Nurses, non-nurse healthcare providers, and clients' perspectives, encounters, and choices of nursing gender in Tanzania: a qualitative descriptive study.

BACKGROUND: A growing share of male nurses in the nursing profession in Tanzania has changed the trend of diversity of nursing gender. This might have created a divergent perspective within the communities. Therefore, the current study aimed to explore the perspective, encounters, and choices of nursing gender among licensed nurses, non-nurse healthcare providers, and clients in Tanzania. METHODS: The study employed a qualitative descriptive design. The data were collected between August 2022 to January 2023 by the principal investigator and one research assistant. Twelve Focus Group Discussions (FGDs) were carried out in four different hospitals in Dar es Salaam comprised of total participants (n = 59). The participants were nurses, clients, and non-nurse healthcare providers. The data was collected through an interview guide developed by the principal investigator and validated by nurse experts. The data was analyzed using qualitative content analysis to generate themes and subthemes. RESULTS: Eight themes and twenty-seven subthemes emerged from the study. The following are themes; ① Variations of male and female nurses in communication ② Differences of male and female nurses in carrying out leadership roles ③ Divergent clinical qualities and outcomes across nursing gender ④ Positive value of male nurses in clinical facilities from colleagues and patients ⑤ Different cooperation of male and female nurses at the clinical settings ⑥ Mixed perspective towards clinical competencies across nursing gender ⑦ Perspective towards gender diversity in nursing ⑧ Preferences of nurse's gender, reasons, and opinion towards gender preferences. CONCLUSION: Male nurses and female nurses differ in how they communicate, execute leadership roles, and clinical qualities. However, their variations don't mean one gender is underrated than the other, but every gender has unique communication styles, leadership styles, and clinical qualities that both lead to effective outcomes. Diversity in nursing gender is very important and should be strategized. Since preferences of nursing gender seems to enhance somebody's freedom and creates an environment where a person can discuss sensitive issues, nursing bodies and healthcare stakeholders might initiate a discussion about approaches to promote the implementation of nursing preference and perform the feasibility studies.

Attitude and prevalence of early sexual debut and associated risk sexual behavior among adolescents in Tanzania; Evidence from baseline data in a Randomized Controlled Trial.

BACKGROUND: Unsafe sexual behaviours and associated sexual ideas among adolescents may contribute to adverse health consequences for sexual health in adulthood. The patterns of sexual ideology and sociodemographic factors profiles on adolescents' sexual behaviours have not been the subject of a definite consensus in research. The purpose of this study was to investigate the attitude and prevalence of early sexual debut and associated risk sexual behavior among adolescents in Tanzania as the evidence from baseline data in a Randomized Controlled Trial. METHODS: The study included 647 randomly chosen in-school adolescents from Tanzania and used an analytical cross-section survey in a quantitative research approach. Sexual-risk Behaviour Beliefs and Self-esteem Scale from previous studies were the main data collection tool. According to the Statistical Analysis Software (SAS), computer software version 9.4 descriptive analysis established respondents' socio-demographic profiles, attitudes, prevalence, and determinants linked to teenagers' early sexual debut. The link between the variables was established via multivariate logistic regression at a 5% significance level and a 95% confidence interval. RESULTS: The mean age was 15 ± 1.869 years while 57.5% of adolescents were females. 69.7% of adolescents were sexually active whereas 44.8% of them practised sexual behaviours willingly against 24.9% who practised coerced sexual behaviours. The majority (44.4%) and 16.2% of them initiated sexual behaviours during the early and middle adolescence stages respectively. Most adolescents had the ideology that sex was okay to them even before the age of 18 years. Their odds of practicing sexual behaviours were significantly high with the ideology that sex was okay to them even before 18 years of age (AOR = 1.293; p < 0.05; 95%CI: 0.689, 2.989), exposure to drug abuse (AOR = 1.210; p < 0.05; 95%CI: 0.803, 2.130), using media (AOR = 1.006; p < 0.05; 95%CI: 0.748, 2.667) and/or exposure to social groups [Jogging, Gym, health clubs, betting, Games] (AOR = 1.032; p < 0.05; 95%CI: 0.889, 2.044). CONCLUSION: Findings suggest that holding a positive attitude towards early sexual debut is a precursor to early sexual activity among adolescents. Unsafe sex, coercive sex, and other risky sexual behaviors are not uncommon among adolescents starting sex before the age of 18 years. Exposure to drug abuse, online sexual content, and/or social groups significantly influenced early sexual debut irrespective of other known factors. Age-appropriate school-based sexuality education programs should be promoted and implemented to address the most prevalent positive attitude towards early sexual debut and associated risk sexual behaviour among adolescents in Tanzania and other similar settings.

Barriers and facilitators of people living with HIV receiving optimal care for hypertension and diabetes in Tanzania: a qualitative study with healthcare professionals and people living with HIV.

