Search

Background: Data entry at the point of collection using mobile electronic devices may make data-handling processes more efficient and cost-effective, but there is little literature to document and quantify gains, especially for longitudinal surveillance systems. Objective: To examine the potential of mobile electronic devices compared with paper-based tools in health data collection. Methods: Using data from 961 households from the Rufiji Household and Demographic Survey in Tanzania, the quality and costs of data collected on paper forms and electronic devices were compared. We also documented, using qualitative approaches, field workers, whom we called ‘enumerators’, and households’ members on the use of both methods. Existing administrative records were combined with logistics expenditure measured directly from comparison households to approximate annual costs per 1,000 households surveyed. Results: Errors were detected in 17% (166) of households for the paper records and 2% (15) for the electronic records (p < 0.001). There were differences in the types of errors (p = 0.03). Of the errors occurring, a higher proportion were due to accuracy in paper surveys (79%, 95% CI: 72%, 86%) compared with electronic surveys (58%, 95% CI: 29%, 87%). Errors in electronic surveys were more likely to be related to completeness (32%, 95% CI 12%, 56%) than in paper surveys (11%, 95% CI: 7%, 17%).The median duration of the interviews (‘enumeration’), per household was 9.4 minutes (90% central range 6.4, 12.2) for paper and 8.3 (6.1, 12.0) for electronic surveys (p = 0.001). Surveys using electronic tools, compared with paper-based tools, were less costly by 28% for recurrent and 19% for total costs. Although there were technical problems with electronic devices, there was good acceptance of both methods by enumerators and members of the community. Conclusions: Our findings support the use of mobile electronic devices for large-scale longitudinal surveys in resource-limited settings. [ABSTRACT FROM PUBLISHER]

Strengthening surgical services in resource-constrained settings is contingent on using high-quality data to inform decision making at clinical, facility, and policy levels. However, the evidence is sparse on gaps in paper-based medical record quality for surgical and obstetric patients in low-resource settings. We aim to examine surgical and obstetric patient medical record data quality in health facilities as part of a surgical system strengthening initiative in northern Tanzania. To measure the incidence of Surgical Site Infections (SSIs), sepsis and maternal sepsis surgical and obstetric inpatients were followed prospectively, over three months in ten primary, district, and regional health facilities in northern Tanzania. Between April 22nd to May 1st, 2018, we retrospectively reviewed paper-based medical records of surgical and obstetric patients diagnosed with SSIs, post-operative sepsis, and maternal sepsis in the three-month follow-up period. A data quality assessment tool with18 data elements related to documentation of SSIs and sepsis diagnosis, their respective symptoms and vital signs, inpatient daily monitoring indicators, and demographic information was developed and used to assess the completeness of patient medical records. Among the 157 patients diagnosed with SSI and sepsis, we found and reviewed 68% of all medical records. Among records reviewed, approximately one third (34%) and one quarter (23%) included documentation of SSI and sepsis diagnoses, respectively. 6% of reviewed records included documentation of all SSI and sepsis diagnoses, symptoms and vital signs, inpatient daily monitoring indicators, and demographic data. Strengthening data quality and record-keeping is essential for surgical team communication, continuity of care, and patient safety, especially in low resource settings where paper-based records are the primary means of data collection. High-quality primary health information provides facilities with actionable data for improving surgical and obstetric care quality at the facility level. [ABSTRACT FROM AUTHOR]

This paper reports on the design of a study to examine the policy landscape relevant to sugar-sweetened beverage taxation in seven sub-Saharan African countries. The study responds to the need for strong policy to address the rising burden of non-communicable diseases in the region. Sugar-sweetened beverage taxation has been widely recommended as a key component of a comprehensive policy approach to NCD prevention. However, it has proved a contentious policy intervention, with industry strongly opposing the introduction of such taxes. The aim was to identify opportunities to strengthen sugar-sweetened beverage taxation- related policy for the prevention of nutrition-related NCDs in a subset of Eastern and Southern African countries: Kenya, Tanzania, Botswana, Rwanda, Namibia, Zambia, Uganda. The study was conducted as a collaboration by researchers from nine institutions; including the seven study countries, South Africa, and Australia. The research protocol was collaboratively developed, drawing on theories of the policy process to examine the existing availability of evidence, policy context, and stakeholder interests and influence. This paper describes the development of a method for a policy landscape analysis to strengthen policies relevant to NCD prevention, and specifically sugar-sweetened beverage taxation. This takes the form of a prospective policy analysis, based on systematic documentary analysis supplemented by consultations with policy actors, that is feasible in low resource settings. Data were collected from policy documents, government and industry reports, survey documentation, webpages, and academic literature. Consultations were conducted to verify the completeness of the policy-relevant data collection. We analysed the frames and beliefs regarding the policy 'problems', the existing policy context and understandings of sugar-sweetened beverage taxation as a potential policy intervention, and the political context across relevant sectors, including industry interests and influence in the policy process. This study design will provide insights to inform public health action to support sugar- sweetened beverage taxation in the region. [ABSTRACT FROM AUTHOR]

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study's programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants' motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation. [ABSTRACT FROM AUTHOR]

