Mid-level healthcare workers knowledge on non-communicable diseases in Tanzania: a district-level pre-and post-training assessment.

INTRODUCTION: Over the past two decades, Tanzania's burden of non-communicable diseases has grown disproportionately, but limited resources are still prioritized. A trained human resource for health is urgently needed to combat these diseases. However, continuous medical education for NCDs is scarce. This paper reports on the mid-level healthcare workers knowledge on NCDs. We assessed the knowledge to measure the effectiveness of the training conducted during the initiation of a Package for Essential Management of Severe NCDs (PEN Plus) in rural district hospitals in Tanzania. METHODS: The training was given to 48 healthcare employees from Dodoma Region's Kondoa Town Council District Hospital. For a total of five (5) days, a fundamental course on NCDs featured in-depth interactive lectures and practical workshops. Physicians from Tanzania's higher education institutions, tertiary university hospitals, research institutes, and medical organizations served as trainers. Before and after the training, a knowledge assessment comprising 28 questions was administered. Descriptive data analysis to describe the characteristics of the specific knowledge on physiology, diagnosis and therapy of diabetes mellitus, rheumatic fever, heart disease, and sickle cell disease was done using Stata version 17 (STATA Corp Inc., TX, USA). RESULTS: Complete assessment data for 42 out of the 48 participants was available. Six participants did not complete the training and the assessment. The mean age of participants was 36.9 years, and slightly above half (52%) were above 35 years. Two-thirds (61.9%) were female, and about half (45%) were nurses. The majority had the experience of working for more than 5 years, and the average was 9.4 years (+/- 8.4 years). Overall, the trainees' average scores improved after the training (12.79 vs. 16.05, p < 0.0001) out of 28 possible scores. Specifically, trainees' average scores were better in treatment than in diagnosis, except for sickle cell disease (1.26 vs. 1.83). Most were not able to diagnose rheumatic heart disease (47.6% able) compared to diabetes mellitus (54.8% able) or sickle cell disease (64.3% able) at baseline. The proportion of trainees with adequate knowledge of the treatment of sickle cell disease and diabetes mellitus was 35% and 38.1%, respectively, and there was a non-statistical difference after training. Those working for less than 5 years had a higher proportion of adequate knowledge (30.8%) compared to their more experienced colleagues (6.9%). After the training, participants' knowledge of NCDs increased by three times (i.e., aPR 3, 95% CI = 1.1, 1.5, and 6.0). CONCLUSION AND RECOMMENDATIONS: PEN Plus training improved the knowledge of healthcare workers at Kondoa Town Council District Hospital. Training is especially needed among nurses and those with a longer duration of work. Continuing education for human resources for health on the management of NCDs is highly recommended in this setting.

Implementation of distance learning IMCI training in rural districts of Tanzania.

BACKGROUND: The standard face-to-face training for the integrated management of childhood illness (IMCI) continues to be plagued by concerns of low coverage of trainees, the prolonged absence of trainees from the health facility to attend training and the high cost of training. Consequently, the distance learning IMCI training model is increasingly being promoted to address some of these challenges in resource-limited settings. This paper examines participants' accounts of the paper-based IMCI distance learning training programme in three district councils in Mbeya region, Tanzania. METHODS: A cross-sectional qualitative descriptive design was employed as part of an endline evaluation study of the management of possible serious bacterial infection in Busokelo, Kyela and Mbarali district councils of Mbeya Region in Tanzania. Key informant interviews were conducted with purposefully selected policymakers, partners, programme managers and healthcare workers, including beneficiaries and training facilitators. RESULTS: About 60 key informant interviews were conducted, of which 53% of participants were healthcare workers, including nurses, clinicians and pharmacists, and 22% were healthcare administrators, including district medical officers, reproductive and child health coordinators and programme officers. The findings indicate that the distance learning IMCI training model (DIMCI) was designed to address concerns about the standard IMCI model by enhancing efficiency, increasing outputs and reducing training costs. DIMCI included a mix of brief face-to-face orientation sessions, several weeks of self-directed learning, group discussions and brief face-to-face review sessions with facilitators. The DIMCI course covered topics related to management of sick newborns, referral decisions and reporting with nurses and clinicians as the main beneficiaries of the training. The problems with DIMCI included technological challenges related to limited access to proper learning technology (e.g., computers) and unfriendly learning materials. Personal challenges included work-study-family demands, and design and coordination challenges, including low financial incentives, which contributed to participants defaulting, and limited mentorship and follow-up due to limited funding and transport. CONCLUSION: DIMCI was implemented successfully in rural Tanzania. It facilitated the training of many healthcare workers at low cost and resulted in improved knowledge, competence and confidence among healthcare workers in managing sick newborns. However, technological, personal, and design and coordination challenges continue to face learners in rural areas; these will need to be addressed to maximize the success of DIMCI.

Body-mass index and diabetes risk in 57 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 685 616 adults.

