Social Cognitive Determinants of HIV Voluntary Counselling and Testing Uptake among Married Individuals in Dar es Salaam Tanzania: Theory of Planned Behaviour (TPB)

Cumulative evidence indicates increasing HIV infection among married individuals. Voluntary Counselling and Testing for HIV (HCT) is known to be an effective intervention to induce safer sex behaviour and access to early treatment, care and support among married individuals, which are important for HIV prevention. In this context, knowledge of factors associated with HCT uptake among married individuals is critical in promoting the use of the services. This study therefore intended to identify the social cognitive factors associated with acceptance of HCT among married individuals. In a cross-sectional analytical study face to face questionnaires were administered among 200 randomly selected married individuals in Kinondoni district, Dar es Salaam Tanzania. The questionnaire included self-reported HCT, socio-demographic variables and social cognitive variables (attitude, subjective norms, perceived control and perceived risk). Logistic regression was used to identify the independent association of social cognitive predictors of HCT among married individuals. Nearly half (42%) of the respondents had never had HCT. Of the social cognitive constructs, the strongest predictor of HCT uptake was attitude (OR per additional score point = 1.07, 95% CI 1.04-1.10) followed by perceived behavioural control (OR = 1.04, 95% CI 1.02-1.06). Subjective norm and perceived risk were not associated with HCT uptake. Public health interventions targeting married individuals should be designed to enhance their positive attitude towards HCT and empower them to overcome barriers to the use of the services

Adherence to artemether/lumefantrine treatment in children under real-life situations in rural Tanzania.

A follow-up study was conducted to determine the magnitude of and factors related to adherence to artemether/lumefantrine (ALu) treatment in rural settings in Tanzania. Children in five villages of Kilosa District treated at health facilities were followed-up at their homes on Day 7 after the first dose of ALu. For those found to be positive using a rapid diagnostic test for malaria and treated with ALu, their caretakers were interviewed on drug administration habits. In addition, capillary blood samples were collected on Day 7 to determine lumefantrine concentrations. The majority of children (392/444; 88.3%) were reported to have received all doses, in time. Non-adherence was due to untimeliness rather than missing doses and was highest for the last two doses. No significant difference was found between blood lumefantrine concentrations among adherent (median 286 nmol/l) and non-adherent [median 261 nmol/l; range 25 nmol/l (limit of quantification) to 9318 nmol/l]. Children from less poor households were more likely to adhere to therapy than the poor [odds ratio (OR)=2.45, 95% CI 1.35-4.45; adjusted OR=2.23, 95% CI 1.20-4.13]. The high reported rate of adherence to ALu in rural areas is encouraging and needs to be preserved to reduce the risk of emergence of resistant strains. The age-based dosage schedule and lack of adherence to ALu treatment guidelines by health facility staff may explain both the huge variability in observed lumefantrine concentrations and the lack of difference in concentrations between the two groups

Intimate Partner Violence and Challenges Facing Women Living with HIV/AIDS in Accessing Antiretroviral Treatment at Singida Regional Hospital, Central Tanzania.

Human immunodeficiency virus (HIV) remains a global public health problem. Sub-Saharan Africa is the region most affected by HIV/AIDS in the world. Globally, and in Tanzania in particular, women are more affected by HIV/AIDS than men. Tanzania has been reported to be among the countries with the highest burden of intimate partner violence (IPV). This study explored the challenges facing women living with HIV/AIDS (LWHA) attending the care and treatment clinic (CTC) in Singida Regional Hospital in Tanzania. A qualitative study was performed in which data were collected through in-depth interviews with 35 women LWHA who also experienced IPV. Content analysis was used to analyse the data. The study findings showed that women LWHA experienced challenges from their male partners in the form of lack of fare to attend CTC, delayed attendance to CTC, verbal threats and intimidation, mistrust partner resulting in changed antiretroviral (ARV) dosing time. Also, systemic challenges such as malfunction of CD4 count testing apparatus contributed to mistrust from their male partners which led to IPV. In this study, women LWHA experienced IPV challenges that resulted in poor adherence to ARV medication and CTC attendance, as well as insufficient time to collect ARV medication. It is recommended that the government address systemic challenges faced by women LWHA, introduce multiple approaches to address the needs of women LWHA experiencing IPV, and develop strong policies to prevent IPV against women in Tanzania, regardless of their HIV status