Adolescents in Tanzania are at risk of many health problems attributed to limited access to quality sexual and reproductive health services. Health professionals are a crucial part of service delivery, and their perspective on providing care is important in understanding the barriers that hamper access to sexual and reproductive health services for adolescents. Better understanding these barriers will support the development of more effective interventions. This paper explores these perspectives in view of the health-policy context that surrounds them. This study has aimed to explore and understand health professionals' perceptions and attitudes regarding the provision of adolescent sexual and reproductive health care in a selected national sexual and reproductive health programme in the Arusha region and Kilimanjaro region, Tanzania. A qualitative cross-sectional interview design was applied. Sixteen in-depth interviews were conducted with health professionals and community health workers. Data was analysed following inductive thematic analysis. Four main themes are identified in the data: concern about the stigma directed towards adolescents; over-medicalisation of services; difficulty involving adolescent males; and ambiguous policies and contradictory messages. The findings suggest that health professionals providing care in the current adolescent sexual and reproductive health programme must navigate the legacy of vertical health programmes as well as contradicting views and messages that are influenced by social norms, by uncertainties about current laws and by statements from political leaders. The findings suggest that future research, policies and health programmes should consider the perspectives of health professionals and their challenges in delivering care for adolescents to help improve the understanding of how to effectively and sensitively implement sexual and reproductive health programmes for adolescents. [ABSTRACT FROM AUTHOR]

Background: Community participation can provide increased understanding and more effective implementation of strategies that seek to improve outcomes for women and newborns. There is limited knowledge on how participatory processes take place and how this affects the results of an intervention. Objective: This paper presents the results of two years of implementing (2013–2015) community groups for maternal health care in Magu District, Tanzania. Method: A total of 102 community groups were established, and 77 completed the four phases of the participatory learning and action cycle. The four phases included identification of problems during pregnancy and childbirth (phase 1), deciding on solutions and planning strategies (phase 2), implementation of strategies (phase 3) and evaluation of impact (phase 4). Community group meetings were facilitated by 15 trained facilitators and groups met monthly in their respective villages. Data was collected as an ongoing process from facilitator and meeting reports, through interviews with facilitators and local leaders and from focus group discussions with community group participants. Results: The majority of groups prioritized problems related to the availability of and accessibility to health services. The most commonly actioned solution was the provision of health education to the community. Almost all groups (95%) experienced a positive impact on the community as results of their actions, including increased maternal health knowledge and positive behaviour changes among health care workers. Facilitators were positive about the community groups, stating that they were grateful for the gained knowledge on maternal health, and positively regarded the involvement of men in community groups, which are traditionally women-only. Conclusion: The process of establishing and undertaking community groups in itself appeared to have a positive perceived impact on the community. However, sustained behaviour change, power dynamics and financial incentives need to be carefully considered during implementation and sustaining the community groups. [ABSTRACT FROM AUTHOR]

The ideal approach for calculating effective coverage of health services using ecological linking requires accounting for variability in facility readiness to provide health services and patient volume by incorporating adjustments for facility type into estimates of facility readiness and weighting facility readiness estimates by service-specific caseload. The aim of this study is to compare the ideal caseload-weighted facility readiness approach to two alternative approaches: (1) facility-weighted readiness and (2) observation-weighted readiness to assess the suitability of each as a proxy for caseload-weighted facility readiness. We utilised the 2014–2015 Tanzania Service Provision Assessment along with routine health information system data to calculate facility readiness estimates using the three approaches. We then conducted equivalence testing, using the caseload-weighted estimates as the ideal approach and comparing with the facility-weighted estimates and observation-weighted estimates to test for equivalence. Comparing the facility-weighted readiness estimates to the caseload-weighted readiness estimates, we found that 58% of the estimates met the requirements for equivalence. In addition, the facility-weighted readiness estimates consistently underestimated, by a small percentage, facility readiness as compared to the caseload-weighted readiness estimates. Comparing the observation-weighted readiness estimates to the caseload-weighted readiness estimates, we found that 64% of the estimates met the requirements for equivalence. We found that, in this setting, both facility-weighted readiness and observation-weighted readiness may be reasonable proxies for caseload-weighted readiness. However, in a setting with more variability in facility readiness or larger differences in facility readiness between low caseload and high caseload facilities, the observation-weighted approach would be a better option than the facility-weighted approach. While the methods compared showed equivalence, our results suggest that selecting the best method for weighting readiness estimates will require assessing data availability alongside knowledge of the country context. [ABSTRACT FROM AUTHOR]

Although alcohol consumption is a well-known risk factor for intimate partner violence (IPV) perpetration, few studies have been conducted among young males in low- and middle-income countries. Alcohol consumption and IPV are both complex phenomena, whose association requires more in-depth exploration regarding drinking patterns and the alcohol-related manifestation of five different forms of IPV. In this study, we sought to explore the relationship between alcohol use and IPV in young Tanzanian men and to identify differences in the magnitude of past-year IPV perpetration among alcohol drinkers and abstainers. Furthermore, we aimed to assess the association between various drinking patterns with the perpetration of different forms of IPV. A cross-sectional survey of 1002 young males residing in Mwanza, Tanzania, was conducted in 2021–2022. Data on alcohol consumption were collected using the alcohol use disorder identification test. IPV perpetration was assessed using an index total of 19 items on acts of physical, sexual, economic, emotional abuse, and controlling behaviour. Logistic regression models were conducted to estimate the relationship between alcohol use and the perpetration of each form of IPV. Among partnered respondents currently consuming alcohol (n = 189, 18.8%), the most and the least prevalent IPV forms in the past 12 months were controlling behaviour (84.1%) and physical IPV (25.4%), respectively. Those reporting recent alcohol consumption reported higher rates of all forms of past-year IPV perpetration compared to abstainers. While no form of IPV was associated with low-risk consumption versus abstention, all forms of IPV were associated with hazardous drinking. Young men who drink alcohol, especially those drinking hazardously, are also more likely to report perpetrating IPV. An understanding of the different drinking patterns and manifestations of forms of IPV can contribute to better-tailored alcohol-related interventions and has the potential to improve young adults' health and reduce IPV perpetration. [ABSTRACT FROM AUTHOR]

