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Osei Afriyie D, Loo PS, Kuwawenaruwa A, Kassimu T, Fink G, Tediosi F, Mtenga S. Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care. Soc Sci Med 2024; 347:116714. [PMID: 38479141 DOI: 10.1016/j.socscimed.2024.116714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/19/2024] [Accepted: 02/20/2024] [Indexed: 04/20/2024]
Abstract
Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care.
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Affiliation(s)
- Doris Osei Afriyie
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland.
| | - Pei Shan Loo
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland.
| | - August Kuwawenaruwa
- Health Systems, Impact Evaluation and Policy Group, Ifakara Health Institute, Dar Es Salaam, United Republic of Tanzania.
| | - Tani Kassimu
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland; Health Systems, Impact Evaluation and Policy Group, Ifakara Health Institute, Dar Es Salaam, United Republic of Tanzania.
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland.
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland.
| | - Sally Mtenga
- Health Systems, Impact Evaluation and Policy Group, Ifakara Health Institute, Dar Es Salaam, United Republic of Tanzania; Institute of Health and Wellbeing, University of Glasgow, Ireland, UK.
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Timoth S, Machange J, Karino K, Mtenga S, Mkopi A, Levira F. The impacts of family planning and HIV service integration on contraceptive prevalence among HIV positive women in Tanzania: a comparative analysis from the 2016/17 Tanzania HIV impact survey. Contracept Reprod Med 2023; 8:58. [PMID: 38057924 DOI: 10.1186/s40834-023-00260-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Prevention of unplanned pregnancies through modern contraceptives among HIV-positive women is one of the essential strategies for reducing mother-to-child transmission of HIV. Family planning and HIV services integration is a national strategy designed to scale-up modern contraceptives among HIV-positive women. This study aims to evaluate the success of a service integration strategy by comparing the prevalence of modern contraceptive use among HIV-positive women receiving ART within integrated services and those not on integrated services (HIV-negative women and HIV-positive women unaware of their status). METHODS We used data from the Tanzania HIV impact survey (THIS) of 2016/17. THIS provided HIV counselling and testing with a return of results in over 30,000 adults over 15 years of age. Women tested positive self reported their enrollment into ARV with further confirmation through laboratory analysis for any detectible ARV in their blood. All non-pregnant women reported their contraceptive use. Univariate and multivariate logistic regression was used to assess the effect of accessing integrated services controlling for potential confounders. RESULTS A total of 14,986 women were included in the analysis; HIV-positive women were 1,066 and HIV-negative women were 13,830. Modern contraceptive use prevalence was 35% among HIV-positive women and 30% among HIV-negative women. Among HIV-positive women, those enrolled in integrated services (ART) had a higher prevalence of modern contraceptive (40%) compared to HIV-positive women unaware of their status (27%, p-value = 0.0014). The most common contraceptive methods in HIV-positive women were injectables (32%) and male condoms (31%), while in HIV-negative women, injectables (39%) and implants (30%, n = 1032) were the most preferred methods. Among HIV-positive women, enrolment into integrated services (currently on ART) demonstrated an increase in the odds of modern contraceptives by 85% (AOD = 1.85, 95%CI: 1.27-2.71). CONCLUSION This study found relatively low modern contraceptive use among HIV-positive women in the general population despite the existance of service integration program and guidelines to guide its implementation.Our study therefore calls for the evaluation on the implementation of the integration programme to identify factors that constrain or facilitate programme effectiveness.
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Affiliation(s)
- Saitoti Timoth
- School of Life Sciences and Bioengineering, The Nelson Mandela African Institution of Science and Technology, P.O. Box 447, Arusha, Tanzania.
- School of Diagnostic Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, #5 Ifakara Street, Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania.
| | - Jane Machange
- School of Life Sciences and Bioengineering, The Nelson Mandela African Institution of Science and Technology, P.O. Box 447, Arusha, Tanzania
| | - Kilaye Karino
- Kilimanjaro Christian Medical University College, P. O. Box 2240, Moshi, Tanzania
| | - Sally Mtenga
- School of Life Sciences and Bioengineering, The Nelson Mandela African Institution of Science and Technology, P.O. Box 447, Arusha, Tanzania
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, #5 Ifakara Street, Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Abdallah Mkopi
- School of Life Sciences and Bioengineering, The Nelson Mandela African Institution of Science and Technology, P.O. Box 447, Arusha, Tanzania
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, #5 Ifakara Street, Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Francis Levira
- School of Life Sciences and Bioengineering, The Nelson Mandela African Institution of Science and Technology, P.O. Box 447, Arusha, Tanzania
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, #5 Ifakara Street, Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
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Tani K, Osetinsky B, Mhalu G, Mtenga S, Fink G, Tediosi F. Healthcare workers' experiences with COVID-19-related prevention and control measures in Tanzania. PLOS Glob Public Health 2023; 3:e0002678. [PMID: 38051721 PMCID: PMC10697532 DOI: 10.1371/journal.pgph.0002678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023]
Abstract
The ability of a health system to withstand shocks such as a pandemic depends largely on the availability and preparedness of health-care workers (HCWs), who are at the frontline of disease management and prevention. Despite the heavy burden placed on HCWs during the COVID-19 pandemic, little is known regarding their experiences in low-income countries. We conducted a web-based survey with HCWs in randomly selected districts of Tanzania to explore their experiences with COVID-19-related prevention and control measures. The survey assessed implementation of COVID-19 control guidelines in health facilities, HCW perceptions of safety, well-being and ability to provide COVID-19 care, and challenges faced by frontline workers during the pandemic. We used multivariate regression analysis to examine the association between HCW and health facility characteristics, a score of guideline implementation, and challenges faced by HCWs. 6,884 Tanzanian HCWs participated in the survey between December 2021 to March 2022. The majority of respondents were aware of the COVID-19 guidelines and reported implementing preventive measures, including masking of both HCWs and patients. However, HCWs faced several challenges during the pandemic, including increased stress, concerns about infection, and inadequate personal protective equipment. In particular, female HCWs were more likely to report exhaustion from wearing protective equipment and emotional distress, while physicians were more likely to experience all challenges. While most HCWs reported feeling supported by facility management, they also reported that their concerns about COVID-19 treatment were not fully addressed. Notably, perceptions of protection and well-being varied widely among different HCW cadres, highlighting the need for targeted interventions based on level of exposure. In addition, various factors such as HCW cadre, facility ownership and COVID-19 designation status influenced HCWs' opinions about the health system's response to COVID-19. These findings highlight the importance of consistent implementation of guidelines and social and emotional support for HCWs.
