Exploring approaches to weighting estimates of facility readiness to provide health services used for estimating input-adjusted effective coverage: a case study using data from Tanzania.

The ideal approach for calculating effective coverage of health services using ecological linking requires accounting for variability in facility readiness to provide health services and patient volume by incorporating adjustments for facility type into estimates of facility readiness and weighting facility readiness estimates by service-specific caseload. The aim of this study is to compare the ideal caseload-weighted facility readiness approach to two alternative approaches: (1) facility-weighted readiness and (2) observation-weighted readiness to assess the suitability of each as a proxy for caseload-weighted facility readiness. We utilised the 2014-2015 Tanzania Service Provision Assessment along with routine health information system data to calculate facility readiness estimates using the three approaches. We then conducted equivalence testing, using the caseload-weighted estimates as the ideal approach and comparing with the facility-weighted estimates and observation-weighted estimates to test for equivalence. Comparing the facility-weighted readiness estimates to the caseload-weighted readiness estimates, we found that 58% of the estimates met the requirements for equivalence. In addition, the facility-weighted readiness estimates consistently underestimated, by a small percentage, facility readiness as compared to the caseload-weighted readiness estimates. Comparing the observation-weighted readiness estimates to the caseload-weighted readiness estimates, we found that 64% of the estimates met the requirements for equivalence. We found that, in this setting, both facility-weighted readiness and observation-weighted readiness may be reasonable proxies for caseload-weighted readiness. However, in a setting with more variability in facility readiness or larger differences in facility readiness between low caseload and high caseload facilities, the observation-weighted approach would be a better option than the facility-weighted approach. While the methods compared showed equivalence, our results suggest that selecting the best method for weighting readiness estimates will require assessing data availability alongside knowledge of the country context.

Engaging men in maternal, infant and young child nutrition in rural Tanzania: Outcomes from a cluster randomized control trial and qualitative study.

There is growing recognition that engaging men in maternal, infant and young child nutrition (MIYCN) interventions can benefit child health and disrupt harmful gender norms. We conducted a cluster-randomized controlled trial in Tanzania, which engaged men and women in behaviour change via mobile messaging (short message service [SMS]) and traditional interpersonal communication (IPC), separately and in combination. Here, we evaluate intervention effects on individual-level men's MIYCN knowledge and discuss barriers to male engagement. Eligible clusters were dispensary catchment areas with >3000 residents. Forty clusters were stratified by population size and randomly allocated to the four study arms, with 10 clusters per arm. Data on knowledge and intervention exposure were collected from 1394 men through baseline and endline surveys (March-April 2018 and July-September 2019). A process evaluation conducted partway through the 15-18-month intervention period included focus group discussions and interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software. Male participants in the short message service + interpersonal communication (SMS + IPC) group reported higher exposure to IPC discussions than IPC-only men (43.8% and 21.9%, respectively). Knowledge scores increased significantly across all three intervention groups, with the greatest impact in the SMS + IPC group. Qualitative findings indicated that the main barriers to male participation were a lack of interest in health/nutrition and perceptions that these topics were a woman's responsibility. Other challenges included meeting logistics, prioritizing income-earning activities and insufficient efforts to engage men. The use of a combined approach fusing IPC with SMS is promising, yet countering gender norms and encouraging stronger male engagement may require additional strategies.

Assessing the challenges to women's access and implementation of text messages for nutrition behaviour change in rural Tanzania.

OBJECTIVE: This process evaluation aimed to understand factors affecting the implementation of a government-sponsored short message service (SMS) programme for delivering nutrition information to rural populations, including message access, acceptability and putting messages into action. DESIGN: The study was nested within a larger randomised controlled trial. Cross-sectional data collection included structured surveys and in-depth interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software. SETTING: The study took place in Tanzania's Mtwara region. PARTICIPANTS: Surveys were conducted with 205 women and 93 men already enrolled in the randomised controlled trial. A sub-set of 30 women and 14 men participated in the in-depth interviews. RESULTS: Among women relying on a spouse's phone, sharing arrangements impeded regular SMS access; men were commonly away from home, forgot to share SMS or did not share them in women's preferred way. Phone-owning women faced challenges related to charging their phones and defective handsets. Once SMS were delivered, most participants viewed them as trustworthy and comprehensible. However, economic conditions limited the feasibility of applying certain recommendations, such as feeding meat to toddlers. A sub-set of participants concurrently enrolled in an interpersonal counselling (IPC) intervention indicated that the SMS provided reminders of lessons learned during the IPC; yet, the SMS did not help participants contextualise information and overcome the challenges of putting that information into practice. CONCLUSIONS: The challenges to accessing and implementing SMS services highlighted here suggest that such platforms may work well as one component of a comprehensive nutrition intervention, yet not as an isolated effort.

Understanding client and provider perspectives of antenatal care service quality: a qualitative multi-method study from Tanzania.