BACKGROUND: The prevalence of overweight, obesity, and diabetes is rising rapidly in low-income and middle-income countries (LMICs), but there are scant empirical data on the association between body-mass index (BMI) and diabetes in these settings. METHODS: In this cross-sectional study, we pooled individual-level data from nationally representative surveys across 57 LMICs. We identified all countries in which a WHO Stepwise Approach to Surveillance (STEPS) survey had been done during a year in which the country fell into an eligible World Bank income group category. For LMICs that did not have a STEPS survey, did not have valid contact information, or declined our request for data, we did a systematic search for survey datasets. Eligible surveys were done during or after 2008; had individual-level data; were done in a low-income, lower-middle-income, or upper-middle-income country; were nationally representative; had a response rate of 50% or higher; contained a diabetes biomarker (either a blood glucose measurement or glycated haemoglobin [HbA1c]); and contained data on height and weight. Diabetes was defined biologically as a fasting plasma glucose concentration of 7·0 mmol/L (126·0 mg/dL) or higher; a random plasma glucose concentration of 11·1 mmol/L (200·0 mg/dL) or higher; or a HbA1c of 6·5% (48·0 mmol/mol) or higher, or by self-reported use of diabetes medication. We included individuals aged 25 years or older with complete data on diabetes status, BMI (defined as normal [18·5-22·9 kg/m2], upper-normal [23·0-24·9 kg/m2], overweight [25·0-29·9 kg/m2], or obese [≥30·0 kg/m2]), sex, and age. Countries were categorised into six geographical regions: Latin America and the Caribbean, Europe and central Asia, east, south, and southeast Asia, sub-Saharan Africa, Middle East and north Africa, and Oceania. We estimated the association between BMI and diabetes risk by multivariable Poisson regression and receiver operating curve analyses, stratified by sex and geographical region. FINDINGS: Our pooled dataset from 58 nationally representative surveys in 57 LMICs included 685 616 individuals. The overall prevalence of overweight was 27·2% (95% CI 26·6-27·8), of obesity was 21·0% (19·6-22·5), and of diabetes was 9·3% (8·4-10·2). In the pooled analysis, a higher risk of diabetes was observed at a BMI of 23 kg/m2 or higher, with a 43% greater risk of diabetes for men and a 41% greater risk for women compared with a BMI of 18·5-22·9 kg/m2. Diabetes risk also increased steeply in individuals aged 35-44 years and in men aged 25-34 years in sub-Saharan Africa. In the stratified analyses, there was considerable regional variability in this association. Optimal BMI thresholds for diabetes screening ranged from 23·8 kg/m2 among men in east, south, and southeast Asia to 28·3 kg/m2 among women in the Middle East and north Africa and in Latin America and the Caribbean. INTERPRETATION: The association between BMI and diabetes risk in LMICs is subject to substantial regional variability. Diabetes risk is greater at lower BMI thresholds and at younger ages than reflected in currently used BMI cutoffs for assessing diabetes risk. These findings offer an important insight to inform context-specific diabetes screening guidelines. FUNDING: Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program.

Effectiveness of instructional videos for enhancing healthcare provider competencies for hypertension management - a pre-post study in primary healthcare settings, Tanzania.

BACKGROUND: Inadequate adherence to hypertension (HT) clinical standards by healthcare providers is one of the major barriers for HT management. We examined the effectiveness of four short instructional training videos on HT management. METHODS: Eighteen primary health care facilities were randomly selected using systematic sampling from five districts in the Dar es Salaam region, Tanzania. Pre-post provider knowledge assessments were conducted six months after training and provider performance was measured using patient observations on 8-10 consecutive adult patients per facility. A Screening Quality Index (SQI), comprised of ten HT screening standards, was used to measure adherence. RESULTS: Pre-post knowledge scores improved significantly, for, time between blood pressure (BP) readings (28.1% to 72.7%, p=0.01), BP threshold for patients with complications (21.2% to 97.0%, p<0.001), and lifestyle/dietary counseling (from 36.4% to 97.0%, p<0.001). SQI was significantly higher following the training for all provider groups; Nurses (3.0±3.5 to 8.4±1.0, p<0.001), Assistant Medical Officers and Medical Officers (3.5±4.1 to 7.6±2.4, p<0.001), and Assistant Clinical Officers and Clinical Officers (5.4±3.8 to 8.4±2.0, p<0.001). After training, significantly higher adherence was evident for key aspects of managing patients with HT: e.g., counseling on medication (62.1% to 92.7%, p=0.002), side effects (41.4% to 56.1%, p=0.009), reducing caloric intake (69.0 % to 95.1%, p=0.003), reducing cooking salt (65.5% to 97.6%, p<0.01), increasing physical activity (55.2% to 92.7% p<0.001), stopping/reducing cigarette smoking (24.1% to 63.4%, p=0.001), and reducing alcohol consumption (24.1% to 68.3%, p<0.001). SQI was significantly associated with number of years of provider experience (more than 2 years), type of primary healthcare facility (public facility), and exposure to the training intervention. CONCLUSION: Training with short instructional videos can improve provider competency and clinical performance for HT management. The strategy has the potential to enhance effective implementation of HT control strategies in primary care clinics in Tanzania and elsewhere.

Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data.

BACKGROUND: Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. METHODS AND FINDINGS: We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. CONCLUSION: In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults.