BACKGROUND: People living with HIV (PLWH) are at a higher risk for developing diabetes and hypertension. Often services are separate for HIV and non-communicable diseases (NCDs), but how this impacts NCD care among PLWH is unknown. We aimed to understand the barriers and facilitators for prevention, early diagnosis and safe effective care for diabetes and hypertension among PLWH. METHODS: Semi-structured interviews (SSIs) were conducted with 10 healthcare professionals (HCPs) that care for PLWH, 10 HCPs that care for people with diabetes and hypertension and 16 PLWH with a comorbidity of diabetes and/or hypertension. Participants were recruited from two healthcare facilities in Dodoma, Tanzania and purposively sampled based on age and sex. Interviews were conducted in Swahili using pre-developed topic guides, audio recorded then translated verbatim into English. An inductive thematic analysis was conducted using The Framework Method. RESULTS: Three themes were found: organisational/healthcare system factors, individual factors and syndemic factors. Organisational/healthcare system factors comprised the only facilitators for prevention (education on lifestyle behaviours and counselling on adherence), but included the most barriers overall: fragmented services, no protocol for NCD screening and lack of access to diagnostic equipment were barriers for early diagnosis whereas the former plus lack of continuity of NCD care were barriers for safe effective care. Individual factors comprised four sub-themes, three of which were considered facilitators: HCPs' knowledge of NCDs for early diagnosis, self-monitoring of NCDs for safe effective care and HCPs' personal practice for both early diagnosis and safe effective care. HCPs' knowledge was simultaneously a barrier for prevention and PLWH knowledge was a barrier for prevention and safe effective care. Syndemic factors comprised three sub-themes; all were barriers for prevention, early diagnosis and/or safe effective care: poverty and mental health of PLWH and HIV stigma. CONCLUSIONS: Organisational/healthcare system, individual and syndemic factors were found to be interlinked with barriers and facilitators that contribute to the prevention, early diagnosis and safe effective care of diabetes and hypertension among PLWH in Tanzania; these findings can inform future initiatives for making small and large health system changes to improve the health of aging PLWH.

Acceptability of the Direct Health Facility Financing (DHFF) initiative in Tanzania: A mixed methods process evaluation of the moderating factors.

Despite wide agreement that stakeholder acceptability plays a critical role in an intervention's effectiveness, gaps remain on understanding acceptability of complex health financing interventions. We aimed to understand the moderators of acceptability of the Direct Health Facility Financing (DHFF) initiative across primary health facilities in Tanzania. Employing a mixed methods approach and guided by the theoretical framework for acceptability (TFA), we collected data from implementers and their supervisors using a structured questionnaire and semi-structured interview guides. We analysed data using a chi square test, logistic regression, and thematic analysis. We recruited 238 participants, of whom 71% were females and 54% were below 37 years old. Acceptability was found to be 63% and received high rating in qualitative interviews. Moderators of acceptability included sex (AOR = 1.93, p = 006), work experience (AOR = 3.47, p = 0.001), knowledge (13.8, p = 0.00), supportive work environment (AOR = 2.28, p = 0.019), and capability to implement the programme (AOR = 0.12, p = 0.00). Moderators reported in qualitative interviews related to individual and contextual factors. This study suggests that the DHFF initiative is acceptable and influenced by factors operating at the individual level and beyond. Addressing moderators of acceptability as programs are designed and implemented is the holy grail of acceptability of complex interventions.

Exploring factors influencing pregnant Women's attitudes, perceived subjective norms and perceived behavior control towards male involvement in maternal services utilization: a baseline findings from a community based interventional study from Rukwa, rural Tanzania.

BACKGROUND: Although male involvement enhances obstetric care-seeking behavior, the practice of male involvement in developing countries remains unacceptably low. Male involvement in maternal services utilization can be influenced by the attitude, subjective norm, and perceived behavior control of their female partners. Little is known about factors influencing pregnant women's attitudes, perceived subjective norms, and perceived behavior control towards male involvement in maternal services utilization. METHODS: A baseline community-based cross-sectional study whose target was pregnant women were performed from 1st June until 30th October 2017. A three-stage probability sampling technique was employed to obtain a sample of 546 pregnant women. A structured questionnaire that hinged the Theory of Planned Behavior was used. The questionnaire explored three main determinants of male involvement, which were: attitudes towards male involvement, perceived subjective norms towards male involvement, and perceived behavior control towards male involvement. RESULTS: After adjusting for the confounders, factors influencing positive attitude towards male involvement were age at marriage [19 to 24 yrs.,(AOR = 1.568 at 95% CI =1.044-2.353), more than 24 yrs. (AOR = 2.15 at 95% CI = 1.150-1.159)]; education status [primary school (AOR = 1.713 at 95% CI = 1.137-2.58)] and economic status [earning more than one dollar per day (AOR = 1.547 at 95% CI = 1.026-2.332)]. Factors influencing perceived subjective norms was only age at marriage [19 to 24 yrs., (AOR = 1.447 at 95% CI = 0.970-2.159), more than 24 years, (AOR = 2.331 at 95% CI = 1.261-4.308)]; factors influencing perceived behavior control were age at marriage [more than 24 years (AOR = 2.331 at 95%CI = 1.261-4.308)], and the intention to be accompanied by their male partners (AOR = 1.827 at 95%CI = 1.171-2.849). CONCLUSION: The study revealed that women who were married at an older age were more likely to have a positive attitude, subjective norms, and perceived behavior control towards male involvement in maternal services utilization than those who were married at a young age. Pregnant women who had primary education and earn more than a dollar per day were more likely to have positive attitudes towards male involvement than poor and uneducated pregnant women. The study recommends an interventional study to evaluate the influence attitude, subjective norms, and perceived behavior control on male involvement in maternal services utilization.