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Affiliation(s)
- Kassimu Tani
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Brianna Osetinsky
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Grace Mhalu
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Sally Mtenga
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Binyaruka P, Mtenga S. Catastrophic health care spending in managing type 2 diabetes before and during the COVID-19 pandemic in Tanzania. PLOS Glob Public Health 2023; 3:e0002180. [PMID: 37607181 PMCID: PMC10443863 DOI: 10.1371/journal.pgph.0002180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/20/2023] [Indexed: 08/24/2023]
Abstract
COVID-19 disrupted health care provision and access and reduced household income. Households with chronically ill patients are more vulnerable to these effects as they access routine health care. Yet, a few studies have analysed the effect of COVID-19 on household income, health care access costs, and financial catastrophe due to health care among patients with type 2 diabetes (T2D), especially in developing countries. This study fills that knowledge gap. We used data from a cross-sectional survey of 500 people with T2D, who were adults diagnosed with T2D before COVID-19 in Tanzania (March 2020). Data were collected in February 2022, reflecting the experience before and during COVID-19. During COVID-19, household income decreased on average by 16.6%, while health care costs decreased by 0.8% and transport costs increased by 10.6%. The overall financing burden for health care and transport relative to household income increased by 32.1% and 45%, respectively. The incidences of catastrophic spending above 10% of household income increased by 10% (due to health care costs) and by 55% (due to transport costs). The incidences of catastrophic spending due to health care costs were higher than transport costs, but the relative increase was higher for transport than health care costs (10% vs. 55% change from pre-COVID-19). The likelihood of incurring catastrophic health spending was lower among better educated patients, with health insurance, and from better-off households. COVID-19 was associated with reduced household income, increased transport costs, increased financing burden and financial catastrophe among patients with T2D in Tanzania. Policymakers need to ensure financial risk protection by expanding health insurance coverage and removing user fees, particularly for people with chronic illnesses. Efforts are also needed to reduce transport costs by investing more in primary health facilities to offer quality services closer to the population and engaging multiple sectors, including infrastructure and transportation.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation, and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Sally Mtenga
- Department of Health System, Impact Evaluation, and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
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Mtenga S, Mhalu G, Osetinsky B, Ramaiya K, Kassim T, Hooley B, Tediosi F. Social-political and vaccine related determinants of COVID-19 vaccine hesitancy in Tanzania: A qualitative inquiry. PLOS Glob Public Health 2023; 3:e0002010. [PMID: 37315101 DOI: 10.1371/journal.pgph.0002010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 05/10/2023] [Indexed: 06/16/2023]
Abstract
Vaccines have played a critical role in the response to the COVID-19 pandemic globally, and Tanzania has made significant efforts to make them available to the public in addition to sensitizing them on its benefit. However, vaccine hesitancy remains a concern. It may prevent optimal uptake of this promising tool in many communities. This study aims to explore opinions and perceptions on vaccine hesitancy to better understand local attitudes towards vaccine hesitancy in both rural and urban Tanzania. The study employed cross-sectional semi-structured interviews with 42 participants. The data were collected in October 2021. Men and women aged between 18 and 70 years were purposefully sampled from Dar es Salaam and Tabora regions. Thematic content analysis was used to categorize data inductively and deductively. We found that COVID-19 vaccine hesitancy exists and is shaped by multiple socio-political and vaccine related factors. Vaccine related factors included worries over vaccine safety (e.g., death, infertility, and zombie), limited knowledge about the vaccines and fear of the vaccine's impact on pre-existing conditions. Participants also found it paradoxical that mask and hygiene mandates are expected even after vaccination, which further exacerbated their doubts about vaccine efficacy and their hesitancy. Participants possessed a range of questions regarding COVID-19 vaccines that they wanted answered by the government. Social factors included preference for traditional and home remedies and influence from others. Political factors included inconsistent messages on COVID-19 from the community and political leaders; and doubts about the existence of COVID-19 and the vaccine. Our findings suggest that the COVID-19 vaccine is beyond a medical intervention, it carries with it a variety of expectations and myths that need to be addressed in order to build trust and acceptance within communities. Health promotion messages need to respond to heterogeneous questions, misinformation, doubts, and concerns over safety issues. An understanding of country-specific perspectives toward COVID-19 vaccines can greatly inform the development of localized strategies for meaningful uptake in Tanzania.
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Affiliation(s)
- Sally Mtenga
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Grace Mhalu
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Brianna Osetinsky
- Swiss Tropical and Public Health Institute (Swiss TPH), Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Tani Kassim
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Swiss Tropical and Public Health Institute (Swiss TPH), Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Brady Hooley
- Swiss Tropical and Public Health Institute (Swiss TPH), Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute (Swiss TPH), Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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Mbanga E, Joachim C, Ilyas O, John R, Rweyemamu L, Mtenga S, Mhalu G, Nanai A, Kileo N, Kessi M, Iriya N, Mapunda M, Phori P, Kirigia D, Valentine N, Told M, Marwa A, Yoti Z. Process of developing the National Health in All Policies Framework to address social determinants of health in Tanzania Mainland: lessons learned, 2018 - 2022. Pan Afr Med J 2023; 45:4. [PMID: 37538361 PMCID: PMC10395109 DOI: 10.11604/pamj.supp.2023.45.1.39693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 04/24/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction social determinants of health (SDH) are the non-medical factors that contribute to various infectious and non-infectious diseases in Tanzania. Studies suggest that SDH account for 30-55% of health outcomes globally. Most SDH are outside the mandate of the health sector; hence, multi-sectoral collaboration through Health in All Policies (HiAP) is critical. Health in All Policies looks at public policies across sectors that consider health implications of decisions, seek synergies, use resources and avoid harmful health impacts to improve population health and health equity. This paper demonstrates lessons learned from the process of developing National HiAP Framework in Tanzania Mainland to address SDH. It is expected that countries will be able to learn and adopt what deems fit in their context as they address SDH to improve population health. Methods different methods were used to promote multi-sectoral collaboration in addressing SDH through HiAP. They included consultations with Prime Minister's Office (PMO) as the coordinator of Government business for their buy-in. High-level advocacy meetings of Directors of Policy and Planning and Permanent Secretaries from sectoral ministries were conducted to move forward the HiAP agenda. Capacity building was provided for sectoral Ministries to understand HiAP concept and SDH. Interministerial collaboration meetings were convened to bring sectors together to identify SDH issues and key areas for inter-sectoral collaboration and develop National HiAP Framework to address SDH. Health in All Policies Secretariat coordinates the HiAP activities. Results it has been noted that almost every sectoral ministry has a health component in its policy which contributes to the Tanzanian population's health. In this regard, every sectoral ministry has a role to play in addressing SDH for sustainable development. Political will is key in moving forward the HiAP agenda. The role of PMO is significant to ensure inter-sectoral collaboration. Achieving the national and Sustainable Development Goals require strong collaboration among sectors and stakeholder coordination at all levels through HiAP. Conclusion implementing HiAP is a win-win situation. It enhances inter-sectoral collaboration, benefiting each sector to achieve its health-related strategic indicators and ultimately achieve national and global goals.