BACKGROUND: Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs-and its variation between countries and population groups-by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage. METHODS: In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval. FINDINGS: Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9-74·3) had ever had their blood pressure measured, 39·2% of participants (38·2-40·3) had been diagnosed with hypertension, 29·9% of participants (28·6-31·3) received treatment, and 10·3% of participants (9·6-11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade. INTERPRETATION: Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage. FUNDING: Harvard McLennan Family Fund, Alexander von Humboldt Foundation.

Sociodemographic inequities associated with participation in leisure-time physical activity in sub-Saharan Africa: an individual participant data meta-analysis.

BACKGROUND: Leisure-time physical activity (LTPA) is an important contributor to total physical activity and the focus of many interventions promoting activity in high-income populations. Little is known about LTPA in sub-Saharan Africa (SSA), and with expected declines in physical activity due to rapid urbanisation and lifestyle changes we aimed to assess the sociodemographic differences in the prevalence of LTPA in the adult populations of this region to identify potential barriers for equitable participation. METHODS: A two-step individual participant data meta-analysis was conducted using data collected in SSA through 10 population health surveys that included the Global Physical Activity Questionnaire. For each sociodemographic characteristic, the pooled adjusted prevalence and risk ratios (RRs) for participation in LTPA were calculated using the random effects method. Between-study heterogeneity was explored through meta-regression analyses and tests for interaction. RESULTS: Across the 10 populations (N = 26,022), 18.9% (95%CI: 14.3, 24.1; I2 = 99.0%) of adults (≥ 18 years) participated in LTPA. Men were more likely to participate in LTPA compared with women (RR for women: 0.43; 95%CI: 0.32, 0.60; P < 0.001; I2 = 97.5%), while age was inversely associated with participation. Higher levels of education were associated with increased LTPA participation (RR: 1.30; 95%CI: 1.09, 1.55; P = 0.004; I2 = 98.1%), with those living in rural areas or self-employed less likely to participate in LTPA. These associations remained after adjusting for time spent physically active at work or through active travel. CONCLUSIONS: In these populations, participation in LTPA was low, and strongly associated with sex, age, education, self-employment and urban residence. Identifying the potential barriers that reduce participation in these groups is necessary to enable equitable access to the health and social benefits associated with LTPA.

Health system performance for people with diabetes in 28 low- and middle-income countries: A cross-sectional study of nationally representative surveys.

BACKGROUND: The prevalence of diabetes is increasing rapidly in low- and middle-income countries (LMICs), urgently requiring detailed evidence to guide the response of health systems to this epidemic. In an effort to understand at what step in the diabetes care continuum individuals are lost to care, and how this varies between countries and population groups, this study examined health system performance for diabetes among adults in 28 LMICs using a cascade of care approach. METHODS AND FINDINGS: We pooled individual participant data from nationally representative surveys done between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl), random plasma glucose ≥ 11.1 mmol/l (200 mg/dl), HbA1c ≥ 6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were as follows: tested, diagnosed, lifestyle advice and/or medication given ("treated"), and controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic region, World Bank income group, and individual-level characteristics (age, sex, educational attainment, household wealth quintile, and body mass index [BMI]). We then used logistic regression models with country-level fixed effects to evaluate predictors of (1) testing, (2) treatment, and (3) control. The final sample included 847,413 adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income). Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of diabetes was 8.8% (95% CI: 8.2%-9.5%), and the prevalence of undiagnosed diabetes was 4.8% (95% CI: 4.5%-5.2%). Health system performance for management of diabetes showed large losses to care at the stage of being tested, and low rates of diabetes control. Total unmet need for diabetes care (defined as the sum of those not tested, tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled) was 77.0% (95% CI: 74.9%-78.9%). Performance along the care cascade was significantly better in upper-middle income countries, but across all World Bank income groups, only half of participants with diabetes who were tested achieved diabetes control. Greater age, educational attainment, and BMI were associated with higher odds of being tested, being treated, and achieving control. The limitations of this study included the use of a single glucose measurement to assess diabetes, differences in the approach to wealth measurement across surveys, and variation in the date of the surveys. CONCLUSIONS: The study uncovered poor management of diabetes along the care cascade, indicating large unmet need for diabetes care across 28 LMICs. Performance across the care cascade varied by World Bank income group and individual-level characteristics, particularly age, educational attainment, and BMI. This policy-relevant analysis can inform country-specific interventions and offers a baseline by which future progress can be measured.

Consumption of Fruits and Vegetables Among Individuals 15 Years and Older in 28 Low- and Middle-Income Countries.