Predictors of Helping Babies Breathe knowledge and skills among nurses in primary health settings in Dodoma region, Tanzania.

BACKGROUND: Globally, birth asphyxia is one of the leading causes of neonatal death. In Tanzania, neonatal deaths are estimated to be 25 deaths per 1000 live births and birth asphyxia accounts for 31% of those deaths. METHOD: A cross-sectional study was conducted in 40 health centers within 7 districts in Dodoma Region among nurses working in maternity units. Simple random sampling was used to select participants. A knowledge questionnaire and performance skills checklist were used to assess nurses' knowledge and skills respectively. Chi-square and binary logistic regression were employed to test association and identify significant predictors of HBB knowledge and skills. RESULTS: A total of 172 participants completed the study out of 176 recruited. This represents a respondent rate of 98%. Findings indicate that age, duration of professional training, and experience in maternity were significant predictors for knowledge and skills. However, after control of the confounders, experience in the maternity unit was found to be the only significant predictor of knowledge and skills in resuscitation of the neonates (AOR = 2.94; CI: 0.96-8.98; P = 0.05) and (AOR = 4.14; CI: 1.12-15.31; P = 0.03) respectively. Nurses with longer maternity nursing care experience of 5 years and above were better able to answer questions that demonstrated adequate knowledge (53.9%) and perform skills correctly (53.2%) related to HBB. Those with less than 5 years' experience had limited knowledge (20%) and skills (10.5%). CONCLUSION: In this setting, direct work experience in the maternity unit was the main factor influencing knowledge and skills in neonatal resuscitation with HBB.

Clinical characteristics and health care received among patients with type 2 diabetes attending secondary and tertiary healthcare facilities in Mwanza Region, Tanzania: a cross-sectional study.

BACKGROUND: Tanzania is among the sub-Saharan African countries facing a tremendous increase in the burden of type 2 diabetes mellitus. In order to provide diabetes health care services, the government has established diabetes care clinics in secondary and tertiary healthcare facilities. However, previous studies have demonstrated a disparity in availability of supplies and equipment for provision of diabetes health care services at these healthcare facilities. This study aims to assess the clinical characteristics and health care received among patients with type 2 diabetes attending secondary and tertiary healthcare facilities in Mwanza Region, Tanzania. METHODS: A cross-sectional study was conducted in Mwanza Region from June to September, 2018.Three hundred and thirty patients were selected by systematic random sampling from three healthcare facilities. A structured questionnaire was utilized to collect information on patient characteristics, health care received and patient perception of care. Patient blood pressure, blood glucose, weight and height were measured during the study. Percentages, chi-square tests and multivariable analysis were conducted to obtain the proportions, make comparisons and determining the correlates of tertiary-level healthcare facility. RESULTS: Approximately half of respondents (54.5%) were from secondary healthcare facilities. The prevalence of hypertension (63.3%), hyperglycemia (95.8%) and obesity (93.3%) were high. The prevalence of hyperglycemia was slightly higher at secondary-level healthcare facility (p = 0.005). The proportion of respondents recently diagnosed with diabetes (≤ 10 years) was significantly higher at tertiary-level healthcare facility (p = 0.000). The prevalence of diabetes related complications was higher at tertiary-level healthcare facility (80.7% versus 53.3%, p = 0.000). Assessments of body weight, blood pressure, blood glucose, feet and eye examination were conducted on a monthly basis at all facilities. None of the respondents had undergone lipid profile testing. All of the respondents (100%) received care from a nurse during diabetes clinic visits and half of the respondents (49.7%) also received care from a clinician. Relatively young patients, married and recently diagnosed patients were more likely to attend clinic at tertiary facilities. Tertiary-level healthcare facilities were more likely to have patients with complications and to have a dietitian available at the clinic.

Assessing health system responsiveness in primary health care facilities in Tanzania.