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Affiliation(s)
- Edward Mbanga
- Ministry of Health, Tanzania Mainland, Dodoma, Tanzania
| | | | - Omar Ilyas
- Prime Minister’s Office, Dodoma, Tanzania
| | - Raynold John
- Ministry of Health, Tanzania Mainland, Dodoma, Tanzania
| | | | - Sally Mtenga
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Grace Mhalu
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Alphoncina Nanai
- World Health Organization, Country Office, Dar es Salaam, Tanzania
| | - Neema Kileo
- World Health Organization, Country Office, Dar es Salaam, Tanzania
| | - Mary Kessi
- Ministry of Health, Tanzania Mainland, Dodoma, Tanzania
| | - Nemes Iriya
- World Health Organization, Country Office, Dar es Salaam, Tanzania
| | | | - Peter Phori
- World Health Organization, Regional Office for Africa, Brazaville, Congo
| | - Doris Kirigia
- World Health Organization, Regional Office for Africa, Brazaville, Congo
| | | | - Michaela Told
- World Health Organization, Headquarters, Geneva, Switzerland
| | | | - Zabulon Yoti
- World Health Organization, Country Office, Dar es Salaam, Tanzania
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Hetherington E, Harper S, Davidson R, Festo C, Lampkin N, Mtenga S, Teixeira C, Vincent I, Nandi A. Impact evaluation of the TAMANI project to improve maternal and child health in Tanzania. J Epidemiol Community Health 2023; 77:410-416. [PMID: 37116960 DOI: 10.1136/jech-2022-219995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 04/12/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND The Tabora Maternal and Newborn Health Initiative project was a multicomponent intervention to improve maternal and newborn health in the Tabora region of Tanzania. Components included training healthcare providers and community health workers, infrastructure upgrades, and improvements to health management. This study aimed to examine the impact of trainings on four key outcomes: skilled birth attendance, antenatal care, respectful maternity care and patient-provider communication. METHODS Trainings were delivered sequentially at four time points between 2018 and 2019 in eight districts (two districts at a time). Cross-sectional surveys were administered to a random sample of households in all districts at baseline and after each training wave. Due to practical necessities, the original stepped wedge cluster randomised design of the evaluation was altered mid-programme. Therefore, a difference-in-differences for multiple groups in multiple periods was adopted to compare outcomes in treated districts to not yet treated districts. Risk differences were estimated for the overall average treatment effect on the treated and group/time dynamic effects. RESULTS Respondents reported 3895 deliveries over the course of the study. The intervention was associated with a 12.9 percentage point increase in skilled birth attendance (95% CI 0.4 to 25.4), which began to increase 4 months after the end of training in each district. There was little evidence of impact on antenatal care visits, respectful treatment during delivery and patient-provider communication. CONCLUSION Interventions to train local healthcare workers in basic and comprehensive emergency obstetric and newborn care increased skilled birth attendance but had limited impact on other pregnancy-related outcomes.
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Affiliation(s)
- Erin Hetherington
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
| | - Sam Harper
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
| | | | - Charles Festo
- Ifakara Health Institute, Ifakara, Morogoro, Tanzania, United Republic of
| | | | - Sally Mtenga
- Ifakara Health Institute, Ifakara, Tanzania, United Republic of
| | | | - Ilona Vincent
- McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
| | - Arijit Nandi
- Institute for Health and Social Policy and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
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Palmeirim MS, Erismann S, Leuenberger A, Berger-González M, Mtenga S, Sayasone S, Odermatt P, Prytherch H, Somerville C. Gender in public health research: Reflections on design and process across four research projects in low-and middle-income countries. PLOS Glob Public Health 2023; 3:e0000808. [PMID: 37043446 PMCID: PMC10096266 DOI: 10.1371/journal.pgph.0000808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/15/2023] [Indexed: 04/13/2023]
Abstract
A growing body of work clearly documents the gendered inequalities in health. The COVID-19 pandemic further exposed these deep inequities: men appear to be more vulnerable to poorer outcomes, but most of the global health workforce is female who are at increased risk of exposure to hospital infection. However, researchers often fail to adequately embed gender as part of the public health research. This paper reports findings from a synthesis exercise that identified some of the challenges of integrating gender in the design and processes of research studies in four projects conducted in six low- and middle-income countries. Through a collective retrospective meta-synthesis process with researchers from each project, we identified two main themes; (i) we deep dive on two of the structural pillars of conducting public health research (design and process) and (ii) we describe some of the underlying opportunities and resistances to the integration of a gender perspective in these research projects. In conclusion, we suggest that public health funding bodies require researchers to integrate gender in public health research from early on as part of the design and to conduct gendered analysis, as part of the overall drive towards more equitable health systems delivery.
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Affiliation(s)
- Marta S Palmeirim
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Séverine Erismann
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Andrea Leuenberger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Sally Mtenga
- Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - Somphou Sayasone
- Lao Tropical and Public Health Institute, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | - Peter Odermatt
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Helen Prytherch
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Claire Somerville
- Graduate Institute of International and Development Studies, Geneva, Switzerland
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Osetinsky B, Mhalu G, Mtenga S, Tediosi F. Care cascades for hypertension and diabetes: Cross-sectional evaluation of rural districts in Tanzania. PLoS Med 2022; 19:e1004140. [PMID: 36469527 PMCID: PMC9762578 DOI: 10.1371/journal.pmed.1004140] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 12/19/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Noncommunicable diseases (NCDs), especially hypertension and diabetes, are rapidly rising in sub-Saharan Africa, necessitating health systems transformations. In Tanzania, current policies aim to improve control of hypertension and diabetes, but information is still needed to assess the gaps in treatment. METHODS AND FINDINGS We conducted a cross-sectional household survey of 784 adults in two districts in Tanzania from December 2020 to January 2021, capturing the cascade-of-care for hypertension and diabetes. The ages of the respondents ranged from 18 to 89 years. Of those screened positive for these conditions, we measured the proportion in each step of the cascades: awareness, care engagement, treatment, and control. We conducted multivariable logistic regression analyses for all four steps along the hypertension care cascade with the independent variables of social health protection schemes, and prior diagnosis of comorbid diabetes, and demographic information. In our sample, of the 771 who had their blood pressure measured, 41% (95% confidence interval (CI): 38% to 44%) were screened positive for hypertension, and of the 707 who had their blood sugar measured, 6% (95% CI: 4% to 8%) were screened positive for diabetes. Of those with hypertension, 43% (95% CI: 38% to 49%) had a prior diagnosis, 25% (95% CI: 21% to 31%) were engaged in care, 21% (95% CI: 3% to 25%) were on treatment, and 11% (95% CI: 8% to 15%) were controlled. Of the 42 respondents with diabetes, 80% (95% CI: 69% to 93%) had a prior diagnosis. The diabetes care cascade had much less drop-off, so 66% of those with diabetes (95% CI: 52% to 82%) were engaged in care and on treatment, and 48% (95% CI: 32% to 63%) had their diabetes controlled at the point of testing. Healthcare fee exemptions were independently associated with higher odds of being previously diagnosed (OR 5.81; 95% CI [1.98 to 17.10] p < 0.005), engaged in care (OR 4.71; 95% CI [1.59 to 13.90] p 0.005), and retained in treatment (OR 2.93; 95% CI [1.03 to 8.35] p < 0.05). Prior diagnosis of comorbid diabetes was highly associated with higher odds of being engaged in care for hypertension (OR 3.26; 95% CI [1.39 to 7.63] p < 0.005). The two primary limitations of this study were reliance on screening at a single time point only of people available at the village at the time of the sample and dependence on self-report for to inform the three cascade steps of prior diagnosis, healthcare visits for engagement in care, and treatment use. CONCLUSIONS The high burden of hypertension and low levels of control in our study underscores the importance of improving the awareness and treatment of hypertension. The differences in the care cascades for hypertension and diabetes demonstrates that chronic NCD treatment is possible in this setting, but efforts will be needed across the entire care cascade to improve hypertension control.