BACKGROUND: The WHO recommends 400 g/d of fruits and vegetables (the equivalent of ∼5 servings/d) for the prevention of noncommunicable diseases (NCDs). However, there is limited evidence regarding individual-level correlates of meeting these recommendations in low- and middle-income countries (LMICs). In order to target policies and interventions aimed at improving intake, global monitoring of fruit and vegetable consumption by socio-demographic subpopulations is required. OBJECTIVES: The aims of this study were to 1) assess the proportion of individuals meeting the WHO recommendation and 2) evaluate socio-demographic predictors (age, sex, and educational attainment) of meeting the WHO recommendation. METHODS: Data were collected from 193,606 individuals aged ≥15 y in 28 LMICs between 2005 and 2016. The prevalence of meeting the WHO recommendation took into account the complex survey designs, and countries were weighted according to their World Bank population estimates in 2015. Poisson regression was used to estimate associations with socio-demographic characteristics. RESULTS: The proportion (95% CI) of individuals aged ≥15 y who met the WHO recommendation was 18.0% (16.6-19.4%). Mean intake of fruits was 1.15 (1.10-1.20) servings per day and for vegetables, 2.46 (2.40-2.51) servings/d. The proportion of individuals meeting the recommendation increased with increasing country gross domestic product (GDP) class (P < 0.0001) and with decreasing country FAO food price index (FPI; indicating greater stability of food prices; P < 0.0001). At the individual level, those with secondary education or greater were more likely to achieve the recommendation compared with individuals with no formal education: risk ratio (95% CI), 1.61 (1.24-2.09). CONCLUSIONS: Over 80% of individuals aged ≥15 y living in these 28 LMICs consumed lower amounts of fruits and vegetables than recommended by the WHO. Policies to promote fruit and vegetable consumption in LMICs are urgently needed to address the observed inequities in intake and prevent NCDs.

Knowledge and perception on type2 diabetes and hypertension among HIV clients utilizing care and treatment services: a cross sectional study from Mbeya and Dar es Salaam regions in Tanzania.

BACKGROUND: Type2 Diabetes and Hypertension (T2DM/HTN) have become serious threats to the health and socio-economic development in the developing countries. People living with HIV (PLHIV) infection are more vulnerable of developing T2DM/HTN due to HIV infection itself and antiretroviral treatments. The situation is worse when behavioral and biological risk factors are pervasive to PLHIV. Despite this vicious circle; information on the level of knowledge and perception regarding prevention of T2DM/HTN, risks factors and associated complications among PLHIV is not well documented in Tanzania. The aim of this paper was assess the level of T2DM/HTN knowledge and perception among PLHIV and utilizing care and treatment clinic (CTC) services. METHODS: A cross-sectional study was conducted in randomly selected 12 CTCs between October 2011 and February 2012. Data on demographic characteristics, type 2 diabetes and hypertension knowledge and perception were collected from the study participants. RESULTS: Out of 754 PLHIV and receiving HIV services at the selected CTCs, 671 (89%) consented for the study. Overall 276/671(41.1%) respondents had low knowledge on type2 diabetes and hypertension risk factors and their associated complications. Locality (rural) (AOR = 2.2; 95%CI 1.4-3.4) and never/not recalling if ever measured blood glucose in life (AOR = 2.3; 95%CI 1.1-5.7) were significant determinants of low knowledge among clients on ART. Being currently not having HIV and T2DM/HTN co-morbidities (AOR = 2.2; 95%CI 1.2-4.9) was the only determinant of low knowledge among ART Naïve clients. With regard to perception, 293/671(43.7%) respondents had negative perception on diabetes and hypertension prevention. Sex (female) (AOR = 2.0, 95%CI 1.2-2.9), being aged < 40 years (AOR = 1.6; 95%CI 1.1-2.5) and education (primary/no formal education) (AOR = 4.4; 95%CI 2.0-9.8) were determinants for negative perception among clients on ART while for ART Naïve clients; HIV and T2DM/HTN co-morbidities (AOR = 2.0; 95%CI 1.2-4.6) was the main determinant for negative perception. CONCLUSION: Considerable number of respondents had low level of knowledge (41.1%) regarding T2DM/HTN specifically on the risk factors, prevention strategies and their associated complications and negative perception (43.7%) towards healthy practices for mitigating risk behaviors of the diseases. There is need for promoting awareness of T2DM/HTN risk factors and complications by considering determinants of low knowledge and negative perception among PLHIV.

Barriers and facilitators to enrollment and re-enrollment into the community health funds/Tiba Kwa Kadi (CHF/TIKA) in Tanzania: a cross-sectional inquiry on the effects of socio-demographic factors and social marketing strategies.

BACKGROUND: Introduction of a health insurance scheme is one of the ways to enhance access to health care services and to protect individuals from catastrophic health expenditures. Little is known on the influence of socio-demographic and social marketing strategies on enrollment and re-enrollment in the Community Health Fund/Tiba Kwa Kadi (CHF/TIKA) in Tanzania. METHODS: This cross-sectional study employed quantitative methods for data collection between November 2014 and March 2015 in Singida and Shinyanga regions. Relationship between variables was obtained through Chi-square test and multivariate logistic regression. RESULTS: We recruited 496 participants in the study. Majority (92.7%) of participants consented to participate, with 229 (49.8%) and 231 (50.2%) members and non members of CHF/TIKA respectively. Majority (90.9%) were aware of CHF/TIKA. Majority of CHF/TIKA members and non-members (90% and 68.3% respectively) reported health facility-based sensitization as the most common social marketing approach employed to market the CHF/TIKA. The most popular marketing strategies in the country including traditional dances, football games, radio, television, news papers, and mosques/church were reported by few CHF and non CHF members. Multivariate Logistic regression models revealed no significant association between social marketing strategies and enrollment, but only socio-demographics; including marital status (AOR = 2.0, 95% CI 1.1-3.8) and family size (household with ≥ 6 members) (AOR = 1.5, 95% CI 1.0-2.5), were significant factors associated with enrollment/re-enrollment rate. CONCLUSIONS: This study indicated that low level of utilization of available social marketing strategies and socio-demographic factors are the barriers for attracting members to join the schemes. There is a need for applying various social marketing strategies and considering different facilitating and impending socio-demographic factors for the growth and sustainability of the scheme as we move towards universal health coverage.