BACKGROUND: Health system performance is one of the important components of the health care delivery; its achievement depends on the quality of services rendered and the health system responsiveness of its beneficiaries. Health system responsiveness is a multi-dimensional concept and is usually measured through several domains. Health system responsiveness (HSR) remains to be a key indicator for evaluation of health system performance in any settings. This study aimed at assessing the situation of health system responsiveness in primary health facilities in Tanzania prior to introduction of the Direct Health Facility Financing (DHFF) program. METHODS: This was a cross sectional study conducted between January and February in 2018. We collected data from 42 primary health facilities (14 health centers and 28 dispensaries) where a questionnaire was administered to a total of 422 participants. The questionnaire collected information on attention, respect to dignity, clear communication, autonomy, access to care, respect to confidentiality and basic amenities. Descriptive analysis was done to determine the distribution of the variables whereas ANOVA and linear regression analysis was employed to discern the association between variables. RESULTS: More than 67% of participants had visited the same health facility more than 5 times. Sixty seven percent of the patients were residing within 5kms from the public primary health care facilities. The geographical access to health care scored the lowest (43.5% for Dispensaries and 36% for Health center) mean as compared to other domains of health system responsiveness. The highest score was in respect to confidentiality (86.7%) followed by respect to dignity (81.4%). Linear regression analysis revealed no statistical association between any of the social demographic features with the overall HSR performances. However, in post hoc analysis, Pwani and Shinyanga regions didn't differ significantly in terms of their performances whereas those two regions differ from all other regions. CONCLUSION: Based on the study findings health system responsiveness domains has performed relatively poor in many regions except for respect of dignity and confidentiality scored high of all the domains. Shinyanga and Pwani regions scored relatively well in all domains this could have been due to the effect of Results Based financing (RBF) in the respective regions. All in all the Government and other stakeholders in the health sector they should deliberately invest on the access to care domain as seem to be a challenge as compared to others.

Using the theory of planned behavior to explain birth in health facility intention among expecting couples in a rural setting Rukwa Tanzania: a cross-sectional survey.

BACKGROUND: According to the theory of planned behavior, an intention to carry out a certain behavior facilitates action. In the context of birth in health facility, the intention to use health facilities for childbirth may better ensure better maternal and neonatal survival. Little is known on the influence of the domains of theory of planned behavior on birth in health facility intention. The study aimed to determine the influence of the domains of theory of planned behavior on birth in health facility intention among expecting couples in the rural Southern Highlands of Tanzania. METHODS: A community based cross-sectional study targeting pregnant women and their partners was performed from June until October 2017. A three-stage probability sampling technique was employed to obtain a sample of 546 couples (making a total of 1092 study participants). A structured questionnaire based upon the Theory of Planned Behavior was used. The questionnaire explored three main domains of birth in health facility intentions. These three domains included; 1) attitudes towards maternal services utilization, 2) perceived subjective norms towards maternal services utilization and 3) perceived behavior control towards maternal services utilization. RESULTS: The vast majority of study participants had birth in health facility intention. This included 499(91.2%) of pregnant women and 488(89.7%%) of their male partners partner. Only perceived subjective norms showed a significant higher mean score among pregnant women (M = 30.21, SD = 3.928) compared to their male partners (M = 29.72, SD = 4.349) t (1090) = - 1.965 at 95% CI = -0.985 to - 0.002; p < 0.049. After adjusting for the confounders, no intention to use health facility for childbirth decreased as the attitude [pregnant women (B = - 0.091; p = 0.453); male partners (B = - 0.084; p = 0.489)] and perceived behavior control [pregnant women (B = - 0.138; p = 0.244); male partners (B = - 0.155; p = 0.205)] scores increase among both pregnant women and their male partners. CONCLUSION: Despite the fact that majority of study respondents had birth in health facility intention, the likelihood of this intention resulting into practice is weak because none of the domains of theory of planned behavior showed a significant influence. Innovative interventional strategies geared towards improving domains of intention is highly recommended in order to elicit strong intention to use health facilities for childbirth.

Predictors of Early Onset Neonatal Sepsis among Neonates in Dodoma, Tanzania: A Case Control Study.

OBJECTIVE: To assess the predictors of early onset neonatal sepsis (EONS) among neonates in Dodoma Tanzania. METHODS: A hospital-based case-control study of randomly selected 105 cases and 217 controls in three hospitals in Dodoma region. Cases were neonates diagnosed with neonatal sepsis. Controls were matched to the cases by mother's age and parity at a ratio of 1 case to 2 controls. A semi-structured questionnaire was used to collect data on the potential mother, neonate and interventional predictors of EONS. Both descriptive and inferential statistical analysis were employed to test for independent association. RESULTS: Most (92.5%) of neonates were born at term (≥37 weeks) and 84% had normal birth weight of ≥3 kg. After adjusting for confounders, the maternal factors which showed significant association with EONS were maternal history of chorioamnionitis [adjusted odds ratios (AOR) = 1.910, p = 0.042, 95% confidence interval (CI): 1.0223.56], HIV status (AOR = 2.909, p = 0.012, 95% CI: 1.020-8.296), prolonged rupture of membrane (AOR = 2.857, p = 0.014, 95% CI: 1.233-6.619) and multiple digital vaginal examinations during labor (AOR = 5.178, p = 0.026, 95% CI: 1.220-21.986). The neonatal history of perinatal asphyxia was observed to have a significant association with EONS (AOR = 6.781, p = 0.006, 95% CI: 1.725-26.652). CONCLUSION: Both maternal and neonatal predictors had significant contribution to EONS. Results shed light on critical factors for consideration to prevent this disease and poor outcomes.