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Affiliation(s)
- Brianna Osetinsky
- Swiss Tropical and Public Health Institute, Allschwill, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
| | - Grace Mhalu
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Sally Mtenga
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Allschwill, Switzerland
- University of Basel, Basel, Switzerland
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Hooley B, Mtenga S, Tediosi F. Informal Support Networks of Tanzanians With Chronic Diseases: Predictors of Support Provision and Treatment Adherence. Int J Public Health 2022; 67:1605366. [PMID: 36506711 PMCID: PMC9726723 DOI: 10.3389/ijph.2022.1605366] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/08/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives: To examine the role of NCD patients' social ties as informal caregivers and whether receiving their support is associated with engagement in care. Methods: NCD outpatients (N2 = 100) in rural Tanzania completed a cross-sectional questionnaire to characterize the support role of their social ties (N1 = 304). Bivariate analyses explored predictors of social support and whether social support is associated with engagement in care. Results: This study found that 87% of participants had health insurance, yet 25% received financial support for financing healthcare. Patient gender, age and marital status were found to be important predictors of social support, with NCD-related disability and disease severity being predictive to a lesser degree. Monthly receipt of both material and non-material support were associated with increased odds of adherence to prescribed medications. Conclusion: These findings indicate that patients' social ties play an important role in filling the gaps in formal social health protection and incur substantial costs by doing so. The instrumental role of even non-material social support in promoting engagement in care deserves greater attention when developing policies for improving this population's engagement in care.
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Affiliation(s)
- Brady Hooley
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
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Abstract
Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.
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Affiliation(s)
- Søren T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Slagelse, Denmark.
| | - Frances S Mair
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Quebec, Canada
| | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Bruno P Nunes
- Postgraduate Program in Nursing, Faculty of Nursing, Universidade Federal de Pelotas, Pelotas, Brazil
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Epidemiology and Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
| | - Sanghamitra Pati
- ICMR Regional Medical Research Centre, Bhubaneswar, Odisha, India
| | - Sally Mtenga
- Department of Health System Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
| | - Susan M Smith
- Discipline of Public Health and Primary Care, Institute of Population Health, Trinity College Dublin, Russell Building, Tallaght Cross, Dublin, Ireland
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Mkopi A, Mtenga S, Festo C, Mhalu G, Shabani J, Tillya R, Masemo A, Kheir K, Nassor M, Mwengee W, Lyimo D, Masanja H. Factors affecting non-coverage of measles-rubella vaccination among children aged 9-59 months in Tanzania. Vaccine 2021; 39:6041-6049. [PMID: 34531077 DOI: 10.1016/j.vaccine.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/21/2021] [Accepted: 09/03/2021] [Indexed: 11/17/2022]
Abstract
Globally, measles remains a major cause of child mortality, and rubella is the leading cause of birth defects among all infectious diseases. In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan that set a target to eliminate Measles-Rubella (MR) in five of the six World Health Organization (WHO) regions by 2020. This was cross-sectional study employed both quantitative and qualitative research methods. The sample size was calculated to provide overall, age- and sex-specific coverage estimates for MR vaccine among children aged between 9 and 59 months at the national level. Using desired precision of ±5% with an expected coverage of 95%, a total of 15,235 households were required. The age of children, a child who had received the MR vaccine before the campaign, household wealth quintile, the age of caregivers, and their marital status were associated with non-coverage of MR vaccination among children aged 9-59 months in Tanzania. Nationally, an estimated 88.2% (95% CI: 87.3-89%) of children aged 9-59 months received the MR campaign dose, as assessed by caregivers' recall. These estimates revealed slightly higher coverage in Zanzibar 89.6% (95% CI: 84.7-93%) compared to Mainland Tanzania 88.1% (95% CI 87.2-88.9%). These associated factors revealed causes of unvaccinated children and may be some of the reasons for Tanzania's failure to meet the MR campaign target of 95 percent vaccination coverage. Thus, vaccine development must increase programmatic oversight in order to improve immunization activities and communication strategies in Tanzanian areas with low MR coverage.
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Affiliation(s)
| | - Sally Mtenga
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Grace Mhalu
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | | | - Ame Masemo
- Zanzibar Health Research Institute, Zanzibar, Tanzania
| | - Khamis Kheir
- Zanzibar Health Research Institute, Zanzibar, Tanzania
| | - Mohamed Nassor
- World Health Organization, Tanzania Country Office, Dar es Salaam, Tanzania
| | - William Mwengee
- World Health Organization, Tanzania Country Office, Dar es Salaam, Tanzania
| | - Dafrossa Lyimo
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, Tanzania
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Abraham E, Gray C, Fagbamigbe A, Tediosi F, Otesinky B, Haafkens J, Mhalu G, Mtenga S. Barriers and facilitators to health insurance enrolment among people working in the informal sector in Morogoro, Tanzania. AAS Open Res 2021. [DOI: 10.12688/aasopenres.13289.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Health insurance is a crucial pathway towards the achievement of universal health coverage. In Tanzania, health-financing reforms are underway to speed up universal health coverage in the informal sector. Despite improved Community Health Fund (iCHF) rollout, iCHF enrolment remains a challenge in the informal sector. This study aimed to explore the perspectives of local women food vendors (LWFV) and Bodaboda (motorcycle taxi) drivers on factors that challenge and facilitate their enrolment in iCHF. Methods: A qualitative study was conducted in Morogoro Municipality through in-depth interviews with LWFV (n=24) and Bodaboda drivers (n=26), and two focus group discussions with LWFV (n=8) and Bodaboda drivers (n=8). Theory of planned behaviour (TPB) constructs (attitude, subjective norms, and perceived control) provided a framework for the study and informed a thematic analysis focusing on the barriers and facilitators of iCHF enrolment. Results: The views of LWFV and Bodaboda drivers on factors that influence iCHF enrolment converged. Three main barriers emerged: lack of knowledge about the iCHF (attitude); negative views from friends and families (subjective norms); and inability to overcome challenges, such as the quality and range of health services available to iCHF members and iCHF not being accepted at non-government facilities (perceived control). A number of facilitators were identified, including opinions that enrolling to iCHF made good financial sense (attitude), encouragement from already-enrolled friends and relatives (subjective norms) and the belief that enrolment payment is affordable (perceived control). Conclusions: Results suggest that positive attitudes supported by perceived control and encouragement from significant others could potentially motivate LWFV and Bodaboda drivers to enroll in iCHF. However, more targeted information about the scheme is needed for individuals in the informal sector. There is also a need to ensure that quality health services are available, including coverage for non-communicable diseases (NCDs), and that non-government facilities accept iCHF.
