratios were derived by controlling for maternal age, birth order, maternal schooling, sex of the child and wealth status of the maternal household. RESULTS: Neonatal mortality for health facility singleton deliveries in 2005 was 32.3 per 1000 live births while for those born in the community it was 29.7 per 1000 live births. In 2006, neonatal mortality rates were 28.9 and 26.9 per 1,000 live births for deliveries in health facilities and in the community respectively. In 2007 neonatal mortality rates were 33.2 and 27.0 per 1,000 live births for those born in health facilities and in the community respectively. Neonates born in a health facility had similar chances of dying as those born in the community in all the three years of study. Adjusted relative risks (ARR) for neonatal death born in a health facility in 2005, 2006 and 2007 were 0.99 (95% CI: 0.58 - 1.70), 0.98 (95% CI: 0.62 - 1.54) and 1.18 (95% CI: 0.76 - 1.85) respectively. CONCLUSIONS: We found no evidence to suggest that delivery in health facilities was associated with better survival chances of the neonates.

Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania.

OBJECTIVE: The authors evaluated the use of conditional cash transfers as an HIV and sexually transmitted infection prevention strategy to incentivise safe sex. DESIGN: An unblinded, individually randomised and controlled trial. SETTING: 10 villages within the Kilombero/Ulanga districts of the Ifakara Health and Demographic Surveillance System in rural south-west Tanzania. PARTICIPANTS: The authors enrolled 2399 participants, aged 18-30 years, including adult spouses. INTERVENTIONS: Participants were randomly assigned to either a control arm (n=1124) or one of two intervention arms: low-value conditional cash transfer (eligible for $10 per testing round, n=660) and high-value conditional cash transfer (eligible for $20 per testing round, n=615). The authors tested participants every 4 months over a 12-month period for the presence of common sexually transmitted infections. In the intervention arms, conditional cash transfer payments were tied to negative sexually transmitted infection test results. Anyone testing positive for a sexually transmitted infection was offered free treatment, and all received counselling. MAIN OUTCOME MEASURES: The primary study end point was combined prevalence of the four sexually transmitted infections, which were tested and reported to subjects every 4 months: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium. The authors also tested for HIV, herpes simplex virus 2 and syphilis at baseline and month 12. RESULTS: At the end of the 12-month period, for the combined prevalence of any of the four sexually transmitted infections, which were tested and reported every 4 months (C trachomatis, N gonorrhoeae, T vaginalis and M genitalium), unadjusted RR for the high-value conditional cash transfer arm compared to controls was 0.80 (95% CI 0.54 to 1.06) and the adjusted RR was 0.73 (95% CI 0.47 to 0.99). Unadjusted RR for the high-value conditional cash transfer arm compared to the low-value conditional cash transfer arm was 0.76 (95% CI 0.49 to 1.03) and the adjusted RR was 0.69 (95% CI 0.45 to 0.92). No harm was reported. CONCLUSIONS: Conditional cash transfers used to incentivise safer sexual practices are a potentially promising new tool in HIV and sexually transmitted infections prevention. Additional larger study would be useful to clarify the effect size, to calibrate the size of the incentive and to determine whether the intervention can be delivered cost effectively. TRIAL REGISTRATION NUMBER: NCT00922038 ClinicalTrials.gov.

Tanzanian Couples' Perspectives on Gender Equity, Relationship Power, and Intimate Partner Violence: Findings from the RESPECT Study.