Poor level of knowledge on elderly care despite positive attitude among nursing students in Zanzibar Island: findings from a cross-sectional study.

BACKGROUND: It is estimated by the year 2050, 80% of the global elderly population will be from the low-and middle income countries. Elderly care requires health workers with skills associated with an understanding of the biological, psychological, social and cultural theories related to aging. Nurses with better knowledge, skills and positive attitudes towards elderly care are highly needed and critically important for better healthcare and wellbeing of the elderly population. Therefore the objective of this study was to assess the level of knowledge and attitude of nursing students towards elderly care in Zanzibar Island. METHODS: A cross-sectional study was conducted in Zanzibar involving three out of five nursing training institutions. Participants were selected by systematic random sampling. Facts on Aging Quiz 2 and Kogan's Attitudes Toward Old People scale were used to assess the level of knowledge and attitude towards elderly care among the students respectively. Simple and multivariable logistic regressions were applied to determine the predictors of knowledge and attitude among the participants. RESULTS: A total of 393 students participated in this study. Only 17% (69) of the participants had good level of knowledge and about 67.9% (267) had positive attitude towards elderly care. Living in an extended family and with an elderly person at home were both associated with good level of knowledge and positive attitude towards elderly care. Furthermore, living in a rural area (adjusted odds ratio = 2.23; 95% confidence interval: 1.22, 4.10) and studying at public institution (adjusted odds ratio = 2.59; 95% confidence interval: 1.41, 4.63) were associated with positive attitude towards elderly care. CONCLUSION: This study has shown that the majority of nursing students in Zanzibar have positive attitude but poor level of knowledge towards elderly care. The current findings have demonstrated that past experience with an elderly person can help in influencing good knowledge and shaping positive attitudes towards elderly care. Low level of knowledge shown in the study suggests for further research on adequacy of nursing curriculum and/or its implementation.

Improving pregnant women's knowledge on danger signs and birth preparedness practices using an interactive mobile messaging alert system in Dodoma region, Tanzania: a controlled quasi experimental study.

BACKGROUND: Unacceptably high maternal and perinatal mortality remain a major challenge in many low income countries. Early detection and management of danger signs through improved access to maternal services is highly needed for better maternal and infant outcomes. The aim of this study was to test the effectiveness of an interactive mobile messaging alert system on improving knowledge on danger signs, birth preparedness and complication readiness practices among pregnant women in Dodoma region, Tanzania. METHODS: A controlled quasi experimental study of 450 randomly selected pregnant women attending antenatal care was carried in Dodoma municipal. Participants were recruited at less than 20 weeks of gestation during the first visit where 150 were assigned to the intervention and 300 to the control group. The intervention groups was enrolled in an interactive mobile messaging system and received health education messages and were also able to send and receive individualized responses on a need basis. The control group continued receiving usual antenatal care services offered at the ANC centers. Pregnant women were followed from their initial visit to the point of delivery. Level of knowledge on danger signs and birth preparedness were assessed at baseline and a post test was again given after delivery for both groups. Analyses of covariance, linear regression were employed to test the effectiveness of the intervention. RESULTS: The mean age of participants was 25.6 years ranging from 16 to 48 years. There was significant mean scores differences for both knowleadge and birth preparedness between the intervention and the control group after the intervention (p < .001). The mean knowleadge score was (M = 9.531,SD = 2.666 in the intervention compared to M = 6.518,SD = 4.304 in the control, equivalent to an effect size of 85% of the intervention. Meanwhile, the mean score for IBPACR was M = 4.165,SD = 1.365 for the intervention compared to M = 2.631,SD = 1.775 in the control group with an effect size of 90% A multivariate linear regression showed a positive association between the intervention (p < 0.001) and level of knowledge (B = 2.910,95%CI = 2.199-3.621) and birth preparediness (B = 1.463,95%CI = 1.185-1.740). CONCLUSION: The Interactive mobile messaging alert system demonstrated to be effective in increasing women's knowledge on danger signs and improving their birth preparedness practices.

Factors influencing men's involvement in antenatal care services: a cross-sectional study in a low resource setting, Central Tanzania.