Perceptions About Repeat HIV Testing in an Incidence Study: A Qualitative Study among a Potential Cohort for HIV Vaccine Trials in Dar es Salaam, Tanzania

Information regarding repeat HIV testing is useful in the conduct of HIV vaccine trials as potential trial participants are required to undergo repeat HIV testing. In an incidence study conducted in 2008 among 1042 Police Officers 30% of them did not participate in a repeat HIV test. This study was therefore conducted to explore perceptions on repeat HIV testing among members of the incidence study cohort that also served as a source of volunteers for subsequent HIV vaccine trials. This qualitative cross-sectional study was conducted in Dar es Salaam. The study included male and female Police Officers who were eligible to participate in the HIV incidence study. Participants were selected purposefully from eight Police stations out of the 32 stations. Data was collected using in-depth interviews and analysed qualitatively using the content analysis approach. A majority of participants were willing to undergo a repeat HIV test and stated that it was important to repeat an HIV test to confirm their health status, and hence continue protecting themselves. Participants who participated in a repeat HIV test as a part of incidence study reported that the repeat HIV testing process was acceptable because counselling was provided, testing was voluntary, there was trust in the health care providers and a freedom to choose where to test. Participants who did not repeat the HIV test held that repeat a HIV test was not necessary since they believed that the initial test was adequate. Others said that communication breakdown was the main cause as they weren't aware of the importance of a repeat HIV test. Fear of the test results was also mentioned as one of the reasons. The participants were eager to gain more knowledge about the importance of a repeat HIV test. In order to facilitate repeat HIV testing in potential cohorts for HIV vaccine trials, more information and education regarding the repeat HIV test is needed. It is also important to make sure that researchers are well informed on what study participants are supposed to know.\u

A qualitative study of discourses on heterosexual anal sexual practice among key, and general populations in Tanzania: implications for HIV prevention.

BACKGROUND: The risk of contracting HIV through heterosexual anal sex (HAS) is significantly higher than from vaginal intercourse. Little has been done to understand the discourses around HAS and terms people use to describe the practice in Tanzania. A better understanding of discourses on HAS would offer useful insights for measurement of the practice as well as designing appropriate interventions to minimise the risks inherent in the practice. METHODS: This study employed qualitative approaches involving 24 focus group discussions and 81 in-depth interviews. The study was conducted in 4 regions of Tanzania, and included samples from the general population and among key population groups (fishermen, truck drivers, sex workers, food and recreational facilities workers). Discourse analysis was conducted with the aid of NVIVO versions 8 and 10 software. RESULTS: Six discourses were delineated in relation to how people talked about HAS. Secrecy versus openness discourse describes the terms used when talking about HAS. "Other" discourse involved participants' perception of HAS as something practiced by others unrelated to them and outside their communities. Acceptability/trendiness discourse: young women described HAS as something trendy and increasingly gaining acceptability in their communities. Materiality discourse: describes HAS as a practice that was more profitable than vaginal sex. Masculinity discourse involved discussions on men proving their manhood by engaging in HAS especially when women initiated the practice. Masculine attitudes were also reflected in how men described the practice using a language that would be considered crude. Public health discourse: describes HAS as riskier for HIV infection than vaginal sex. The reported use of condoms was low due to the perceptions that condoms were unsuitable for anal sex, but also perceptions among some participants that anal sex was safer than vaginal sex. CONCLUSION: Discourses among young women and adult men across the study populations were supportive of HAS. These findings provide useful insights in understanding how different population groups talked about HAS and offer a range of terms that interventions and further research on magnitude of HAS could draw on when addressing health risks of HAS among different study populations

Factors influencing adherence to referral advice following pre-referral treatment with artesunate suppositories in children in rural Tanzania

