Cluster randomized trial of comprehensive gender-based violence programming delivered through the HIV/AIDS program platform in Mbeya Region, Tanzania: Tathmini GBV study

The Tathmini GBV study was a cluster randomized trial to assess the impact of a comprehensive health facility- and community-based program delivered through the HIV/AIDS program platform on reduction in gender-based violence and improved care for survivors. Twelve health facilities and surrounding communities in the Mbeya Region of Tanzania were randomly assigned to intervention or control arms. Population-level effects were measured through two cross-sectional household surveys of women ages 15–49, at baseline (n = 1,299) and at 28 months following program scale-out (n = 1,250). Delivery of gender-based violence services was assessed through routine recording in health facility registers. Generalized linear mixed effects models and analysis of variance were used to test intervention effects on population and facility outcomes, respectively. At baseline, 52 percent of women reported experience of recent intimate partner violence. The odds of reporting experience of this violence decreased by 29 percent from baseline to follow-up in the absence of the intervention (time effect OR = 0.71, 95% CI: 0.57–0.89). While the intervention contributed an additional 15 percent reduction, the effect was not statistically significant. The program, however, was found to contribute to positive, community-wide changes including less tolerance for certain forms of violence, more gender equitable norms, better knowledge about gender-based violence, and increased community actions to address violence. The program also led to increased utilization of gender-based violence services at health facilities. Nearly three times as many client visits for gender-based violence were recorded at intervention (N = 1,427) compared to control (N = 489) facilities over a 16-month period. These visits were more likely to include provision of an HIV test (55.3% vs. 19.6%, p = .002). The study demonstrated the feasibility and impact of integrating gender-based violence and HIV programming to combat both of these major public health problems. Further opportunities to scale out GBV prevention and response strategies within HIV/AIDS service delivery platforms should be pursued.

Trial Registration: Pan African Clinical Trials Registry No. PACTR201802003124149.

Understanding women's experiences of distress during pregnancy in Dar es Salaam, Tanzania

Several studies show depression is common during pregnancy. However, there is limited information in Tanzania on the magnitude of perceived distress during pregnancy and meanings ascribed to such distress. A descriptive survey collected data using unstructured interviews from 12 traditional practitioners and 10 peri-urban women with previous pregnancy related mental health concerns identified using a depression vignette. The objectives were to describe the sources and characteristics of distress during pregnancy, and idioms of distress that could inform cultural adaptation of depression screening tools. Narrative analysis showed an emergent category of "problematic pregnancies" framed women's recollections of prolonged periods of sadness. This experience was qualified using various idioms of distress that were differentially emphasized depending on informant's perceived causes of health concern. The idiom kusononeka was consistently used to describe extreme sadness across causal categories and clustered with at least two typical features of major depression. This suggested existence of a construct with similarities to biomedical criteria for depression. "Thinking too much" emerged as a distinctive expression associated with prolonged sadness. Distinctive expressions of social functioning impairments were identified that can inform depression severity assessments. In conclusion, contextual inquiry into experiences of psychological distress showed distinct local idioms that clustered in patterns similar to symptoms of biomedical depressive episodes. Further studies to assess the utility of local idioms of distress and distress related functional impairment in depression assessment tools are warranted.

Socio-economic and partner relationship factors associated with antenatal depressive morbidity among pregnant women in Dar es Salaam, Tanzania

Depression during pregnancy may negatively influence social functioning, birth outcomes and postnatal mental health. A cross-sectional analysis of the baseline survey of a prospective study was undertaken with an objective of determining the prevalence and socio-demographic factors associated with depressive morbidity during pregnancy in a Tanzanian peri-urban setting. Seven hundred and eighty seven second to third trimester pregnant women were recruited at booking for antenatal care at two primary health care clinics. Prenatal structured interviews assessed socio-economic, quality of partner relationships and selected physical health measures. Depressive symptoms were measured at recruitment and three and eight months postpartum using the Kiswahili version of the Hopkins Symptom Checklist. Completed antenatal measures available for 76.2% participants, showed a 39.5% prevalence of depression. Having a previous depressive episode (OR 4.35, P<0.01), low (OR 2.18, P<0.01) or moderate (OR 1.86, P=0.04) satisfaction with ability to access basic needs, conflicts with the current partner (OR 1.89, P<0.01), or booking earlier for antenatal care (OR 1.87, P=0.02) were independent predictors of antenatal depression in the logistic regression model; together explaining 21% of variance in depression scores. Attenuation of strength of multivariate associations suggests confounding between the independent risk factors and socio-demographic and economic measures. In conclusion, clinically significant depressive symptoms are common in mid and late trimester antenatal clinic attendees. Interventions for early recognition of depression should target women with a history of previous depressive episodes or low satisfaction with ability to access basic needs, conflict in partner relationships and relatively earlier booking for antenatal care. Findings support a recommendation that antenatal services consider integrating screening for depression in routine antenatal care.

Skinning the goat and pulling the load: transactional sex among youth in Dar es Salaam, Tanzania

Transactional sex has been associated with risk of HIV infection in a number of studies throughout sub-Saharan Africa. Urban young women are economically vulnerable and at heightened risk of HIV infection in Tanzania; yet there are few studies that have explored relationship dynamics, including transactional sex, in this setting. This paper sheds light on the broader context of sexual relationships among youth at risk for HIV, how transactional sex plays out in these relationships, and how the transactional nature of relationships affects women's risk for HIV. We conducted 60 in depth interviews and 14 focus group discussions with young men and women, 16-24 years old, in Dar es Salaam, Tanzania. These data guided the development of a community based HIV and violence prevention intervention for young men. Youth described the exchange of sex for money or other material goods in all types of sexual relationships. While the exchange was explicit in casual relationships, young women voiced material and monetary expectations from their committed partners as well. Young men described their pursuit of multiple partners as sexually motivated, while women sought multiple partners for economic reasons. Young men were aware of the expectations of material support from partners, and acknowledged that their ability to provide for a partner affected both the longevity and exclusivity of their relationships. Youth described a deep mistrust of the motivations and commitment of their sexual partners. Furthermore, young women's financial dependence on men impacted their ability to negotiate safe sexual behaviors in both casual and committed relationships. Programs designed to reduce HIV risk among Tanzanian youth need to take into account the transactional component of sexual relationships and how such exchanges differ according to partner type.

Validity of the Hopkins Symptom Checklist-25 amongst HIV-positive pregnant women in Tanzania

OBJECTIVE

To validate the Hopkins Symptom Checklist-25 (HSCL-25) for use as a depression screen amongst human immuno-deficiency virus (HIV) positive pregnant women.

METHOD

Amongst 903 (mean age 24.8 years) HIV-positive pregnant women, a two-phased design included measures for health-related quality of life, perceived social support, and the HSCL-25 screen for depressive (HSCL-15 subscale) and anxiety symptoms. The Structured Clinical Interview for DSM-IV (SCID) was independently administered on a stratified random subsample.

RESULTS

Internal consistency of the HSCL-25 (alpha 0.93) and HSCL-15 (alpha 0.9) was adequate, with expected findings demonstrated in discriminant validity analysis. A depression-anxiety construct explained nearly 40% of the variance. Eight individual HSCL-25 items demonstrated an area under the curve (AUC) greater than 0.6 for DSM-IV major depression and the HSCL-25 and HSCL-revised had an optimal depression cut-off score of 1.06 and 1.03 for the HSCL-15.

CONCLUSION

The HSCL-25 demonstrated utility as a screen for depression; its inability to gauge severity of symptoms in this cultural context is discussed.