BACKGROUND: Measures of quality of care in low- and middle-income countries (LMICs) rarely include experience of care. This gap in service quality metrics may be driven by a lack of understanding of client and provider perspectives. Understanding these perspectives is a critical first step in not only improving metrics, but also in improving service delivery. This study identifies the items antenatal care (ANC) clients and health care providers in Tanzania associate with a quality ANC service and explores the experience of care domain from both client and provider perspectives. METHODS: We conducted semi-structured interviews with15 providers and 35 clients in Tanzania that included a free-listing activity to elicit items clients and providers associate with quality ANC services. We analyzed the free-listing for rank order and frequency to identify the most salient items, which were included in the second phase of data collection. We then conducted semi-structured interviews with a pile sort activity with the same 15 providers and 32 new clients to understand the importance of the items identified in the free-listing. We used a thematic analysis driven by the framework approach to analyze interview data. RESULTS: Both clients and providers perceived quality of ANC as being comprised of items related to experience of care, provision of care, and cross-cutting essential physical and human resources. The free-listing findings illuminated that the experience of care was equally important to clients and providers as the availability of physical and human resources and the content of the care delivered. In addition, clients and providers perceived that a positive patient care experience - marked by good communication, active listening, keeping confidentiality, and being spoken to politely - increased utilization of health services and improved health outcomes. CONCLUSIONS: The experience of care in LMICs is an overlooked, yet critically important topic. Understanding the experience of care from those who receive and deliver services is key to measuring and improving the quality of ANC. Our research highlights the importance of incorporating experience of care into future quality improvement activities and quality measures. By doing so, we identify barriers and facilitating factors of practical use to policy-makers and governments in LMICs.

Optimizing data visualization for reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) policymaking: data visualization preferences and interpretation capacity among decision-makers in Tanzania.

BACKGROUND: Reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) data is an indispensable tool for program and policy decisions in low- and middle-income countries. However, being equipped with evidence doesn't necessarily translate to program and policy changes. This study aimed to characterize data visualization interpretation capacity and preferences among RMNCH&N Tanzanian program implementers and policymakers ("decision-makers") to design more effective approaches towards promoting evidence-based RMNCH&N decisions in Tanzania. METHODS: We conducted 25 semi-structured interviews in Kiswahili with junior, mid-level, and senior RMNCH&N decision-makers working in Tanzanian government institutions. We used snowball sampling to recruit participants with different rank and roles in RMNCH&N decision-making. Using semi-structured interviews, we probed participants on their statistical skills and data use, and asked participants to identify key messages and rank prepared RMNCH&N visualizations. We used a grounded theory approach to organize themes and identify findings. RESULTS: The findings suggest that data literacy and statistical skills among RMNCH&N decision-makers in Tanzania varies. Most participants demonstrated awareness of many critical factors that should influence a visualization choice-audience, key message, simplicity-but assessments of data interpretation and preferences suggest that there may be weak knowledge of basic statistics. A majority of decision-makers have not had any statistical training since attending university. There appeared to be some discomfort with interpreting and using visualizations that are not bar charts, pie charts, and maps. CONCLUSIONS: Decision-makers must be able to understand and interpret RMNCH&N data they receive to be empowered to act. Addressing inadequate data literacy and presentation skills among decision-makers is vital to bridging gaps between evidence and policymaking. It would be beneficial to host basic data literacy and visualization training for RMNCH&N decision-makers at all levels in Tanzania, and to expand skills on developing key messages from visualizations.

Explaining progress towards Millennium Development Goal 4 for child survival in Tanzania.

BACKGROUND: During the Millennium Development Goal (MDG) era (1990-2015) the government in Mainland Tanzania and partners launched numerous initiatives to advance child survival including the comprehensive One Plan for Maternal Newborn and Child Health in 2008-2015 and a "sharpened" One Plan strategy in early 2014. Moving into the Sustainable Development Goal era, the government needs to learn from successes and challenges of striving towards MDG 4. METHODS: We expand previous work by presenting data for the full MDG period and sub-national results. We used data from six nationally-representative household surveys conducted between 1999 and 2015 to examine trends in coverage of 22 lifesaving maternal, newborn, child health and nutrition (MNCH&N) interventions, nutritional status (stunting; wasting) and breastfeeding practice across Mainland Tanzania and sub-nationally in seven standardized geographic zones. We used the Lives Saved Tool (LiST) to model the relative contribution of included interventions which saved under 5 lives during the period from 2000-2015 compared to 1999 on a national level and within the seven zones. FINDINGS: Child survival and nutritional status improved across Mainland Tanzania and in each of the seven zones across the 15-year period. MNCH&N intervention coverage varied widely and across zones with several key interventions declining across Mainland Tanzania or in specific geographical zones during all or part the period. According to our national LiST model, scale-up of 22 MNCH&N interventions - together with improvements in breastfeeding practice, stunting and wasting - saved 838 460 child lives nationally between 2000 and 2015. CONCLUSIONS: Mainland Tanzania has made significant progress in child survival and nutritional outcomes but progress cannot be completely explained by changes in intervention coverage alone. Further examination of the implementation and contextual factors shaping these trends is important to accelerate progress in the SDG era.