BACKGROUND: Men's involvement can impact the delays in the decision to seek health care and in reaching a health facility, which are contributing causes for increased maternal mortality. Despite of the call to involve men in antenatal care, their participation is not well understood. This study aimed to determine the level of men's involvement in antenatal care and the factors influencing their involvement in these services. METHODS: A cross sectional study of 966 randomly selected men aged 18 years or older was conducted in Dodoma Region, from June 2014 to November 2015. Face to face interviews were conducted using a pretested structured questionnaire. The outcome variable was men's involvement and was constructed from four dichotomized items which were scored zero to two for low involvement and three to four for high involvement. A multiple logistic model was used to measure the factors influencing men's involvement in antenatal care services. RESULTS: The level of men's involvement in antenatal care was high (53.9%). Majority 89% of respondents made joint decisions on seeking antenatal care. More than half (63.4%) of respondents accompanied their partners to the antenatal clinic at least once. Less than a quarter (23.5%) of men was able to discuss issues related to pregnancy with their partner's health care providers. About 77.3% of respondents provided physical support to their partners during the antenatal period. Factors influencing men's involvement in antenatal care were occupation (AOR = 0.692, 95% CI = 0.511-0.936), ethnicity (AOR = 1.495, 95% CI = 1.066-2.097), religion (AOR = 1.826, 95% CI = 1.245-2.677), waiting time (AOR = 1.444, 95% CI = 1.094-1.906), information regarding men's involvement in antenatal care (AOR = 3.077, 95% CI = 2.076-4.562) and men's perception about theattitude of health care providers (AOR = 1.548, 95%CI = 1.090-2.199). CONCLUSION: Overall, more than half of respondents reported high involvement in antenatal care services. Access to information on men's involvement, religion, occupation, ethnicity, waiting time and men's perception about the attitude of care providers were significant factors influencing men's involvement in antenatal care services in this study. Health promotion is needed to empower men with essential information for meaningful involvement in antenatal care services.

Understanding the implementation of Direct Health Facility Financing and its effect on health system performance in Tanzania: a non-controlled before and after mixed method study protocol.

BACKGROUND: Globally, good health system performance has resulted from continuous reform, including adaptation of Decentralisation by Devolution policies, for example, the Direct Health Facility Financing (DHFF). Generally, the role of decentralisation in the health sector is to improve efficiency, to foster innovations and to improve quality, patient experience and accountability. However, such improvements have not been well realised in most low- and middle-income countries, with the main reason cited being the poor mechanism for disbursement of funds, which remain largely centralised. The introduction of the DHFF programme in Tanzania is expected to help improve the quality of health service delivery and increase service utilisation resulting in improved health system performance. This paper describes the protocol, which aims to evaluate the effects of DHFF on health system performance in Tanzania. METHODS: An evaluation of the effect of the DHFF programme will be carried out as part of a nationwide programme rollout. A before and after non-controlled concurrent mixed methods design study will be employed to examine the effect of the DHFF programme implementation on the structural quality of maternal health, health facility governing committee governance and accountability, and health system responsiveness as perceived by the patients' experiences. Data will be collected from a nationally representative sample involving 42 health facilities, 422 patient consultations, 54 health workers, and 42 health facility governing committees in seven regions from the seven zones of the Tanzanian mainland. The study is grounded in a conceptual framework centered on the Theory of Change and the Implementation Fidelity Framework. The study will utilise a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews and documentary review). The study will collect information related to knowledge, acceptability and practice of the programme, fidelity of implementation, structural qualities of maternal and child health services, accountability, governance, and patient perception of health system responsiveness. DISCUSSION: This evaluation study will generate evidence on both the process and impact of the DHFF programme implementation, and help to inform policy improvement. The study is expected to inform policy on the implementation of DHFF within decentralised health system government machinery, with particular regard to health system strengthening through quality healthcare delivery. Health system responsiveness assessment, accountability and governance of Health Facility Government Committee should bring autonomy to lower levels and improve patient experiences. A major strength of the proposed study is the use of a mixed methods approach to obtain a more in-depth understanding of factors that may influence the implementation of the DHFF programme. This evaluation has the potential to generate robust data for evidence-based policy decisions in a low-income setting.

Health insurance is important in improving maternal health service utilization in Tanzania-analysis of the 2011/2012 Tanzania HIV/AIDS and malaria indicator survey.

BACKGROUND: Maternal mortality rates vary significantly from region to region. Interventions such as early and planned antenatal care attendance and facility delivery with skilled health workers can potentially reduce maternal mortality rates. Several factors can be attributed to antenatal care attendance, or lack thereof, including the cost of health care services. The aim of this study was to examine the role of health insurance coverage in utilization of maternal health services in Tanzania. METHODS: Secondary data analysis was conducted on the nationally representative sample of men and women aged 15-49 years using the 2011/12 Tanzania HIV and Malaria Indicator Survey. It included 4513 women who had one or more live births within three years before the survey. The independent variable was health insurance coverage. Outcome variables included proper timing of the first antenatal care visit, completing the recommended number of antenatal care (ANC) visits, and giving birth under skilled worker. Data were analyzed both descriptively and using regression analyses to examine independent association of health insurance and maternal health services. RESULTS: Of 4513 women, only 281 (6.2%) had health insurance. Among all participants, only 16.9%, 7.1%, and 56.5%, respectively, made their first ANC visit as per recommendation, completed the recommended number of ANC visits, and had skilled birth assistance at delivery. A higher proportion of women with health insurance had a proper timing of 1st ANC attendance compared to their counterparts (27.0% vs. 16.0%, p < 0.001). Similar trend was for skilled birth attendance (77.6% vs. 55.1%, p < 0.001). After adjusting for other confounders and covariates, having health insurance was associated with proper timing of 1st ANC attendance (AOR = 1.89, p < 0.001) and skilled birth attendance (AOR = 2.01, p < 0.01). CONCLUSIONS: Health insurance coverage and maternal health services were low in this nationally representative sample in Tanzania. Women covered by health insurance were more likely to have proper timing of the first antenatal visit and receive skilled birth assistance at delivery. To improve maternal health, health insurance alone is however not enough. It is important to improve other pillars of health system to attain and sustain better maternal health in Tanzania and areas with similar contexts.