Performance of health laboratories in provision of HIV diagnostic and supportive services in selected districts of Tanzania.

BACKGROUND: Roll-out and implementation of antiretroviral therapy (ART) necessitated many countries in Sub-Saharan Africa to strengthen their national health laboratory systems (NHLSs) to provide high quality HIV diagnostic and supportive services. This study was conducted to assess the performance of health laboratories in provision of HIV diagnostic and supportive services in eight districts (from four regions of Iringa, Mtwara, Tabora and Tanga), after nine years of implementation of HIV/AIDS care and treatment plan in Tanzania. METHODS: In this cross-sectional study, checklists and observations were utilized to collect information from health facilities (HFs) with care and treatment centres (CTCs) for HIV/AIDS patients; on availability of laboratories, CTCs, laboratory personnel, equipment and reagents. A checklist was also used to collect information on implementation of quality assurance (QA) systems at all levels of the NHLS in the study areas. RESULTS: The four regions had 354 HFs (13 hospitals, 41 Health Centres (HCs) and 300 dispensaries); whereby all hospitals had laboratories and 11 had CTCs while 97.5 and 61.0% of HCs had both laboratories and CTCs, respectively. Of the dispensaries, 36.0 and 15.0% had laboratories and CTCs (mainly in urban areas). Thirty nine HFs (12 hospitals, 21 HCs and six dispensaries) were assessed and 56.4% were located in urban areas. The assessed HFs had 199 laboratory staff of different cadres (laboratory assistants = 35.7%; technicians =32.7%; attendants = 22.6%; and others = 9.1%); with >61% of the staff and 72.3% of the technicians working in urban areas. All laboratories were using rapid diagnostic tests for HIV testing. Over 74% of the laboratories were performing internal quality control and 51.4% were participating in external QA programmes. Regional and district laboratories had all key equipment and harmonization was maintained for Fluorescence-Activated Cell Sorting (FACS) machines. Most of the biochemical (58.0%) and haematological analysers (74.1%) were available in urban areas. Although >81% of the equipment were functional with no mechanical faulty, 62.6% had not been serviced in the past three years. CONCLUSION: Diagnostic and supportive services for HIV were available in most of the HCs and hospitals while few dispensaries were providing the services. Due to limitations such as shortage of staff, serving of equipment and participation in QA programmes, the NHLS should be strengthened to ensure adequate human resource, implementation of QA and sustainable preventive maintenance services of equipment.

The readiness of the national health laboratory system in supporting care and treatment of HIV/AIDS in Tanzania.

BACKGROUND: Strong health laboratory systems and networks capable of providing high quality services are critical components of the health system and play a key role in routine diagnosis, care, treatment and disease surveillance. This study aimed to assess the readiness of the national health laboratory system (NHLS) and its capacity to support care and treatment of HIV/AIDS in Tanzania. METHODS: A documentary review was performed to assess the structure of the health system with reference to the status and capacity of the NHLS to support HIV diagnosis. Key informant interviews were also held with laboratory staff in all levels of the health care delivery system in four regions with different levels of HIV prevalence. Information sought included availability and utilization of laboratory guidelines, quality and the capacity of laboratories for diagnosis of HIV. RESULTS: The findings indicate that a well-established NHLS was in place. However, the coordination of HIV laboratory services was found to be weak. Forty six respondents were interviewed. In most laboratories, guidelines for HIV diagnosis were available but health care providers were not aware of their availability. Utilization of the guidelines for HIV diagnosis was higher at national level than at the lower levels. The low level of awareness and utilization of guidelines was associated with inadequate training and supervision. There was a shortage of human resource, mostly affecting the primary health care level of the system and this was associated with inequity in employment and training opportunities. Laboratories in public health facilities were better staffed and had more qualified personnel than private-owned laboratories. CONCLUSION: Tanzania has a well established national health laboratory network sufficient to support HIV care and treatment services. However, laboratories at the primary health care level are constrained by inadequate resources and operate within a limited capacity. Improving the laboratory capacity in terms of number of qualified personnel, staff training on the national guidelines, laboratory diagnostic tools and coordination should be given a higher priority.

Magnitude and risk factors of non-communicable diseases among people living with HIV in Tanzania: a cross sectional study from Mbeya and Dar es Salaam regions.