Routinely collected clinic data have the potential to provide much needed information on the uptake of services to prevent mother-to-child transmission (PMTCT) of HIV, and to measure HIV prevalence in pregnant women. This article describes the methodological challenges associated with using such data, based on the experiences of researchers and programme implementers in Tanzania and drawing from other examples from East Africa. PMTCT data are routinely collected in maternal and child health (MCH) clinics in East Africa using paper-based registers corresponding to distinct services within the PMTCT service continuum. This format has inherent limitations with respect to maintaining and accurately recording unique identifiers that can link patients across the different clinics (antenatal, delivery, child), and also poses challenges when compiling aggregate data. Recent improvements to recording systems include assigning unique identifiers to HIV-positive pregnant women in MCH clinics, although this should ideally be extended to all pregnant women, and recording mother and infant identifiers alongside each other in registers. The use of 'health passports', as in Malawi, which maintains the same antenatal clinic identifier over time, also holds promise. Routine data hold tremendous potential for clinic-level patient management, surveillance, and evaluating PMTCT/MCH programmes. Linking clinic data to community research datasets can also provide population-level estimates of coverage with PMTCT services, currently a problematic but vital statistic for monitoring programme performance and negotiating donor funding. Enhancements to indexing and recording of routine PMTCT/MCH data are needed if we are to capitalise on this rich data source. [ABSTRACT FROM AUTHOR]

Background: Maternal and infant mortality rates in Tanzania have decreased over the past decades, but remain high. One of the challenges the country faces, is the lack of skilled health care workers. High fertility rates make midwives and their patients particularly susceptible to stress as a result of understaffing. Objective: This paper explores the challenges midwives face in their day-to-day practice at a regional referral hospital in Tanzania, and investigates which measures the midwives themselves find necessary to implement to improve their situation. Methods: A qualitative study design with focus group discussions (FGDs) was employed to explore which challenges the midwives experienced. Each focus group consisted of five to six midwives. A FGD topic guide covering challenges, consequences, motivation, ideal situation and possible solutions was used. These data were analyzed using Systematic Text Condensation. Results: A total of 28 Midwives, six men and 22 women, participated in five FGDs. Four categories emerged from the collected material: Feelings of demoralization, shortage of resources, societal challenges and personal struggles. A feeling of demoralization was especially prevalent and was caused by a lack of support from the leaders and little appreciation from the patients. Shortage of resources, and shortage of personnel in particular, was also highlighted as it led to an excessive workload resulting in difficulties with providing adequate care. These difficulties were intensified by lack of equipment, facilities and a non-optimal organization of the healthcare system. Conclusion: The challenges revealed during the FGDs prevent the midwives from providing sufficient midwifery care. To improve the situation, measures such as supportive leadership, reduction of workload, increasing availability of equipment and increasing knowledge of reproductive health in society, should be taken. [ABSTRACT FROM AUTHOR]

Population-based intervention coverage data are used to inform the design of projects, programs, and policies and to evaluate their impact. In low- and middle-income countries (LMICs), household surveys are the primary source of coverage data. Many coverage surveys are implemented by organizations with limited experience or resources in population-based data collection. We developed a streamlined survey and set of supporting materials to facilitate rigorous survey design and implementation. The RADAR coverage survey tool aimed to 1) rigorously measure priority reproductive, maternal, newborn, child health & nutrition coverage indicators, and allow for equity and gender analyses; 2) use standard, valid questions, to the extent possible; 3) be as light as possible; 4) be flexible to address users' needs; and 5) be compatible with the Lives Saved Tool for analysis of program impact. Early interactions with stakeholders also highlighted survey planning, implementation, and analysis as challenging areas. We therefore developed a suite of resources to support implementers in these areas. The toolkit was piloted by implementers in Tanzania and in Burkina Faso. Although the toolkit was successfully implemented in these settings and facilitated survey planning and implementation, we found that implementers must still have access to sufficient resources, time, and technical expertise in order to use the tool appropriately. This potentially limits the use of the tool to situations where high-quality surveys or evaluations have been prioritized and adequately resourced. [ABSTRACT FROM AUTHOR]

Diabetes mellitus (DM) is a common comorbidity among people with tuberculosis (TB). Despite the availability of guidelines on how to integrate dual TB/DM in Tanzania, the practice of integration at various healthcare levels is unclear. To explore the participants' experiences and perceptions on the pathway towards clinical management of dual TB/DM. The research was carried out in Dar es Salaam, Iringa, and Kilimanjaro regions between January and February 2020. A qualitative, in-depth interview approach was used to collect participants' experiences and perspectives on the acquisition of dual TB/DM services at various levels of healthcare facilities. The information gathered were coded and classified thematically. The participants' perception of TB services within the healthcare facilities was positive due to the support they received from the healthcare providers. On the other hand, participants reported difficulty receiving management in various health facilities for each condition in terms of access to dual TB/DM care and access to DM medication. This was viewed as a significant challenge for the participants with dual TB/DM. The current disjunction and disruption in healthcare for people with dual TB/DM makes it difficult to access services at various levels of health facilities. For optimal clinical management for people with dual TB/DM, patient-centered strategies and integrated approaches are urgently needed. [ABSTRACT FROM AUTHOR]