Predictors for uptake of intermittent preventive treatment of malaria in pregnancy (IPTp) in Tanzania.

BACKGROUND: Tanzania adopted Intermittent-preventive treatment of malaria in pregnancy (IPTp) policy in 2000; the guidelines at the time of the study recommended the timing of the first dose of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) (IPTp-SP) at 20-24 weeks and the timing of the second dose at 28-32 weeks. The aim of this study was to identify factors that are responsible for the uptake of IPTp among pregnant Tanzanian women. Further, this study aims to justify the need for appropriate interventions that would strengthen the Tanzanian IPTp program towards the realization of the Roll Back Malaria (RBM) targets. METHODS: Data were analyzed from the 2011-2012 Tanzania HIV and Malaria Indicators Survey (THMIS) of 1,616 women aged 15-49 years who had a live birth in the 2 years prior to the survey and received antenatal care (ANC) services. RESULTS: Logistic regression analysis results showed that (1) being in the age groups 30-34 and 35-39 versus other age groups and being married or living with partner versus those who reported as never married or divorced/separated were associated with high uptake of IPTp; (2) women pregnant with their first or second child versus those who already have had two or more children had higher odds of completing the recommended number of IPTp dosage; and (3) being a resident from the Eastern Zone versus Lake Zone as well as having the first antenatal visit in the first or second trimester versus third trimester were associated with higher uptake of IPTp. CONCLUSION: Applying these results could contribute to positive social change by helping providers, clinics, and organizations seeking to increase IPTp uptake among ANC attendees and providing health education programs to women, especially those residing in rural areas. This study could also help achieve United Nations Millennium Development Goals (MDG) 6 (combat HIV/AIDS, Malaria and Other Diseases).

Risk Factors for Birth Asphyxia in Hospital-Delivered Newborns in Dodoma, Tanzania: A Case-Control Study.

Introduction: Asphyxia at birth remains the leading cause of neonatal morbidity and mortality worldwide, accounting for ∼23% of all neonatal deaths. Although the causes vary from country to country, early identification and treatment of risk factors can improve the situation. Objectives: To determine the risk factors of birth asphyxia in hospital-delivered neonates in Dodoma, Tanzania. Methods: A matched case-control study was conducted from May to July 2017 at Dodoma Region Referral Hospital. Data were collected using a semistructured questionnaire and a standard antenatal care index card. Cases were neonates diagnosed with asphyxia at birth (N = 100), while controls were neonates not diagnosed with asphyxia at birth (N = 300). A binary logistic regression model was used to assess the independent variables associated with birth asphyxia and reported as crude and adjusted odds ratios along with their 95% confidence intervals. Results: A total of 400 newborns and their birth mothers were involved in the study. The average age of the case mothers was 26.9 years (SD = 7.85) and that of the control mothers was 27.24 years (SD = 6.08). Place of residence, anemia, maternal age, prenatal visits attended, use of herbs during labor, previously complicated pregnancy, duration of labor, meconium-stained amniotic fluid, and mode of delivery were predictors of birth asphyxia. Conclusion: The study showed that most predictors of birth asphyxia can be prevented. The results suggest appropriate health education before conception, effective follow-up through prenatal care, early identification and treatment of high-risk pregnant women, and proper monitoring of labor and delivery.

HIV pre-exposure prophylaxis use during periods of unprotected sex among female sex workers in Tanga city, Tanzania: a control arm analysis of the pragmatic quasi-experimental trial.