BACKGROUND: HIV and Non communicable diseases (NCDs) are major problem of public health importance in developing countries. This study was conducted to explore and establish information on the magnitude, distribution of NCDs risk factors among people living with HIV (PLWHIV) which is scarce in Tanzania. METHOD: A cross sectional study was conducted to PLWHIV from 12 care and treatment clinics in Dar es Salaam and Mbeya regions from October 2011 to February 2012. Data on demographic characteristics, NCD risk factors including behavioral, biochemical tests and physical measurements was collected from PLWHIV. RESULTS: Of 754 PLWHIV recruited, 671(89.0%) consented to participate in the study and 354/671(52.8%) were on antiretroviral therapy (ART). The following NCD risk factors: raised blood levels of low density lipoprotein (61.3% vs 38.7%, p < 0.001) total cholesterol (TC) (71.6% vs 28.4%, p < 0.001) and triglyceride (67.0% vs 33.0%, p = 0.001) as well as overweight/obesity (61.1% vs 38.9%, p = 0.010), abnormal waist circumference (61.7% vs 38.3%, p < 0.001) and being aged >40 years (63.3% vs 36.7%, p < 0.001) were more prevalent among PLWHIV on ART than ART naïve. The prevalence of Diabetes mellitus among PLWHIV was 4.2% and was slightly high among those ART naïve (4.7% vs 3.7%). The prevalence of hypertension was 26.2% and was high among those on ART (30.0% vs 21.9%, p = 0.010). Being aged >40 years (AOR = 2.52, 95% CI 1.37-4.63), abnormal waist circumference (AOR = 2.37 95% CI 1.13-5.00), overweight/obesity (AOR = 2.71, 95% CI 1.26-5.84) and male sex (AOR = 1.17, 1.02-4.20) were the predictors of hypertension among patients on ART while raised TC (AOR = 1.47 (1.01-2.21) and being aged >40 years (AOR = 3.42, 95% CI 2.06-5.70) were predictors for hypertension among ART naïve patients. CONCLUSION: This study has revealed that the magnitude of NCD risk factors is significantly higher among PLWHIV on ART than those not on ART. Initiating and strengthening of interventions for minimizing preventable NCD risks should be considered when initiating ART among PLWHIV. Regular monitoring of NCD risk factors is of paramount importance among ART patients.

Multiple cardiovascular risk factor care in 55 low- and middle-income countries: A cross-sectional analysis of nationally-representative, individual-level data from 280,783 adults.

The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representative population-based surveys (2009-2019) with measured blood pressure (BP) and diabetes biomarker. We restricted our analysis to non-pregnant individuals aged 40-69 years and defined three mutually exclusive groups (i.e., hypertension only, diabetes only, and both hypertension-diabetes) to compare individuals living with concurrent hypertension and diabetes to individuals with each condition separately. We included 90,086 individuals who lived with hypertension only, 11,975 with diabetes only, and 16,228 with hypertension-diabetes. We estimated the percentage of individuals who were aware of their diagnosis, used pharmacological therapy, or achieved appropriate hypertension and diabetes management. A greater percentage of individuals with hypertension-diabetes were fully diagnosed (64.1% [95% CI: 61.8-66.4]) than those with hypertension only (47.4% [45.3-49.6]) or diabetes only (46.7% [44.1-49.2]). Among the hypertension-diabetes group, pharmacological treatment was higher for individual conditions (38.3% [95% CI: 34.8-41.8] using antihypertensive and 42.3% [95% CI: 39.4-45.2] using glucose-lowering medications) than for both conditions jointly (24.6% [95% CI: 22.1-27.2]).The percentage of individuals achieving appropriate management was highest in the hypertension group (17.6% [16.4-18.8]), followed by diabetes (13.3% [10.7-15.8]) and hypertension-diabetes (6.6% [5.4-7.8]) groups. Although health systems in LMICs are reaching a larger share of individuals living with both hypertension and diabetes than those living with just one of these conditions, only seven percent achieved both BP and blood glucose treatment targets. Implementation of cost-effective population-level interventions that shift clinical care paradigm from disease-specific to comprehensive CVD care are urgently needed for all three groups, especially for those with multiple CVD risk factors.

Radiation safety in an era of diagnostic radiology growth in Africa: Lessons learned from Tanzania.

PURPOSE: As radiology continues to grow in low- and middle-income countries (LMICs), radiation exposure and risk to patients and staff will concurrently increase. This study aims to assess the knowledge of radiation safety among medical staff in Tanzania. METHODS: A survey was distributed to 350 staff members at a national referral hospital in Tanzania over a 7-month period (February-August 2021). This consisted of a structured questionnaire evaluating participants' knowledge and awareness ionizing radiation and radiation safety. Chi-square and Fisher's exact tests were used to determine the association between independent and dependent categorical variables. RESULTS: A total of 300 surveys were completed (86% response rate). Mean age was 31 and 53% of participants were female. The majority (89%) were clinical staff employed in direct patient care. Most reported having heard of radiation protection (85%) but only 61% reported receiving training in radiation protection. Regarding radiation knowledge, 73% correctly answered how to protect oneself from radiation and 74% knew which medical staff were at greater risk of radiation exposure. However, only 32% correctly answered which imaging tests emit more radiation and only 53% correctly answered which age group was at greatest risk of radiation effects. Non-clinical staff had a significantly lower radiation awareness than clinical staff, with 69.7% reporting having heard about radiation protection, compared to 88.3% of clinical staff (p = 0.004). Female participants were more knowledgeable of radiation risks in pregnancy (p = 0.002). More early career staff reported receiving radiation protection training (64.5%) compared to those with >5 years work experience (53.9%), though this difference was not statistically significant (p = 0.09). When stratifying radiation knowledge by high (score of 80-100%), moderate (60-79.9%) and low (<60%), 20% of participants scored high, 47% moderate, and 33% low. CONCLUSION: Most staff had low to moderate knowledge on radiation safety. Our findings highlight the importance of education on ionizing radiation as medical imaging continues to rise in Africa.