In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed. Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania. A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used 'wedge sampling' protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the 'Real Accountability: Data Analysis for Results Coverage Survey to women 15–49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD. Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [−0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019. Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved. [ABSTRACT FROM AUTHOR]

Despite improvements in educational opportunities, policy changes, and pay raises in the nursing and midwifery professions in East Africa, poor working conditions, few professional development opportunities, and a general lack of respect for these professions predominate. These issues contribute to a low quality of care among a population with a high burden of communicable diseases. Health professional associations may help to address these challenges by providing a voice for nurses and midwives. This study evaluated the impact of a 5-year programme focused on strengthening nurses' and midwives' professional associations in East Africa. This study used a mixed methods design. Quantitative, cross-sectional descriptive data were captured via surveys (n = 1,266) distributed to association members. In-depth interviews (n = 65) were used to obtain qualitative data and complement the survey responses. Quantitative and qualitative data collection occurred concurrently. The results were compared to assess the impact of the programme across Uganda, Kenya, and Tanzania. The programme successfully built capacity in four of five organisational capacity areas: resource mobilisation, financial management, strategy, and monitoring and evaluation. Marketing and communications, the fifth targeted area, did not show improvement. Capacity in both research and service delivery was also improved, despite the programme not providing training in these areas. In addition, collaboration among associations and their members was improved. These results support existing evidence on the impact of capacity building among professional nursing associations and coincide with the World Health Organization's objectives for nursing. Future capacity building programmes should consider replicating the successful activities from this programme and investigate ways to reach more rural branches and provide tailored content. This study contributes to a small but growing body of knowledge that supports capacity building among the African health workforce. [ABSTRACT FROM AUTHOR]

Adolescent pregnancy and associated neonatal mortality are major global health challenges. In low-income settings where 90% of the 21 million global adolescent pregnancies occur, half are unintended and a fifth experience unsafe abortion. In Kenya, Uganda, and Tanzania, the survival patterns of neonates born to adolescents are unclear. To assess survival patterns among neonates born to adolescents and the effect of pregnancy intentions and marital status on survival in Kenya, Uganda, and Tanzania. Cross-sectional data from demographic and health surveys in Kenya, Uganda, and Tanzania 2014–2016 were used. Kaplan-Meier estimates investigated patterns of neonatal survival among adolescent mothers, aged 15–19 years, compared to mothers aged 20–29 years. Cox proportional hazards regression determined the hazard ratios (HR) for the predictors of neonatal survival. About 50% of adolescent pregnancies were unintended and neonatal death rate was twice as high than older mothers (26.6 versus 12.0 deaths/1000 live births). The median survival time was two days for adolescent-born babies and four days among older mothers. The hazard of death for all adolescent-born neonates was about twofold that of 20–29 years-old-mothers, HR 1.80 (95% CI 1.22–2.63). Among married adolescents with unintended newborn pregnancies, the HR was 4-folds higher than corresponding older mothers, HR 4.08 (95% CI 1.62–10.31). Among married, primiparous adolescents with unintended pregnancies, the HR was six times higher than corresponding older mothers. Our findings reveal how unintended pregnancies and deaths of neonates born to adolescents contribute substantially to preventable neonatal deaths in East Africa. Full implementation of existing adolescent health policies and utilization of contraceptives should be ensured. Partnership with youths and novel efforts that address sociocultural norms to reduce adolescent pregnancies or marriage should be supported. Regulations requiring adolescents' obstetric care conducted by only skilled personnel should be introduced and implemented. [ABSTRACT FROM AUTHOR]

An effective disease surveillance system is critical for early detection and response to disease epidemics. This study aimed to assess the capacity to manage and utilize disease surveillance data and implement an intervention to improve data analysis and use at the district level in Tanzania. Mapping, in-depth interview and desk review were employed for data collection in Ilala and Kinondoni districts in Tanzania. Interviews were conducted with members of the council health management teams (CHMT) to assess attitudes, motivation and practices related to surveillance data analysis and use. Based on identified gaps, an intervention package was developed on basic data analysis, interpretation and use. The effectiveness of the intervention package was assessed using pre-and post-intervention tests. Individual interviews involved 21 CHMT members (females = 10; males = 11) with an overall median age of 44.5 years (IQR = 37, 53). Over half of the participants regarded their data analytical capacities and skills as excellent. Analytical capacity was higher in Kinondoni (61%) than Ilala (52%). Agreement on the availability of the opportunities to enhance capacity and skills was reported by 68% and 91% of the participants from Ilala and Kinondoni, respectively. Reported challenges in disease surveillance included data incompleteness and difficulties in storage and accessibility. Training related to enhancement of data management was reported to be infrequently done. In terms of data interpretation and use, despite reporting of incidence of viral haemorrhagic fevers for five years, no actions were taken to either investigate or mitigate, indicating poor use of surveillance data in monitoring disease occurrence. The overall percentage increase on surveillance knowledge between pre-and post-training was 37.6% for Ilala and 20.4% for Kinondoni indicating a positive impact on of the training. Most of CHMT members had limited skills and practices on data analysis, interpretation and use. The training in data analysis and interpretation significantly improved skills of the participants. [ABSTRACT FROM AUTHOR]