Objective: WHO recommends artemisinin suppository formulations as pre-referral treatment for children who are unable to take oral medication and cannot rapidly reach a facility for parenteral treatment. We investigated factors influencing caretakers’ adherence to referral advice following pre-referral treatment of their children with rectal artesunate suppositories. Methods: The study was nested within an intervention study that involved pre-referral treatment of all children who came to a community dispenser for treatment because they were unable to take oral medications because of repeated vomiting, lethargy, convulsions or altered consciousness. All patients who did not comply with referral advice were stratified by actions taken post-referral: taking their children to a drug shop, a traditional healer, or not seeking further treatment, and added to a random selection of patients who complied with referral advice. Caretakers of the children were interviewed about their socio-economic status (SES), knowledge about malaria, referral advice given and actions they took following pre-referral treatment. Interview data for 587 caretakers were matched with symptoms of the children, the time of treatment, arrival at a health facility or other actions taken post–pre-referral treatment. Results: The majority (93.5%) of caretakers reported being given referral advice by the community drug dispenser. The odds of adherence with this advice were three times greater for children with altered consciousness and/or convulsions than for children with other symptoms [odds ratio (OR) 3.47, 95% confidence interval (CI) 2.32–5.17, P \u3c 0.001]. When questioned, caretakers who remembered when (OR 2.19, 95% CI 1.48–3.23, P \u3c 0.001) and why (OR 1.77, 95% CI 1.07–2.95, P = 0.026) they were advised to proceed to health facility – were more likely to follow referral advice. Cost did not influence adherence except within a catchment area of facilities that charged for services. In these areas, costs deterred adherence by four to five times for those who had previously paid for laboratory services (OR = 0.25, 95% CI: 0.09–0.67, P = 0.006) or consultation (OR 0.20, 95% CI: 0.06–0.61, P = 0.005) compared with those who had not. Conclusion: When given referral advice, caretakers of patients with life-threatening symptoms adhere to referral advice more readily than other caretakers. Health service charges deter adherence

The Challenges of Developing an Instrument to Assess Health Provider Motivation at Primary Care Level in Rural Burkina Faso, Ghana and Tanzania.

The quality of health care depends on the competence and motivation of the health workers that provide it. In the West, several tools exist to measure worker motivation, and some have been applied to the health sector. However, none have been validated for use in sub-Saharan Africa. The complexity of such tools has also led to concerns about their application at primary care level. To develop a common instrument to monitor any changes in maternal and neonatal health (MNH) care provider motivation resulting from the introduction of pilot interventions in rural, primary level facilities in Ghana, Burkina Faso, and Tanzania. Initially, a conceptual framework was developed. Based upon this, a literature review and preliminary qualitative research, an English-language instrument was developed and validated in an iterative process with experts from the three countries involved. The instrument was then piloted in Ghana. Reliability testing and exploratory factor analysis were used to produce a final, parsimonious version. This paper describes the actual process of developing the instrument. Consequently, the concepts and items that did not perform well psychometrically at pre-test are first presented and discussed. The final version of the instrument, which comprises 42 items for self-assessment and eight for peer-assessment, is then shown. This is followed by a presentation and discussion of the findings from first use of the instrument with MNH providers from 12 rural, primary level facilities in each of the three countries. It is possible to undertake work of this nature at primary health care level, particularly if the instruments are kept as straightforward as possible and well introduced. However, their development requires very lengthy preparatory periods. The effort needed to adapt such instruments for use in different countries within the region of sub-Saharan Africa should not be underestimated

Health workers' experiences of implementation of Helping Mothers Survive Bleeding after Birth training in Tanzania: a process evaluation using the i-PARIHS framework

BACKGROUND: In-service training, including the competency-based Helping Mothers Survive Bleeding After Birth (HMS BAB) is widely implemented to improve the quality of maternal health services. To better understand how this specific training responds to the needs of providers and fits into the existing health systems, we explored health workers' experiences of the HMS BAB training. METHODS: Our qualitative process evaluation was done as part of an effectiveness trial and included eight focus group discussions with 51 healthcare workers in the four districts which were part of the HMS BAB trial. We employed deductive content analysis informed by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) construct of context, recipients, innovation and facilitation. RESULTS: Overall, health workers reported positive experiences with the training content and how it was delivered. They are perceived to have improved competencies leading to improved health outcomes. Interviews proposed that peer practice coordinators require more support to sustain the weekly practices. Competing tasks within the facility in the context of limited time and human resources hindered the sustainability of weekly practices. Most health facilities had outlined the procedure for routine learning environments; however, these were not well operational. CONCLUSION: The HMS BAB training has great potential to improve health workers' competencies around the time of childbirth and maternal outcomes. Challenges to successful implementation include balancing the intervention within the routine facility setting, staff motivation and workplace cultures

Managing malaria in under-fives : Prompt access, adherence to treatment and referral in rural Tanzania