Intimate partner violence (IPV) is widely prevalent in Tanzania. Inequitable gender norms manifest in men's and women's attitudes about power and decision making in intimate relationships and are likely to play an important role in determining the prevalence of IPV. We used data from the RESPECT study, a randomized controlled trial that evaluated an intervention to prevent sexually transmitted infections in a cohort of young Tanzanian men and women, to examine the relationship between couples' attitudes about IPV, relationship power, and sexual decision making, concordance on these issues, and women's reports of IPV over 12 months. Women expressed less equitable attitudes than men at baseline. Over time, participants' attitudes tended to become more equitable and women's reports of IPV declined substantially. Multivariable logistic regression analyses suggested that inequitable attitudes and couple discordance were associated with higher risk of IPV. Our findings point to the need for a better understanding of the role that perceived or actual imbalances in relationship power have in heightening IPV risk. The decline in women's reports of IPV and the trend towards gender-equitable attitudes indicate that concerted efforts to reduce IPV and promote gender equity have the potential to make a positive difference in the relatively short term.

Design, implementation and evaluation of a national campaign to distribute nine million free LLINs to children under five years of age in Tanzania.

BACKGROUND: After a national voucher scheme in 2004 provided pregnant women and infants with highly subsidized insecticide-treated nets (ITNs), use among children under five years (U5s) in mainland Tanzania increased from 16% in 2004 to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned a catch-up campaign to rapidly and equitably deliver a free long-lasting insecticidal net (LLIN) to every child under five years in Tanzania. METHODS: The ITN Cell, a unit within the National Malaria Control Programme (NMCP), coordinated the campaign on behalf of the Ministry of Health and Social Welfare. Government contractors trained and facilitated local government officials to supervise village-level volunteers on a registration of all U5s and the distribution and issuing of LLINs. The registration results formed the basis for the LLIN order and delivery to village level. Caregivers brought their registration coupons to village issuing posts during a three-day period where they received LLINs for their U5s. Household surveys in five districts assessed ITN ownership and use immediately after the campaign. RESULTS: Nine donors contributed to the national campaign that purchased and distributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including all campaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented one zone at a time from March 2009 until May 2010. ITN ownership at household level increased from Tanzania's 2008 national average of 45.7% to 63.4%, with significant regional variations. ITN use among U5s increased from 28.8% to 64.1%, a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions. CONCLUSION: A national-level LLIN distribution strategy that fully engaged local government authorities helped avoid additional burden on the healthcare system. Distribution costs per net were comparable to other public health interventions. Particularly among rural residents, ITN ownership and use increased significantly for the intended beneficiaries. The upcoming universal LLIN distribution and further behaviour change communication will further improve ITN ownership and use in 2010-2011.

Assessing the impact of malaria interventions on morbidity through a community-based surveillance system.

BACKGROUND: The ACCESS Programme aims at understanding and improving access to prompt and effective malaria treatment in rural Tanzania with a set of integrated interventions targeting both users and providers. The aim of this article is to evaluate the programme's impact on the community and health facility burden of malaria and to investigate the value of community-based reporting for routine malaria control programme monitoring. METHODS: This work was implemented within the Ifakara Demographic Surveillance System (DSS) between 2004 and 2008. At community level the DSS staff routinely collected data on reported history of fever and severe malaria (convulsions) based on a 2-week recall. In parallel, we collected in-patient and out-patient fever and malaria diagnoses data from the 15 health facilities in the area. Treatment-seeking surveys conducted in the study area and nationally representative data were used to validate our measure of community fever. RESULTS: Between 2005 and 2008, community-reported fever incidence rates in children under the age of 5 years declined by 34%, from 4.9 to 3.2 average cases per child per year, whereas convulsions, a marker of severe malaria morbidity in children, decreased by 46%, from 4263 to 2320 cases for every 100,000 children per year. The decrease in the community rates was paralleled by a decrease in the health facility fever rates, although the number of fever cases seen in health facilities did not change because of population growth. Our data showed very good internal and external consistency with independent local and national surveys. CONCLUSIONS: There is an evidence of a substantial decline in the community burden of malaria morbidity between 2005 and 2008 in the Kilombero and Ulanga DSS areas in Tanzania, most likely as a result of malaria control efforts. The good internal and external consistency of the data shows that history of fever in the previous 2 weeks in children under the age of 5 years can be used as a morbidity monitoring tool.