Determinants for women's care seeking for birth in low-income setting are multifactorial and remain poorly understood. A life course approach can assist to structure the interplay of the different factors that lead to women seeking care or not. In this study we aimed to explore individual women's reproductive pathways, and increase understanding of how important life events including previous pregnancy and birth experiences can help us to understand individual choices made for care seeking during childbirth. The study took place in Tanzania between 2015 and 2017. 14 women were followed throughout their pregnancy, birth and postpartum period through participant observation and in-depth interviews. In total 94 in-depth interviews were held (between 5–7 interviews per woman). Analysis occurred continuous throughout the data collection period resulting in detailed narratives of crucial events across women's life course, with specific attention to their current pregnancy. Of the 14 women, seven had a facility birth, six a home birth and one woman gave birth at the home of a local birth attendant. Four different story plots were identified: expected home birth, expected facility birth, unexpected facility birth and unexpected home birth. Birth narratives of four women representative of the different story plots are presented. Narratives illustrate women's individual reproductive pathways including the various factors influencing women's expectations and justifications for their actions during their pregnancy and birth. Women's agency, including women's perception of self, the self in relation to the social environment and reflection on risks associated with the range of options, influences the final decision made for birth. Women's narratives suggest that quality of care can function as a primary pull factor for facility birth. As long as home birth is by some perceived to be a better alternative, achieving skilled care for all will be difficult to achieve. [ABSTRACT FROM AUTHOR]

High-quality essential newborn care (ENC) can improve newborn health and reduce preventable newborn mortality. The World Health Organization recommends specific ENC interventions. Video recordings have potential as a tool for assessment of clinical care also in low and middle-income countries. To use video observations of healthy newborns to describe ENC practices in a low-income setting and compare actual clinical practice with WHO recommendations. This is a cross-sectional observational study. Video records of neonatal interventions to 324 healthy newborns were assessed. They were obtained at baseline of a pre-post intervention study during a 10-week study period in Pemba, Tanzania. Data also included postnatal structured questionnaires. Eight ENC interventions and quality indicators were defined as per the WHO recommendations. Descriptive statistics were used to summarize ENC practices and maternal and neonatal characteristics. None of the newborns received all eight recommended ENC interventions. The median duration of separation from the mother was 25 minutes and 15 seconds (ranging from 22 seconds to 3 hours and 36 minutes), 51% of the newborns received proper thermal care during the separation. Twenty-one percent had sufficient umbilical cord care, 8% were stimulated for breathing, 69% were observed at least once by healthcare staff and 9% did undergo suctioning. None of the newborns received antibiotic ointments or vitamin K. Video recording of healthy newborns was feasible. The study identified omission of key ENC practices including proper thermal care, skin-to-skin contact and establishment of breastfeeding within the first hour of life, vitamin K administration as well as application of unnecessary practices such as excessive suctioning of breathing newborns. [ABSTRACT FROM AUTHOR]

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained. Trial registration number: NCT04685668 [ABSTRACT FROM AUTHOR]

Background: A number of countries have adopted sugar-sweetened beverage taxes to prevent non-communicable diseases but there is variance in the structures and rates of the taxes. As interventions, sugar-sweetened beverage taxes could be cost-effective but must be compliant with existing legal and taxation systems. Objectives: To assess the legal feasibility of introducing or strengthening taxation laws related to sugar-sweetened beverages, for prevention of non-communicable diseases in seven countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia. Methods: We assessed the legal feasibility of adopting four types of sugar-sweetened beverage tax formulations in each of the seven countries, using the novel FELIP framework. We conducted a desk-based review of the legal system related to sugar-sweetened beverage taxation and assessed the barriers to, and facilitators and legal feasibility of, introducing each of the selected formulations by considering the existing laws, laws related to impacted sectors, legal infrastructure, and processes involved in adopting laws. Results: Six countries had legal mandates to prevent non-communicable diseases and protect the health of citizens. As of 2019, all countries had excise tax legislation. Five countries levied excise taxes on all soft drinks, but most did not exclusively target sugar-sweetened beverages, and taxation rates were well below the World Health Organization's recommended 20%. In Uganda and Kenya, agricultural or HIV-related levies offered alternative mechanisms to disincentivise consumption of sugar-sweetened beverages without the introduction of new taxes. Nutrition-labelling laws in all countries made it feasible to adopt taxes linked to the sugar content of beverages, but there were lacunas in existing infrastructure for more sophisticated taxation structures. Conclusion: Sugar-sweetened beverage taxes are legally feasible in all seven countries Existing laws provide a means to implement taxes as a public health intervention. [ABSTRACT FROM AUTHOR]

Background: Non-communicable diseases are on the rise across sub-Saharan Africa. The region has become a targeted growth market for sugar-sweetened beverages, which are associated with weight gain, cardiovascular diseases and diabetes. Objective: To identify politico-economic factors relevant to nutrition-related fiscal policies, and to draw lessons regarding strategies to strengthen sugar-sweetened beverages taxation in the region and globally. Methods: We collected documentary data on policy content, stakeholders and corporate political activity from seven countries in east and southern Africa augmented by qualitative interviews in Botswana, Namibia, Kenya and Zambia, and stakeholder consultations in Rwanda, Tanzania and Uganda. Data were analysed using a political economy framework, focusing on ideas, institutions, interests and power, and a 'bricolage' approach was employed to identify strategies for future action. Results: Non-communicable diseases were recognised as a priority in all countries. Kenya, Zambia, Rwanda, Tanzania and Uganda had taxes on non-alcoholic beverages, which varied in rate and tax base, but appeared to be motivated by revenue rather than health concerns. Botswana and Namibia indicated intention to adopt sugar-sweetened beverage taxes. Health-oriented sugar-sweetened beverage taxation faced challenges from entrenched economic policy paradigms for industry-led economic growth and was actively opposed by sugar- sweetened beverage-related industries. Strategies identified to support stronger sugar-sweetened beverage taxation included shifting the economic discourse to strengthen health considerations, developing positive public opinion, forging links with the agriculture sector for shared benefit, and leadership by a central government agency. Conclusions: There are opportunities for more strategic public health engagement with the economic sector to foster strong nutrition-related fiscal policy for non-communicable disease prevention in the region. [ABSTRACT FROM AUTHOR]