Factors Influencing Participation of Adults in Voluntary Medical Male Circumcision in Lindi Region, Tanzania.

Background: Voluntary Medical Male Circumcision (VMMC) is a surgical procedure done by a qualified medical personnel using anesthesia. In Tanzania, there is a gap between adult men who are not circumcised and adolescents. This calls for a review of the current situation of VMMC services in the community at large in order to inform policymakers and stakeholders involved in the fight against HIV and other sexually transmitted diseases. The present study explored the factors influencing utilisation of VMMC services among adult males in Lindi Region, Tanzania. Materials and methods: A cross-sectional study was conducted among adults male (15-49 years). Data were collected by using a structured modified measure evaluation quantitative Version 2 questionnaire using a Tablet/Android device with an Open Data Kit (ODK) application (Google Inc. California, USA). Results: The socio-demographic set up of the study participants was mainly composed of males less than 30yrs, single, unemployed, with primary education as the highest level of study and of a Muslim faith. Majority of the respondents (92%) recommended circumcision to a male family member who is not yet circumcised. The study showed that improved sexual performance (81%), penile hygiene (97%) and circumcision as a modern civilization (96%) to be the key factors that motivated respondents' utilisation of VMMC services. However, only 20.6% of the respondents could barely say that VMMC is a surgical procedure done by qualified medical personnel under anaesthesia. The major reasons for recommending the utilisation of VMMC services to their family members were the VMMC usefulness in preventing STIs (48.9%), cultural practices and norms (31.5%), improved penile hygiene (17.4%) and religious reasons (2.2%). Conclusion: VMMC is positively favoured by the local coastal communities of the Lindi region of Tanzania Mainland. Our findings may be inferred to reflect on the other neighbouring regions with similar sociocultural set ups such as Mtwara, Pwani, Rural Dar es Salaam and Tanga and the isles of Unguja and Pemba. Programs addressing VMMC may be well instituted in these local communities with high degree of favourability and success.

The effectiveness of interventions to reduce cardio-metabolic risk factors among regular street food consumers in Dar es Salaam, Tanzania: The pre-post findings from a cluster randomized trial (Registered by Pan African clinical trial registry with trial # PACTR202208642850935).

INTRODUCTION: The healthy plate model (HPM) is a practical guide to modulate the portion of staple food in main meals, subsequently affecting the risks associated with Non-communicable Diseases include type2 diabetes mellitus (T2DM). OBJECTIVE: This study investigated the effectiveness of health information and the healthy plate model on cardio-metabolic risk factors, knowledge and attitude towards T2DM prevention measures. METHODS: A pre-post analysis, as part of a cluster randomized trial with street food vendors and their customers, was implemented in three randomly selected districts in Dar es Salaam, Tanzania. Two vendor-customer clusters each with 15 and more vendors from each district were randomly assigned to receive either T2DM health information only (Intervention package1 [IP1]) or IP1 plus a subsidized meal with vegetables and fruits, following the principles of the HPM (Intervention package2 [IP2]). Within the clusters the participants were informed on the importance of the intervention they received. An intervention period lasted for three months from 1st April to 31st June 2019. We applied Generalized Linear Mixed Models and Bayesian Modelling (for sensitivity analysis) to assess the effectiveness of the interventions. RESULTS: Overall, 336 (IP2 = 175 and IP1 = 161) out of 560 (280/arm) previous study participants participated in evaluation. Diastolic BP was lower among IP2 participants in the evaluation than baseline AßC = -4.1mmHg (95%CI:-5.42 to -2.76). After adjusting for the interaction between IP2 and age of the consumers, the BMI was significantly lower among IP2 in the evaluation than baseline AßC = -0.7kg/m2 (95%CI: -1.17 to -0.23). With interaction between IP2 and income, BMI was higher in the IP2 in the evaluation than baseline AßC = 0.73kg/m2 (95%CI: 0.08 to 1.38). Systolic and diastolic BP were significantly lower among IP1 in the evaluation than baseline AßC = -3.5mmHg (95%CI:-5.78 to -1.24) and AßC = -5.9mmHg (95%CI:-7.34 to -4.44) respectively. Both the knowledge scores and positive attitudes towards T2DM prevention measures were higher in the evaluation than baseline in both interventions arms. CONCLUSION: The positive effects on cardio-metabolic risk factors, knowledge and attitude were observed in both intervention arms. Due to interactions between IP2, age and income; designing interventions relating to food and cardio-metabolic risk factors, should consider combining socio-economic factors.

Diabetes risk and provision of diabetes prevention activities in 44 low-income and middle-income countries: a cross-sectional analysis of nationally representative, individual-level survey data.