Background: Pre-exposure prophylaxis (PrEP) prevention-effective adherence is of critical importance but challenging particularly among key populations where periods of high HIV risk are frequent. We assessed the use of PrEP with reference to periods of unprotected sex among female sex workers in the city of Tanga. Methods: This was part of the pragmatic quasi-experimental trial for HIV PrEP rollout in Tanzania involving a control cohort of 313 female sex workers aged ≥18 years recruited by respondent-driven sampling and followed for 12 months. PrEP use and periods of condomless or unprotected sex were assessed at the 6th and 12th month of follow-up. Prevention-effective adherence was defined as PrEP use of ≥2 pills/week and ≥6 pills/week for anal and vaginal condomless sex. Multivariable modified Poisson regression was conducted to determine factors influencing PrEP use (≥2 pills/week). Results: Overall, 59.2 and 45.9% of participants had unprotected anal and vaginal sex with a client, respectively. The prevention-effective adherence for anal sex ranged from 8.0% (months 6) to 10.0% (months 12) while that of vaginal sex was from 10.1% (month 6) to 3.8% (month 12). Participants who lived with friends were 25.5 times more likely to use ≥2 PrEP doses per week than those who lived alone (aPR = 25.5; 95%CI: 2.55-255.42, p = 0.006). Compared to self-reporting poor health status, self-reporting good health status significantly increased the use of ≥2 PrEP doses per week (aPR = 17.4; 95%CI: 3.01-101.02, p = 0.001). Refusing condomless sex with a steady partner increased the likelihood of using ≥2 PrEP doses per week than accepting condomless sex with a steady partner (aPR = 11.2; 95%CI: 1.55-80.48, p = 0.017). The prevalence of using ≥2 PrEP doses per week was less among participants accepting condomless sex at high pay than those who refused (aPR = 0.1; 95%CI: 0.03-0.26, p = 0.000). Conclusion: Use of PrEP during periods of unprotected sex was rare among female sex workers. Living with friends, self-reporting good health status, and refusing condomless sex with steady partners were associated with increased use of ≥2 PrEP doses per week. However, accepting condomless sex for increased payment was associated with reduced use of ≥2 PrEP doses per week. This calls for an in-depth study to understand the perspectives and circumstances shaping poor adherence during periods of unprotected sex among female sex workers.

Exploring the preferred integration approach for HIV, diabetes and hypertension care and associated barriers and facilitators in Central Tanzania: An exploratory qualitative study.

Timely diagnosis and management of diabetes and hypertension among people living with HIV (PLWH) is imperative; however, many barriers exist within the current model of care for these comorbidities. We aimed to understand how HIV, diabetes, and hypertension care should be delivered and the associated barriers and facilitators for the preferred delivery approach. We conducted semi-structured interviews with 16 PLWH with comorbidities of diabetes and/or hypertension (referred to hereafter as non-communicable diseases [NCDs]), 10 healthcare professionals (HCPs) that provide care for NCDs, and 10 HCPs that provide care for HIV. Participants were recruited from two healthcare facilities in Dodoma, Tanzania and interviewed in Swahili. Interviews were audio recorded, transcribed verbatim and translated into English. We used the differentiated service delivery building blocks as a framework to determine where, who, what and when care should be provided. We applied the Theoretical Domains Framework (TDF) to HCP transcripts to determine barriers and facilitators for the preferred integration approach. There was a consensus among participants that all care for NCDs should be provided for PLWH at HIV clinics (known as care and treatment centres [CTCs]) by either CTC doctors or NCD specialists. Participants preferred flexible follow-up care for NCDs and for it to be aligned with HIV follow-up appointments. The main barriers were mapped to the TDF domains of environmental context and resources, and social influences; the former included the lack of NCD medications, NCD diagnostic equipment, space, staff and guidelines whereas the latter included negative influences from peers and traditional healers. Several facilitators were mentioned regarding CTC HCPs' knowledge, skills, optimism and beliefs regarding their capabilities to care for PLWH with NCDs. The preferred integration approach should be tested, utilising the enabling factors described. The barriers described must be addressed with or without integration to achieve optimal care for PLWH with NCDs.

The effectiveness of interactive mobile health technologies in improving antenatal care service utilization in Dodoma region, Tanzania: A quasi-Experimental study.

Antenatal care (ANC) provides a platform for important health care during pregnancy, including health promotion, screening, diagnosis and disease prevention. Timely and appropriate utilization of antenatal care can prevent complications as well as ensure optimal maternal and newborn health care. This study assessed the effectiveness of interactive (two way communication) mobile health technologies during antenatal period to improve maternal and newborn service utilization in Dodoma region, Tanzania. Using quasi-experimental design, participants were randomly selected to achieve a sample size of 450 pregnant women (Intervention = 150 and Control = 300) in Dodoma city from January to November, 2018. Interventions were matched to controls by gravidity, education level and gestational age at a ratio of 1 to 2. The intervention group received health education messages through their mobile phones, while the control group continued with standard antenatal care services offered in local clinics. Pregnant women were followed from their initial visit to the point of delivery. The Chi-square test was used to establish the association and regression analysis were used to test the effect of the intervention. The median age of participants was found to be 25 years that ranged from 16 to 41 years. Generally, 77.3 percent of participants in the intervention group utilized adequate (i. ANC care provided by skilled health personnel, ii. Sufficient number of ANC visits (4 or more visits during pregnancy), iii. Appropriate ANC contents provided (visits included at least 13 out of 15 of the recommended basic care procedures or contents) ANC services compared to 57.7 percent in the control group. Interactive mobile health technology system was observed to be effective on improving antenatal care service utilization (AOR = 2.164, P<0.05, 95% CI = 1.351-3.466) compared to conventional antenatal care health education given in local health facilities. Use of interactive mobile health technologies during antenatal period has the potential of improving access to information and antenatal care service utilization in the study setting. Trial Registration: PACTR202008834066796 "Retrospectively registered".