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Sikana L, Lembo T, Hampson K, Lushasi K, Mtenga S, Sambo M, Wight D, Coutts J, Kreppel K. Dog ownership practices and responsibilities for children's health in terms of rabies control and prevention in rural communities in Tanzania. PLoS Negl Trop Dis 2021; 15:e0009220. [PMID: 33690720 PMCID: PMC7946275 DOI: 10.1371/journal.pntd.0009220] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 02/08/2021] [Indexed: 12/25/2022] Open
Abstract
Interventions tackling zoonoses require an understanding of healthcare patterns related to both human and animal hosts. The control of dog-mediated rabies is a good example. Despite the availability of effective control measures, 59,000 people die of rabies every year worldwide. In Tanzania, children are most at risk, contributing ~40% of deaths. Mass dog vaccination can break the transmission cycle, but reaching the recommended 70% coverage is challenging where vaccination depends on willingness to vaccinate dogs. Awareness campaigns in communities often target children, but do not consider other key individuals in the prevention chain. Understanding factors related to dog ownership and household-level responsibility for dog vaccination and child health is critical to the design of vaccination strategies. We investigated who makes household decisions about dogs and on health care for children in rural Tanzania. In the Kilosa district, in-depth interviews with 10 key informants were conducted to inform analysis of data from a household survey of 799 households and a survey on Knowledge Attitudes and Practices of 417 households. The in-depth interviews were analysed using framework analysis. Descriptive analysis showed responsibilities for household decisions on dogs' and children's health. Multivariate analysis determined factors associated with the probability of dogs being owned and the number of dogs owned, as well as factors associated with the responsibility for child health. Dog ownership varied considerably between villages and even households. The number of dogs per household was associated with the size of a household and the presence of livestock. Children are not directly involved in the decision to vaccinate a dog, which is largely made by the father, while responsibility for seeking health care if a child is bitten lies with the mother. These novel results are relevant for the design and implementation of rabies interventions. Specifically, awareness campaigns should focus on decision-makers in households to improve rabies prevention practices and on the understanding of processes critical to the control of zoonoses more broadly.
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Affiliation(s)
- Lwitiko Sikana
- Environmental Health and Ecological Sciences, Ifakara Health Institute, Ifakara, Tanzania
- Global Health and Biomedical Sciences, School of Life Sciences and Bio-Engineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Tiziana Lembo
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Katie Hampson
- Environmental Health and Ecological Sciences, Ifakara Health Institute, Ifakara, Tanzania
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Kennedy Lushasi
- Environmental Health and Ecological Sciences, Ifakara Health Institute, Ifakara, Tanzania
- Global Health and Biomedical Sciences, School of Life Sciences and Bio-Engineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Sally Mtenga
- Environmental Health and Ecological Sciences, Ifakara Health Institute, Ifakara, Tanzania
| | - Maganga Sambo
- Environmental Health and Ecological Sciences, Ifakara Health Institute, Ifakara, Tanzania
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Daniel Wight
- Medical Research Council/Chief Scientist Office (MRC/CSO), Social and Public Health Sciences Unit, University of Glasgow, Glasgow, United Kingdom
| | - Jane Coutts
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Katharina Kreppel
- Global Health and Biomedical Sciences, School of Life Sciences and Bio-Engineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health & Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
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15
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Bajaria S, Abdul R, Exavery A, Minja E, Charles J, Mtenga S, Jere E, Geubbels E. Programmatic determinants of successful referral to health and social services for orphans and vulnerable children: A longitudinal study in Tanzania. PLoS One 2020; 15:e0239163. [PMID: 32946528 PMCID: PMC7500632 DOI: 10.1371/journal.pone.0239163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/31/2020] [Indexed: 11/18/2022] Open
Abstract
Background Trained community workers (CWs) successfully deliver health and social services, especially due to greater community acceptance. Orphans and vulnerable children (OVC) and their caregivers (CG) often need support from several sectors. We identified CW, program and referral characteristics that were associated with success of referrals provided to OVC and their CG in Tanzania in a cross-sectoral bi-directional referral system. Methods Data for this secondary analysis come from the first two years (2017–2018) of the USAID funded Kizazi Kipya project. Referral success was defined as feedback and service received within 90 days post-referral provision. We analyzed factors that are associated with the referral success of HIV related, education, nutrition, parenting, household economic strengthening, and child protection services among OVC and CG, using generalized estimating equations. Results During the study period, 19,502 CWs in 68 councils provided 146,996 referrals to 132,640 beneficiaries. OVC had much lower referral success for HIV related services (48.1%) than CG (81.2%). Adjusted for other covariates, CW age (26–49 versus 18–25 years, for OVC aOR = 0.83, 95%CI (0.78, 0.87) and CW gender (males versus females, for OVC aOR = 1.12, 95%CI (1.08, 1.16); CG aOR = 0.84, 95%CI (0.78, 0.90)) were associated with referral success. CWs who had worked > 1 year in the project (aOR = 1.52, 95%CI 1.46, 1.58) and those with previous work experience as CW (aOR = 1.57, 95%CI (1.42, 1.74) more successfully referred OVC. Referrals provided to OVC for all other services were more successful compared to HIV referrals, with aORs ranging from 2.99 to 7.22. Longer project duration in the district council was associated with increased referral success for OVC (aOR = 1.16 per month 95%CI 1.15,1.17), but decreased for CG (aOR = 0.96, 95%CI 0.94, 0.97). Referral success was higher for OVC and CGs with multiple (versus single) referrals provided within the past 30 days (aOR = 1.28 95%CI 1.21, 1.36) and (aOR = 1.17, 95%CI (1.06, 1.30)) respectively. Conclusion CW characteristics, referral type and project maturity had different and often contrasting associations with referral success for OVC versus for CG. These findings could help policymakers decide on the recruitment and allocation of CWs in community based multi-sectoral intervention programs to improve referral successes especially for OVC.