Background: A number of countries have adopted sugar-sweetened beverage taxes to prevent non-communicable diseases but there is variance in the structures and rates of the taxes. As interventions, sugar-sweetened beverage taxes could be cost-effective but must be compliant with existing legal and taxation systems. Objectives: To assess the legal feasibility of introducing or strengthening taxation laws related to sugar-sweetened beverages, for prevention of non-communicable diseases in seven countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia. Methods: We assessed the legal feasibility of adopting four types of sugar-sweetened beverage tax formulations in each of the seven countries, using the novel FELIP framework. We conducted a desk-based review of the legal system related to sugar-sweetened beverage taxation and assessed the barriers to, and facilitators and legal feasibility of, introducing each of the selected formulations by considering the existing laws, laws related to impacted sectors, legal infrastructure, and processes involved in adopting laws. Results: Six countries had legal mandates to prevent non-communicable diseases and protect the health of citizens. As of 2019, all countries had excise tax legislation. Five countries levied excise taxes on all soft drinks, but most did not exclusively target sugar-sweetened beverages, and taxation rates were well below the World Health Organization's recommended 20%. In Uganda and Kenya, agricultural or HIV-related levies offered alternative mechanisms to disincentivise consumption of sugar-sweetened beverages without the introduction of new taxes. Nutrition-labelling laws in all countries made it feasible to adopt taxes linked to the sugar content of beverages, but there were lacunas in existing infrastructure for more sophisticated taxation structures. Conclusion: Sugar-sweetened beverage taxes are legally feasible in all seven countries Existing laws provide a means to implement taxes as a public health intervention. [ABSTRACT FROM AUTHOR]

Rift Valley Fever virus (RVFV) is a zoonotic arbovirus of public health impact infecting livestock, wildlife, and humans mainly in Africa and other parts of the world. Despite its public health importance, mechanisms of RVFV maintenance during interepidemic periods (IEPS) remain unclear. We aimed to examine comparatively exposure to RVFV between humans and goats and RVFV infection between humans, goats and mosquitoes. A cross sectional study was performed in the Lower Moshi area of the Kilimanjaro region from March to June 2020. RVFV exposure was determined by detecting IgG/IgM to RVFV using a competitive enzyme linked immunosorbent assay whereas infection was determined by real time quantitative polymerase chain reaction (RT-qPCR) assay. Results show that the male gender was related to RVFV seropositivity (χ2 = 5.351; p=0.030). Being 50 years and above was related to seropositivity (χ2 =14.430; p=0.006) whereas bed net use, larger numbers of persons living in the same house (>7 persons) and RVFV seropositivity in goats were related to higher seropositivity to RVFV among humans χ2 =6.003; p=0.021, χ2 =23.213; p < 0.001 and χ2 =27.053; p < 0.001), respectively. By the use of RT-qPCR, goats exhibited the highest RVFV infection rate of 4.1%, followed by humans (2.6%), Ae. aegypti (2.3%), and Cx. pipiens complex(1.5%). Likewise, a higher proportion of goats (23.3%) were RVFV seropositive as compared with humans (13.2%). Our findings suggest the Lower Moshi area as a potential hotspot for Rift Valley Fever (RVF), posing the danger of being a source of RVFV spread to other areas. Goats had the highest infection rate, suggesting goats as important hosts for virus maintenance during IEPs. We recommend the implementation of strategies that will warrant active RVF surveillance through the identification of RVF hotspots for targeted control of the disease. [ABSTRACT FROM AUTHOR]

Stroke causes great suffering and severe disability worldwide, and rehabilitation following a stroke seeks to restore lost functions. The extent to which stroke patients get access to rehabilitation in Tanzania is not well estimated, and drawing a current picture of the rehabilitation services for these persons is the first step in developing a more effective rehabilitation model in the country. The objective of this study was to establish the characteristics of stroke and its rehabilitation at the Kilimanjaro Christian Medical Centre (KCMC), a consultant referral hospital in northern Tanzania. This was a records-based descriptive study in which demographic, clinical, and rehabilitation information of stroke patients admitted to the KCMC between January 2012 and December 2015 was collected and audited. The means, percentages, and proportions were used to summarise the demographic, clinical, and rehabilitation patterns using SPSS version 24.0 software. The chi-squared statistic was used to examine the relationships between categorical variables, and a p-value<0.05 was considered statistically significant. Of the 17,975 patients admitted to the KCMC during the period of the study, 753 (4.2%) had suffered a stroke, with a mean age of 68.8 ± 16.4 years. The predominant cause of stroke was hypertension, which accounted for 546 (72.5%) patients. A total of 357 (47.4%) patients had various forms of rehabilitation during the admission to hospital. Following a discharge home 240 (31.9%) patients did not return to the hospital for the continuation of rehabilitation. Stroke patients at the KCMC lack access to rehabilitation therapies. Insufficient access to rehabilitation therapies may warrant the need to explore alternative approaches such as tele-rehabilitation technologies in Tanzania. [ABSTRACT FROM AUTHOR]