BACKGROUND: The global burden of diabetes is rising rapidly, yet there is little evidence on individual-level diabetes prevention activities undertaken by health systems in low-income and middle-income countries (LMICs). Here we describe the population at high risk of developing diabetes, estimate diabetes prevention activities, and explore sociodemographic variation in these activities across LMICs. METHODS: We performed a pooled, cross-sectional analysis of individual-level data from nationally representative, population-based surveys conducted in 44 LMICs between October, 2009, and May, 2019. Our sample included all participants older than 25 years who did not have diabetes and were not pregnant. We defined the population at high risk of diabetes on the basis of either the presence of impaired fasting glucose (or prediabetes in countries with a haemoglobin A1c available) or overweight or obesity, consistent with the WHO Package of Essential Noncommunicable Disease Guidelines for type 2 diabetes management. We estimated the proportion of survey participants that were at high risk of developing diabetes based on this definition. We also estimated the proportion of the population at high risk that reported each of four fundamental diabetes prevention activities: physical activity counselling, weight loss counselling, dietary counselling, and blood glucose screening, overall and stratified by World Bank income group. Finally, we used multivariable Poisson regression models to evaluate associations between sociodemographic characteristics and these activities. FINDINGS: The final pooled sample included 145 739 adults (86 269 [59·2%] of whom were female and 59 468 [40·4%] of whom were male) across 44 LMICs, of whom 59 308 (40·6% [95% CI 38·5-42·8]) were considered at high risk of diabetes (20·6% [19·8-21·5] in low-income countries, 38·0% [37·2-38·9] in lower-middle-income countries, and 57·5% [54·3-60·6] in upper-middle-income countries). Overall, the reach of diabetes prevention activities was low at 40·0% (38·6-41·4) for physical activity counselling, 37·1% (35·9-38·4) for weight loss counselling, 42·7% (41·6-43·7) for dietary counselling, and 37·1% (34·7-39·6) for blood glucose screening. Diabetes prevention varied widely by national-level wealth: 68·1% (64·6-71·4) of people at high risk of diabetes in low-income countries reported none of these activities, whereas 49·0% (47·4-50·7) at high risk in upper-middle-income countries reported at least three activities. Educational attainment was associated with diabetes prevention, with estimated increases in the predicted probability of receipt ranging between 6·5 (3·6-9·4) percentage points for dietary fruit and vegetable counselling and 21·3 (19·5-23·2) percentage points for blood glucose screening, among people with some secondary schooling compared with people with no formal education. INTERPRETATION: A large proportion of individuals across LMICs are at high risk of diabetes but less than half reported receiving fundamental prevention activities overall, with the lowest receipt of these activities among people in low-income countries and with no formal education. These findings offer foundational evidence to inform future global targets for diabetes prevention and to strengthen policies and programmes to prevent continued increases in diabetes worldwide. FUNDING: Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program and the EU's Research and Innovation programme Horizon 2020.

Barriers to the implementation, uptake and scaling up of the healthy plate model among regular street food consumers: a qualitative inquiry in Dar-es-Salaam city, Tanzania.

INTRODUCTION: The healthy plate model is considered one of the practical approaches to reduce the average portion of staple food in main meals, consequently reducing the risks associated with diabetes and other Non-communicable Diseases (NCDs). Despite its potential benefits, studies on the implementation of the healthy plate model are limited in Africa. An inquiry explored barriers to implementation, uptake, and scaling up of the healthy plate model among street food vendors and consumers in three districts of Dar-es-Salaam city in Tanzania. METHODS: A qualitative research design was adopted. Qualitative data collection techniques were employed including; Key Informant Interviews (KIIs) with purposefully selected food and nutrition stakeholders at the National, Regional, District and Ward levels. Focus Group Discussions (FGDs) were conducted with purposefully selected street food consumers and vendors. A total of (13) KIIs were conducted as well as (6) FGDs with street food vendors (2 FGDs) and consumers (4 FGDs). Interview data was managed using Nvivo 12 Software and analyzed thematically. RESULTS: Three key themes emerged from participants' accounts: (i) strategic policy barriers, (ii) food production and preparation environment barriers (producers and vendors), and (iii) individual barriers (consumers and vendors). The strategic policy barriers included absence of guidelines and regulations that focus on NCDs linked to nutrition and lack of education guidance for vendors and consumers. The food production and preparation environment barriers included safety and risks concerns regarding the quality of water used for irrigation and washing fruits and vegetables and the areas where vegetables and fruits are grown and prepared. Individual barriers included low consumer income, knowledge on nutrition, unhealthy eating practices and; low vendors' knowledge as well as low investment capital. CONCLUSION: Implementation, uptake and scaling up of the healthy plate model for street food consumers in Dar es Salaam City continues to be constrained by barriers in policy, food production and preparation environment, and individual obstacles. Strengthening of food and nutrition policies, ensuring safety of the food production and preparation environment and, consumer and vendor awareness creation and income generation efforts, provide useful entry points for the successful scaling up of a healthy plate model. This could consequently contribute towards prevention of diet related NCDs, including diabetes.