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Affiliation(s)
- Shraddha Bajaria
- Health Systems, Impact Evaluation and Policy Department, Ifakara Health Institute, Dar es Salaam, Tanzania
- * E-mail:
| | - Ramadhani Abdul
- Health Systems, Impact Evaluation and Policy Department, Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | | | | | - Sally Mtenga
- Health Systems, Impact Evaluation and Policy Department, Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Eveline Geubbels
- Health Systems, Impact Evaluation and Policy Department, Ifakara Health Institute, Dar es Salaam, Tanzania
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16
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Frank JW, Pagliari C, Geubbels E, Mtenga S. New forms of data for understanding low- and middle-income countries’ health inequalities: the case of Tanzania. J Glob Health 2018. [DOI: 10.7189/jogh.08.020302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Mtowa A, Gerritsen AA, Mtenga S, Mwangome M, Geubbels E. Socio-demographic inequalities in HIV testing behaviour and HIV prevalence among older adults in rural Tanzania, 2013. AIDS Care 2017; 29:1162-1168. [DOI: 10.1080/09540121.2017.1308462] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | | | - Sally Mtenga
- Ifakara Health Institute, Dar Es Salaam, Tanzania
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18
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Mtenga S, Kimweri A, Romore I, Ali A, Exavery A, Sicuri E, Tanner M, Abdulla S, Lusingu J, Kafuruki S. Stakeholders' opinions and questions regarding the anticipated malaria vaccine in Tanzania. Malar J 2016; 15:189. [PMID: 27048260 PMCID: PMC4822277 DOI: 10.1186/s12936-016-1209-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 03/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Within the context of combined interventions, malaria vaccine may provide additional value in malaria prevention. Stakeholders' perspectives are thus critical for informed recommendation of the vaccine in Tanzania. This paper presents the views of stakeholders with regards to malaria vaccine in 12 Tanzanian districts. METHODS Quantitative and qualitative methods were employed. A structured questionnaire was administered to 2123 mothers of under five children. Forty-six in-depth interviews and 12 focus group discussions were conducted with teachers, religious leaders, community health workers, health care professionals, and scientists. Quantitative data analysis involved frequency distributions and cross tabulations using Chi square test to determine the association between malaria vaccine acceptability and independent variables. Qualitative data were analysed thematically. RESULTS Overall, 84.2% of the mothers had perfect acceptance of malaria vaccine. Acceptance varied significantly according to religion, occupation, tribe and region (p < 0.001). Ninety two percent reported that they will accept the malaria vaccine despite the need to continue using insecticide-treated nets (ITNs), while 88.4% reported that they will accept malaria vaccine even if their children get malaria less often than non-vaccinated children. Qualitative results revealed that the positive opinions towards malaria vaccine were due to a need for additional malaria prevention strategies and expectations that the vaccine will reduce visits to the health facility, deaths, malaria episodes and treatment-related expenses. Vaccine related questions included its side effects, efficacy, protective duration, composition, interaction with other medications, provision schedule, availability to the pregnant women, mode of administration (oral or injection?) and whether a child born of HIV virus or with a chronic illness will be eligible for the vaccine? CONCLUSION Stakeholders had high acceptance and positive opinions towards the combined use of the anticipated malaria vaccine and ITNs, and that their acceptance remains high even when the vaccine may not provide full protection, this is a crucial finding for malaria vaccine policy decisions in Tanzania. An inclusive communication strategy should be designed to address the stakeholders' questions through a process that should engage and be implemented by communities and health care professionals. Social cultural aspects associated with vaccine acceptance should be integrated in the communication strategy.
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Affiliation(s)
- Sally Mtenga
- Ifakara Health Institute (IHI), P.O. Box 78373, Dar es Salaam, Tanzania.
| | - Angela Kimweri
- Ifakara Health Institute (IHI), P.O. Box 78373, Dar es Salaam, Tanzania
| | - Idda Romore
- Ifakara Health Institute (IHI), P.O. Box 78373, Dar es Salaam, Tanzania
| | - Ali Ali
- Ifakara Health Institute (IHI), P.O. Box 78373, Dar es Salaam, Tanzania
| | - Amon Exavery
- Ifakara Health Institute (IHI), P.O. Box 78373, Dar es Salaam, Tanzania
| | - Elisa Sicuri
- ISGlobal, Barcelona Centre International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Health Economics Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Salim Abdulla
- Ifakara Health Institute (IHI), P.O. Box 78373, Dar es Salaam, Tanzania
| | - John Lusingu
- National Institute for Medical Research Institute (NIMR), Tanga, Tanzania
| | - Shubi Kafuruki
- Ifakara Health Institute (IHI), P.O. Box 78373, Dar es Salaam, Tanzania
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Mtenga S, Masanja IM, Mamdani M. Strengthening national capacities for researching on Social Determinants of Health (SDH) towards informing and addressing health inequities in Tanzania. Int J Equity Health 2016; 15:23. [PMID: 26860192 PMCID: PMC4746920 DOI: 10.1186/s12939-016-0308-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 01/25/2016] [Indexed: 11/10/2022] Open
Abstract
Background Tanzania’s socio-economic development is challenged by sharp inequities between and within urban and rural areas, and among different socio-economic groups. This paper discusses the importance of strengthening SDH research, knowledge, relevant capacities and responsive systems towards addressing health inequities in Tanzania. Methods Based on a conceptual framework for building SDH research capacity, a mapping of existing research systems was undertaken between February and June 2012. It involved a review of national policies, strategies and published SDH-related research outputs from 2005 onwards, and 34 in-depth interviews with a range of stakeholders in Tanzania. Results The conceptualization of SDH varies considerably among stakeholders and their professional background, but with some consensus that it is linked to “inequities” being a consequence of poverty, poor planning, limited attention to basic humanity and citizenship rights, weak governance structures and inefficient use of available resources. Commonly perceived SDH factors include age, income, education, beliefs, cultural norms, gender, occupation, nutritional status, access to health care, access to safe water and sanitation and child bearing practices. SDH research is in its infancy but gaining momentum. In the absence of a specific “SDH portfolio”, SDH research is scattered and hidden within disease specific, poverty-related research and research on universal health coverage. Research is mainly externally funded, which has implications on the focus of context specific SDH research, national priorities and transfer to policy. This create mismatch with population and research capacity needs. Conclusion Most research analysis in the country fails to consider the context specific structural determinants of health and inequities towards a broader understanding of existing vulnerabilities. The challenge is on promoting a culture of critical inter-disciplinary research and analysis that is central to SDH research. Establishing a system to promote collaboration across sectors and strengthen collective capacities for individuals and institutions researching in SDH will augment existing SDH research initiatives and better inform appropriate intersectoral policies towards addressing prevailing health inequities across the country.
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Affiliation(s)
- Sally Mtenga
- Ifakara Health Institute, Po Box 78373, Dar es Salaam, Tanzania.
| | - Irene M Masanja
- Ifakara Health Institute, Po Box 78373, Dar es Salaam, Tanzania.
| | - Masuma Mamdani
- Ifakara Health Institute, Po Box 78373, Dar es Salaam, Tanzania.
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Mtenga S, Shamba D, Wamoyi J, Kakoko D, Haafkens J, Mongi A, Kapiga S, Geubbels E. How long-distance truck drivers and villagers in rural southeastern Tanzania think about heterosexual anal sex: a qualitative study. Sex Transm Infect 2015; 91:576-80. [PMID: 26113730 PMCID: PMC4680186 DOI: 10.1136/sextrans-2015-052055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/25/2015] [Indexed: 11/04/2022] Open
Abstract
Objective To explore ideas of truck drivers and villagers from rural Tanzania about heterosexual anal sex (HAS) and the associated health risks. Methods Qualitative study using 8 in-depth interviews (IDIs) and 2 focus group discussions (FGDs) with truck drivers and 16 IDIs and 4 FGDs with villagers from the Morogoro region. Study participants included 24 women and 46 men. Data analysis was performed thematically employing standard qualitative techniques. Results Reasons why men would practice HAS included sexual pleasure, the belief that anal sex is safer than vaginal sex, alternative sexual practice, exploration and proof of masculinity. Reasons why women would practice HAS included financial need, retaining a partner, alternative for sex during menses, pregnancy prevention and beauty enhancement because HAS is believed to ‘fatten the female buttocks’. Most participants believed that condoms are not needed during HAS. This was linked to the ideas that infections only ‘reside in wet places’ (vagina) and that the anus is not ‘conducive’ for condom use; condoms reduce ‘dryness’ and ‘friction’ (pleasure) and may ‘get stuck inside’. Conclusions The study participants reported practices and ideas about HAS that put them at risk for HIV and sexually transmitted infections. Greater attention to education about HAS is urgently needed in Tanzania, where this sexual practice is still regarded as a taboo. This study offers useful information that could be included in sex education programmes.