Background: Despite routine supportive supervision of health service delivery, maternal and newborn outcomes have remained poor in sub-Saharan Africa in general and in Tanzania in particular. There is limited research evidence on factors limiting the effectiveness of supportive supervision in improving the quality of maternal and newborn care. Objective: This study explored enablers of and barriers to supportive supervision in maternal and newborn care at the district and hospital levels in Shinyanga region in Tanzania. Methods: This study employed a qualitative case study design. A purposeful sampling approach was employed to recruit a stratified sample of health system actors: members of the council health management team (CHMT), members of health facility management teams (HMTs), heads of units in the maternity department and health workers. Results: This study identified several barriers to the effectiveness of supportive supervision. First, the lack of a clear policy on supportive supervision. Despite the general acknowledgement of supportive supervision as a managerial mechanism for quality improvement at the district and lower-level health facilities, there is no clear policy guiding it. Second, limitations in measurement of progress in quality improvement; although supportive supervision is routinely conducted to improve maternal and newborn outcomes, efforts to measure progress are limited due to shortfalls in the setting of goals and targets, as well as gaps in M&E. Third, resource constraints and low motivation; that is, the shortage of resources – CHMT supervisors, health staff and funds – results in irregular supervision and low motivation. Conclusion: Besides resource constraints, lack of clear policies and limitations related to progress measurement impair the effectiveness of supportive supervision in improving maternal and newborn outcomes. There is a need to reform supportive supervision so that it aids and measures progress not only at the district but also at the health facility level. [ABSTRACT FROM AUTHOR]

Background: 14.9 million women (≥15 years) in Tanzania are at risk of developing cervical cancer. Limited cancer care facilities, prevention programs and sparse knowledge among community members and healthcare workers contribute to late-stage presentation leading to a high mortality rate. Objective: This study aims to scientifically accompany prevention and awareness campaigns (PrevACamp) in northern Tanzania in its real-world settings to obtain (1) a better understanding about cervical cancer and HPV knowledge amongst female PrevACamp participants and (2) to determine the prevalence of pre-cancerous lesions among women undergoing cervical cancer VIA screening. Method: Cross-sectional survey among PrevACamp attendees in two regions in Northern Tanzania. Two data collections tools were used: Questionnaires and clinical data from VIA screening. Data were collected from October 2017 to March 2019. Results: 2,192 PrevACamp attendees were interviewed and 2,224 received VIA screening. There was significant nescience on cervical cancer regardless of education level, resident status, or number of children as well as nescience on HPV in all age groups, especially in urban areas and misconceptions about cancer. Screening revealed VIA positivity rate of 3.1%. Conclusion: There is an alarming lack of knowledge about cervical cancer and, to a lesser Extent, about HPV among the study participants. Having health insurance influenced the level of knowledge significantly. Outreach programs in rural areas appear to target the population in need of health education. Low positive VIA screening results are paralleled with lower HIV rates among the women. We assume that the high density of primary health care coverage in northern Tanzania contributes to these findings.. [ABSTRACT FROM AUTHOR]

Despite the implementation of various initiatives to address low enrollment in voluntary micro health insurance (MHI) schemes in sub-Saharan Africa, the problem of low enrollment remains unresolved. The lack of process evaluations of such interventions makes it difficult to ascertain whether their poor results are because of design failures or implementation weaknesses. In this paper, we describe a process evaluation protocol aimed at opening the 'black box' to evaluate the implementation processes of the Redesigned Community Health Fund (CHF) program in the Dodoma region of Tanzania. The study employs a cross-sectional mixed methods design and is being carried out 3 years after the launch of the Redesigned CHF program. The study is grounded in a conceptual framework which rests on the Diffusion of Innovation Theory and the Implementation Fidelity Framework. The study utilizes a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews, and document review), and aligns the evaluation to the Theory of Intervention developed by our team. Quantitative data will be used to measure program adoption, implementation fidelity, and their moderating factors. Qualitative data will be used to explore the responses of stakeholders to the intervention, contextual factors, and moderators of adoption, implementation fidelity, and sustainability. This protocol describes a systematic process evaluation in relation to the implementation of a reformed MHI. We trust that the theoretical approaches and methodologies described in our protocol may be useful to inform the design of future process evaluations focused on the assessment of complex interventions, such as MHI schemes. [ABSTRACT FROM AUTHOR]

Background: Health care systems in developing countries such as Tanzania depend heavily on out-of-pocket payments. This mechanism contributes to inefficiency, inequity and cost, and is a barrier to patients seeking access to care. There are efforts to expand health insurance coverage to vulnerable groups, including older adults, in Sub-Saharan African countries. Objective: To analyse the association between health insurance and health service use in rural residents aged 60 and above in Tanzania. Methods: Data were obtained from a household survey conducted in the Nzega and Igunga districts. A standardised survey instrument from the World Health Organization Study on global AGEing and adult health was used. This comprised of questions regarding demographic and socio-economic characteristics, health and insurance status, health seeking behaviours, sickness history (three months and one year prior to the survey), and the receipt of health care. A multistage sampling method was used to select wards, villages and respondents in each district. Local ward and hamlet officers guided the researchers in identifying households with older people. Crude and adjusted logistic regression methods were used to explore associations between health insurance and outpatient and inpatient health care use. Results: The study sample comprised 1,899 people aged 60 and above of whom 44% reported having health insurance. A positive statistically significant association between health insurance and the utilisation of outpatient and inpatient care was observed in all models. The odds of using outpatient (adjusted OR = 2.20; 95% CI: 1.54, 3.14) and inpatient services (adjusted OR = 3.20; 95% CI: 2.46, 4.15) were higher among the insured. Conclusion: Health insurance is a predictor of outpatient and inpatient health services in people aged 60 and above in rural Tanzania. Further research is needed to understand the perceptions of both the insured and uninsured regarding the quality of care received. [ABSTRACT FROM AUTHOR]

