Study protocol : improving newborn survival in rural southern Tanzania : a cluster-randomised trial to evaluate the impact of a scaleable package of interventions at community level with health system strengthening

Child mortality has declined substantially in many countries including Tanzania, but newborn mortality remains high and around 3 million babies die every year in the first 28 days of life. Community-based approaches with home visits in the first week of life have shown great potential to reduce newborn mortality. INSIST aimed1 to develop, implement and evaluate an integrated, two-part strategy that combines interventions at community level with health system strengthening in rural Southern Tanzania to reduce newborn mortality. The community intervention focused around interpersonal communication through home visits in pregnancy and the early neonatal period by a village-based "agent of change". Key messages focused on hygiene during delivery, immediate and exclusive breastfeeding, and identification and extra care for babies born small because of low birth weight or prematurity. Extra care for babies born small included skin-to-skin care for small babies and referral to hospital for very small babies. The community intervention was implemented in six poor rural districts in Southern Tanzania, with 65 of the 132 wards within these districts randomized to receive the community intervention. In addition, a health system quality-improvement package was implemented in all health facilities of one district. Data collection for the evaluation included i) a baseline household survey in 2007 of all 243,000 households in 5 of the 6 study districts to estimate baseline mortality and prevalence of newborn care behaviours, ii) an adequacy survey in 2011 in a representative sample of 5,000 households to estimate coverage of home visits and prevalence of newborn care behaviours, and iii) an endline household survey in 2013 in a representative sample of 200,000 households to estimate newborn and maternal mortality and prevalence of newborn care behaviours. The final analysis was based on "intention to treat", comparing newbor

Failure to return pillbox is a predictor of being lost to follow-up among people living with HIV on antiretroviral therapy in rural Tanzania

OBJECTIVES: Pill count is used to assess drug adherence in people living with HIV (PLHIV). Carrying a pillbox is associated with fear of concealment and stigma and might indicate poor adherence and predict someone who will be lost to follow-up (LTFU). We therefore assessed the association between pillbox return and being LTFU in rural Tanzania. METHODS: This is a nested study of the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO). We included PLHIV aged >/= 18 years enrolled in KIULARCO between January 2013 and March 2019 with follow-up through January 2020, who were on antiretroviral treatment (ART) for >/= 6 months. Baseline was defined as the latest ART initiation or KIULARCO enrolment. We determined the association between time-dependent failed pillbox return updated at every visit and LTFU using Kaplan-Meier estimation and Cox models. RESULTS: Among 2552 PLHIV included in the study, 1735 (68.0%) were female, 959 (40.3%) had a WHO stage III/IV and 1487 (66.4%) had a CD4 cell count < 350 cells/microL. The median age was 38.4 years [interquartile range (IQR): 31.7-46.2]. During a median follow-up of 33.1 months (IQR: 17.5-52.4), 909 (35.6%) participants were LTFU, 43 (1.7%) died and 194 (7.6%) had transferred to another clinic. The probability of being LTFU was higher among PLHIV with failed pillbox return than among those who returned their pillbox [30.0%, 95% confidence interval (CI): 26.8-33.2% vs. 19.4%, 95% CI: 17.4-21.6%, respectively, at 24 months (hazard ratio = 1.67, 95% CI: 1.46-1.90; p < 0.001)]. CONCLUSIONS: Failed pillbox return was associated with a higher risk of being LTFU and could be used as a simple tool to identify PLHIV for appropriate interventions to reduce their chance of being LTFU

Як уникнути підйому рівня води?

East Africa’s Lake Victoria provides resources and services to millions of people on the lake’s shores and abroad. In particular, the lake’s fisheries are an important source of protein, employment, and international economic connections for the whole region. Nonetheless, stock dynamics are poorly understood and currently unpredictable. Furthermore, fishery dynamics are intricately connected to other supporting services of the lake as well as to lakeshore societies and economies. Much research has been carried out piecemeal on different aspects of Lake Victoria’s system; e.g., societies, biodiversity, fisheries, and eutrophication. However, to disentangle drivers and dynamics of change in this complex system, we need to put these pieces together and analyze the system as a whole. We did so by first building a qualitative model of the lake’s social-ecological system. We then investigated the model system through a qualitative loop analysis, and finally examined effects of changes on the system state and structure. The model and its contextual analysis allowed us to investigate system-wide chain reactions resulting from disturbances. Importantly, we built a tool that can be used to analyze the cascading effects of management options and establish the requirements for their success. We found that high connectedness of the system at the exploitation level, through fisheries having multiple target stocks, can increase the stocks’ vulnerability to exploitation but reduce society’s vulnerability to variability in individual stocks. We describe how there are multiple pathways to any change in the system, which makes it difficult to identify the root cause of changes but also broadens the management toolkit. Also, we illustrate how nutrient enrichment is not a self-regulating process, and that explicit management is necessary to halt or reverse eutrophication. This model is simple and usable to assess system-wide effects of management policies, and can serve as a paving stone for future quantitative analyses of system dynamics at local scales

Public policy, health system, and community actions against illness as platforms for response to NCDs in Tanzania: a narrative review

This review was supported by grants from the Netherlands Organization for International Co-operation in Higher Education and the Ifakara Health Institute, Tanzania

STUDY PROTOCOL: Improving newborn survival in rural southern Tanzania: a cluster-randomised trial to evaluate the impact of a scaleable package of interventions at community level with health system strengthening

Child mortality has declined substantially in many countries including Tanzania, but newborn mortality remains high and around 3 million babies die every year in the first 28 days of life. Community-based approaches with home visits in the first week of life have shown great potential to reduce newborn mortality. INSIST aimed1 to develop, implement and evaluate an integrated, two-part strategy that combines interventions at community level with health system strengthening in rural Southern Tanzania to reduce newborn mortality. The community intervention focused around interpersonal communication through home visits in pregnancy and the early neonatal period by a village-based “agent of change”. Key messages focused on hygiene during delivery, immediate and exclusive breastfeeding, and identification and extra care for babies born small because of low birth weight or prematurity. Extra care for babies born small included skin-to-skin care for small babies and referral to hospital for very small babies. The community intervention was implemented in six poor rural districts in Southern Tanzania, with 65 of the 132 wards within these districts randomized to receive the community intervention. In addition, a health system quality-improvement package was implemented in all health facilities of one district. Data collection for the evaluation included i) a baseline household survey in 2007 of all 243,000 households in 5 of the 6 study districts to estimate baseline mortality and prevalence of newborn care behaviours, ii) an adequacy survey in 2011 in a representative sample of 5,000 households to estimate coverage of home visits and prevalence of newborn care behaviours, and iii) an endline household survey in 2013 in a representative sample of 200,000 households to estimate newborn and maternal mortality and prevalence of newborn care behaviours. The final analysis was based on “intention to treat”, comparing newbor