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Affiliation(s)
- S Mtenga
- Department of Impact Evaluation, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - D Shamba
- Department of Impact Evaluation, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - J Wamoyi
- National Institute for Medical Research Institute (NIMR), Mwanza Center, Mwanza, Tanzania
| | - D Kakoko
- Department of Behavioural Sciences, Muhimbili University of Health and Allied Science (MUHAS), School of Public Health, Dar es Salaam, Tanzania
| | - J Haafkens
- Department of General Practice, Centre for Social Science and Global Health, University of Amsterdam and Academic Medical Centre, Amsterdam, The Netherlands
| | - A Mongi
- Mwanza Intervention Trial Unit (MITU), Mwanza, Tanzania
| | - S Kapiga
- Mwanza Intervention Trial Unit (MITU), Mwanza, Tanzania
| | - E Geubbels
- Department of Impact Evaluation, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
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Nyogea D, Mtenga S, Henning L, Franzeck FC, Glass TR, Letang E, Tanner M, Geubbels E. Determinants of antiretroviral adherence among HIV positive children and teenagers in rural Tanzania: a mixed methods study. BMC Infect Dis 2015; 15:28. [PMID: 25637106 PMCID: PMC4314748 DOI: 10.1186/s12879-015-0753-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 01/13/2015] [Indexed: 11/16/2022] Open
Abstract
Background Around 3.3 million children worldwide are infected with HIV and 90% of them live in sub-Saharan Africa. Our study aimed to estimate adherence levels and find the determinants, facilitators and barriers of ART adherence among children and teenagers in rural Tanzania. Methods We applied a sequential explanatory mixed method design targeting children and teenagers aged 2–19 years residing in Ifakara. We conducted a quantitative cross sectional study followed by a qualitative study combining focus group discussions (FGDs) and in-depth interviews (IDIs). We used pill count to measure adherence and defined optimal adherence as > =80% of pills being taken. We analysed determinants of poor adherence using logistic regression. We held eight FGDs with adolescent boys and girls on ART and with caretakers. We further explored issues emerging in the FGDs in four in-depth interviews with patients and health workers. Qualitative data was analysed using thematic content analysis. Results Out of 116 participants available for quantitative analysis, 70% had optimal adherence levels and the average adherence level was 84%. Living with a non-parent caretaker predicted poor adherence status. From the qualitative component, unfavorable school environment, timing of the morning ART dose, treatment longevity, being unaware of HIV status, non-parental (biological) care, preference for traditional medicine (herbs) and forgetfulness were seen to be barriers for optimal adherence. Conclusion The study has highlighted specific challenges in ART adherence faced by children and teenagers. Having a biological parent as a caretaker remains a key determinant of adherence among children and teenagers. To achieve optimal adherence, strategies targeting the caretakers, the school environment, and the health system need to be designed.
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Affiliation(s)
- Daniel Nyogea
- Ifakara Health institute, P.O Box 153, Ifakara, Tanzania. .,Swiss Tropical and Public Health Institute, Basel, Switzerland.
| | - Sally Mtenga
- Ifakara Health institute, P.O Box 153, Ifakara, Tanzania.
| | - Lars Henning
- Ifakara Health institute, P.O Box 153, Ifakara, Tanzania. .,Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University Hospital of Zurich, Zürich, Switzerland.
| | - Fabian C Franzeck
- Ifakara Health institute, P.O Box 153, Ifakara, Tanzania. .,Swiss Tropical and Public Health Institute, Basel, Switzerland.
| | - Tracy R Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland.
| | - Emilio Letang
- Ifakara Health institute, P.O Box 153, Ifakara, Tanzania. .,Swiss Tropical and Public Health Institute, Basel, Switzerland. .,ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
| | - Marcel Tanner
- Ifakara Health institute, P.O Box 153, Ifakara, Tanzania. .,Swiss Tropical and Public Health Institute, Basel, Switzerland.
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de Walque D, Dow WH, Nathan R, Abdul R, Abilahi F, Gong E, Isdahl Z, Jamison J, Jullu B, Krishnan S, Majura A, Miguel E, Moncada J, Mtenga S, Mwanyangala MA, Packel L, Schachter J, Shirima K, Medlin CA. Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania. BMJ Open 2012; 2:e000747. [PMID: 22318666 PMCID: PMC3330254 DOI: 10.1136/bmjopen-2011-000747] [Citation(s) in RCA: 145] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE The authors evaluated the use of conditional cash transfers as an HIV and sexually transmitted infection prevention strategy to incentivise safe sex. DESIGN An unblinded, individually randomised and controlled trial. SETTING 10 villages within the Kilombero/Ulanga districts of the Ifakara Health and Demographic Surveillance System in rural south-west Tanzania. PARTICIPANTS The authors enrolled 2399 participants, aged 18-30 years, including adult spouses. INTERVENTIONS Participants were randomly assigned to either a control arm (n=1124) or one of two intervention arms: low-value conditional cash transfer (eligible for $10 per testing round, n=660) and high-value conditional cash transfer (eligible for $20 per testing round, n=615). The authors tested participants every 4 months over a 12-month period for the presence of common sexually transmitted infections. In the intervention arms, conditional cash transfer payments were tied to negative sexually transmitted infection test results. Anyone testing positive for a sexually transmitted infection was offered free treatment, and all received counselling. MAIN OUTCOME MEASURES The primary study end point was combined prevalence of the four sexually transmitted infections, which were tested and reported to subjects every 4 months: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium. The authors also tested for HIV, herpes simplex virus 2 and syphilis at baseline and month 12. RESULTS At the end of the 12-month period, for the combined prevalence of any of the four sexually transmitted infections, which were tested and reported every 4 months (C trachomatis, N gonorrhoeae, T vaginalis and M genitalium), unadjusted RR for the high-value conditional cash transfer arm compared to controls was 0.80 (95% CI 0.54 to 1.06) and the adjusted RR was 0.73 (95% CI 0.47 to 0.99). Unadjusted RR for the high-value conditional cash transfer arm compared to the low-value conditional cash transfer arm was 0.76 (95% CI 0.49 to 1.03) and the adjusted RR was 0.69 (95% CI 0.45 to 0.92). No harm was reported. CONCLUSIONS Conditional cash transfers used to incentivise safer sexual practices are a potentially promising new tool in HIV and sexually transmitted infections prevention. Additional larger study would be useful to clarify the effect size, to calibrate the size of the incentive and to determine whether the intervention can be delivered cost effectively. TRIAL REGISTRATION NUMBER NCT00922038 ClinicalTrials.gov.