Background: Nearly a million people die of malaria each year, the majority are children in rural African settings. These deaths could be reduced if children had prompt access to artemisinin-based combination therapy (ACTs), demonstrated adherence to treatment and to referral advice for severe malaria. However, health systems are weak to deliver the interventions. Although many African countries, including Tanzania, changed malaria treatment policy to ACTs in the last decade, few children reportedly get prompt access to ACTs. Main aim: To determine factors influencing prompt access to effective antimalarials; adherence to treatment schedules and to referral advice among children under five, in rural settings. Methods: Community-based studies were conducted in rural villages in Kilosa (I,II) and Mtwara rural (II,IV) districts, in Tanzania. Study I and II were prospective designed while study III and IV were nested in a community-based rectal-artesunate deployment intervention study. In study I, a total of 1,235 children from 12 randomly selected villages were followed up for six months. Caretakers of children reported to have fever were interviewed at home about the type and source of treatment using a questionnaire. In study II, all children (3918) in five selected villages were followed-up for 12 months, to determine adherence to treatment when they had malaria, diagnosed using Rapid Diagnostic Test (RDT) and treated with artemether-lumefantrine (ALu). In study III, 587 children who received pre-referral rectal artesunate during the deployment study were traced home and caretakers interviewed on a number of factors likely to influence adherence to referral advice, using a questionnaire. Study IV was qualitative, 12 focus group discussions were conducted in three purposively selected villages to explore reasons for non-adherence to referral advice. Results: Only one-third (37.6%) of febrile children had prompt access to ALu, the recommended ACTs in Tanzania, mainland (I). Lack of prompt access was mostly (>80 percent) attributed to receiving non-recommended drugs. Less than half of the febrile children were taken to government facilities, where they were 17-times more likely to have prompt access compared to those who went elsewhere. Less than 10% (41/607) of febrile children had access to ALu (I) from faith-based organisation facilities and accredited drug dispensing outlets, despite having subsidized ALu. Reported adherence to treatment schedules was high (>80 percent) and non-adherence was attributed mainly to untimely dosing, rather than taking a fewer number of doses (II). While social economic status influenced prompt access to ALu and adherence to treatment, basic education did not (I, II). Caretakers of children with altered consciousness and convulsion were almost 4-times more likely to adhere to referral advice than those whose children had less severe symptoms (III). They seemed to weigh child condition against obstacles to accessing care at health facilities, if the condition was less severe prior to or improved after rectal artesunate dose, caretakers were likely to be deterred from adhering to referral advice (IV). Detailed understanding of provider’s advice was likely to lead to adherence to the treatment schedule (II) and to referral advice (III, IV). Conclusion: This thesis has shown that once a child had access to ALu, caretakers were likely to adhere to treatment schedule; and to referral advice, if child had severe symptoms or not improved after pre-referral treatment. More efforts should therefore be directed towards increasing access to ALu by strengthening the public health sector to reach rural remote areas. A wide coverage in prompt access to ALu will also reduce the need for the rectal artesunate strateg

Training in the art and science of facilitation to scale research mentor training in low and middle income countries

Advancing biomedical research in low and middle income countries (LMICs) to expand the capacity for LMICs to integrate biomedical research into their health care systems and education has been the focus of many programs in global health over the past two decades. Central to the success of these programs is effective research mentoring, characterized by academic, career and psychosocial support through culturally appropriate practices. Research mentoring is a learned skill, developed through training, mutual discussions, practice and feedback. The majority of extant training programs are designed and delivered by US partners, so the next stage in building capacity is to train facilitators within the LMIC partner institutions to contextualize and advance mentoring specifically within their cultural and institutional norms by co-developing, delivering and evaluating semi-annual research mentoring training. To this end, we describe the development, delivery and outcome evaluation of a 5-week course in the art and skill of facilitation. Care was taken to explicitly distinguish between concepts of “teaching” and “facilitation,” since “teaching” is closely connected to a transmission or banking model of education, which is characterized by “top-down,” hierarchical relationship. The course discussed power and positionality, themes that resonate with partners in Nigeria and Tanzania. These themes provided unique entry into deeper conversations core to advancing mentoring practice away from the traditional dyadic power structure that remains from colonization. Evaluation findings indicate significant advances in awareness of differences between teaching and facilitating, increased confidence in facilitation skills, especially in the area of structured planning and organization, as well as improved communication and interpersonal skills. All respondents felt that students in Nigeria and Tanzania would respond well to the facilitation approach conveyed during the course and they found value in participating in the course as a cohort