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Affiliation(s)
- Damien de Walque
- The World Bank, Development Research Group, Washington, District of Columbia, USA
| | - William H Dow
- School of Public Health, University of California, Berkeley, California, USA
| | - Rose Nathan
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
| | | | | | - Erick Gong
- Department of Economics, Middlebury College, Middlebury, Vermont, USA
| | | | - Julian Jamison
- Center for Behavioural Economics, Federal Reserve Bank of Boston, Boston, Massachusetts, USA
| | | | - Suneeta Krishnan
- Research Triangle Institute International, Research Triangle Park, North Carolina, USA
| | | | | | - Jeanne Moncada
- Department of Laboratory Medicine, University of California, San Francisco, California, USA
| | - Sally Mtenga
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
| | | | - Laura Packel
- Global Health Sciences Prevention and Public Health Group, University of California, San Francisco, California, USA
| | - Julius Schachter
- Department of Laboratory Medicine, University of California, San Francisco, California, USA
| | | | - Carol A Medlin
- Health Economics and Finance, Global Health Program, The Bill and Melinda Gates Foundation, Seattle, Washington, USA
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Nyika A, Chilengi R, Ishengoma D, Mtenga S, Thera MA, Sissoko MS, Lusingu J, Tiono AB, Doumbo O, Sirima SB, Lemnge M, Kilama WL. Engaging diverse communities participating in clinical trials: case examples from across Africa. Malar J 2010; 9:86. [PMID: 20346126 PMCID: PMC2907873 DOI: 10.1186/1475-2875-9-86] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Accepted: 03/26/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the advent of increasing international collaborative research involving participants drawn from populations with diverse cultural backgrounds, community engagement becomes very critical for the smooth conduction of the research. The African Malaria Network Trust (AMANET) is a pan-African non-governmental organization that sponsors and technically supports malaria vaccine trials in various African countries. CASE DESCRIPTION AMANET sponsored phase Ib or IIb clinical trials of several malaria vaccine candidates in various Africa countries. In Burkina Faso, Mali and Tanzania trials of the merozoite surface protein 3 -- in its Long Synthetic Peptide configuration (MSP3 LSP) -- were conducted. In Mali, the apical membrane antigen 1 (AMA1) was tested, while a hybrid of glutamate rich protein (GLURP) and MSP3 (GMZ2) was tested in Gabon. AMANET recognizes the importance of engaging with the communities from which trial participants are drawn, hence community engagement was given priority in all project activities conducted in the various countries. DISCUSSION AND EVALUATION Existing local social systems were used to engage the communities from which clinical trial participants were drawn. This article focuses on community engagement activities employed at various AMANET-supported clinical trial sites in different countries, highlighting subtle differences in the approaches used. The paper also gives some general pros and cons of community engagement. CONCLUSIONS Community engagement enables two-way sharing of accurate information and ideas between researchers and researched communities, which helps to create an environment conducive to smooth research activities with enhanced sense of research ownership by the communities.
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Affiliation(s)
- Aceme Nyika
- African Malaria Network Trust (AMANET), P. O. Box 33207, Dar es Salaam, Tanzania
| | - Roma Chilengi
- KEMRI-Wellcome Trust Research Programme, Kilifi District Hospital Grounds, P.O. Box 230, Kilifi, Kenya
| | - Deus Ishengoma
- National Institute for Medical Research, Tanga Medical Research Centre, P.O Box 5004, Tanga, Tanzania
| | - Sally Mtenga
- Ifakara Health Institute (IHI), P. O. Box 78373, Dar es Salaam, Tanzania
| | - Mahamadou A Thera
- Malaria Research and Training Centre (MRTC), PB 1805, University of Bamako, Mali
| | - Mahamadou S Sissoko
- Malaria Research and Training Centre (MRTC), PB 1805, University of Bamako, Mali
| | - John Lusingu
- National Institute for Medical Research, Tanga Medical Research Centre, P.O Box 5004, Tanga, Tanzania
| | - Alfred B Tiono
- Centre National de Recherche et de Formation sur le Paludisme (CNRFP), 01 BP 2208 Ouagadougou 01, Burkina Faso
| | - Ogobara Doumbo
- Malaria Research and Training Centre (MRTC), PB 1805, University of Bamako, Mali
| | - Sodiomon B Sirima
- Centre National de Recherche et de Formation sur le Paludisme (CNRFP), 01 BP 2208 Ouagadougou 01, Burkina Faso
| | - Martha Lemnge
- National Institute for Medical Research, Tanga Medical Research Centre, P.O Box 5004, Tanga, Tanzania
| | - Wen L Kilama
- African Malaria Network Trust (AMANET), P. O. Box 33207, Dar es Salaam, Tanzania
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Egwaga S, Range N, Lwilla F, Mkopi A, Barongo V, Mtenga S, Mshinda H, Cobelens F, Haag V, van Leth F, Grewal P. Assessment of patient preference in allocation and observation of anti-tuberculosis medication in three districts in Tanzania. Patient Prefer Adherence 2008; 2:1-6. [PMID: 19920938 PMCID: PMC2770399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The new tuberculosis (TB) treatment in Tanzania contains rifampicin for six months. Direct observation of drug intake at the health facility for this period is not feasible. METHODS Patients and health staff in three districts were interviewed to assess the burden of the current treatment strategy, and opinions on a proposed new strategy where patients are able to choose the place of treatment and the treatment supervisor, and receive treatment as a daily combination tablet. RESULTS The study included 343 patients in 42 facilities. Daily collection of drugs was perceived as burdensome irrespective of distance needed to travel. Eighty percent of patients viewed medication taken at home or at a closer health facility as an improvement in TB-services. The proposed new treatment strategy was rated favorably by 85% of patients and 75% of health staff. Fifty-three percent of patients would opt for home-based treatment, and 75% would choose a family member or the spouse as treatment supporter. CONCLUSION Home-based supervision of TB treatment with fewer drugs is an expressed preference of TB patients in Tanzania. Such a strategy is now being assessed in a pilot study. If effective and feasible, the strategy will contribute to an improved TB control strategy.
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Affiliation(s)
- Saidi Egwaga
- National Tuberculosis and Leprosy Programme, Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | - Nyagosya Range
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Fred Lwilla
- National Tuberculosis and Leprosy Programme, Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | - Abdallah Mkopi
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Vivien Barongo
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Sally Mtenga
- Ifakara Health Research and Development Centre, Ifakara, Tanzania
| | - Hassan Mshinda
- Ifakara Health Research and Development Centre, Ifakara, Tanzania
| | - Frank Cobelens
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
- Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Vera Haag
- Novartis Foundation for Sustainable Development, Basle, Switzerland
| | - Frank van Leth
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
- Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, The Netherlands
- Correspondence: Frank van Leth, KNCV Tuberculosis Foundation, PO Box 146, 2501 CC The Hague, The Netherlands, Tel + 31 70 427 0982, Fax + 31 70 358 4004, Email
| | - Penny Grewal
- Novartis Foundation for Sustainable Development, Basle, Switzerland
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