In Tanzania only an estimated one-quarter of births are registered and certified. Birth registration uses a centralized system with geographic and cost barriers for families. A pilot decentralized birth registration system has been trialled in 11 of 26 regions, substantially increasing registration points, and enabling notification, registration and certification to occur in one step. This study compares completeness of birth registration and certification and achievement of key birth registration milestones in two districts where the birth registration system decentralized and two districts with the existing centralized system. Registration, notification, census and survey data were used to estimate birth registration completeness and quantify achievement of key registration milestones for births in 2012–16. These were compared between districts of Mbozi (decentralized in 2013) and Iringa (decentralized in 2016) and districts of Dodoma and Kibaha which remained centralized. For births that occurred from 2012 to 2016, completeness of birth registration/certification (by early 2017) was higher in districts that decentralized (Iringa 60%; Mbozi 52%) than remained centralized (Kibaha 36%; Dodoma 20%). Introduction of the decentralized system saw completeness for births registered within 12 months of occurrence increase in Iringa from 1% in 2014 to 67% in 2016, and in Mbozi from 15% in 2012 to 36% in 2013 before falling and subsequently increasing to 53% in 2016. In contrast, completeness in centralized districts did not increase. Although a higher proportion of births are notified in centralized than decentralized districts, registration and certification occurs for all notified births in decentralized districts but only one-third in centralized districts. Benefits of a decentralized system are more proximate registration points and the merging of notification, registration and certification steps. The findings, while demonstrating the immediate impact of the decentralized system on completeness, also show that continued efforts are necessary to sustain these improvements. [ABSTRACT FROM AUTHOR]

Background: Healthcare Workers may stigmatize and discriminate against Men who have Sex with Men in East Africa. Objective: To understand the predictors of abuse and discrimination of sexual minority men in healthcare settings by Healthcare workers in seven cities in Tanzania. Method: In total, 300 sexual minority men over the age of 18 were interviewed in 7 Tanzanian cities by trained local interviewers. Abuse from others (physical, verbal, sexual, discrimination/humiliation), and abuse from Healthcare workers, was ascertained. Gender role mannerisms were self-rated by the respondent, and at the end of the interview, by the interviewer, on a Likert scale from very feminine to very masculine. Respondents also indicated whether they had revealed their homosexual behavior or had it exposed in the health consultation. Results: Median age was 27. Verbal abuse and community discrimination were the most commonly reported forms of abuse. Eighty-four percent had visited a healthcare center with a sexually related complaint (usually a sexually transmitted infection); of these, 24% reported abuse or discrimination from from a healthcare worker. Correlation between self-rated gender role mannerisms and interviewer-rated was r = 0.84. Regression analysis indicated that the degree of perceived gender role nonconformity was the major and significant predictor from Healthcare worker abuse: confirmation of homosexual behavior was non-significant. Gender role nonconformity predicted 21% of the variance in health worker abuse. Conclusion: There is speculation that abuse of sexual minority men by Healthcare workers in public clinics is due to factors in addition to their sexual behavior as gay/bisexual, and that it is due to violating perceived gender roles. Data confirm that perceived feminine gender role is a significant predictor, of abuse in healthcare and other settings. Common confusion between homosexual behavior and gender role norms may trigger discrimination, which may be as much due to violation of perceived gender roles as having sex with other men. [ABSTRACT FROM AUTHOR]

Previous research suggests that Tanzanian MSM might prefer consulting pharmacies and drugstores, rather than public healthcare services, when in need of STI medicines and treatment. Yet, few studies have explored the experiences of providing services to MSM clients among those working at pharmacies and drugstores and examined what challenges they encounter in providing these services. To gain increased knowledge and understanding of the perceived challenges encountered by pharmacists and drugstore workers when providing STI services to MSM clients in Dar es Salaam, Tanzania. In early 2016, 16 semi-structured interviews were conducted with persons working at private pharmacies and drugstores in Dar es Salaam. Data were interpreted through qualitative content analysis. The overarching theme that emerged was labelled 'Fighting an uphill battle', which reflected the challenges pharmacy workers experienced during interactions with MSM clients, and in particular service provision. Pharmacy workers tried to act upon the best of their knowledge to meet the needs of clients, given their understanding of risks and obstacles that MSM faced. Yet, the lack of educational and professional preparedness and insufficient financial and human resources, regarded as necessary to meet the needs of a stigmatised client group, formed barriers for effective service delivery. In order to support pharmacists and drug-store workers in Tanzania to address perceived challenges for service delivery to MSM clients, systematic and continuous training on MSM's sexual health is required. Furthermore, inter-professional cooperation that harnesses provider involvement from all tiers in the healthcare system is essential to offer complementary services to ensure proper STI care and treatment. Thus, interventions that focus on inter-professional communication and interaction between pharmacists and physicians could have a positive impact on timely referrals of suspected STI cases among marginalised populations. [ABSTRACT FROM AUTHOR]

Background: In many low-resource settings, in-service training is a common strategy to improve the performance of health workers and ultimately reduce the persistent burden of maternal mortality and morbidities. An evaluation of the Helping Mothers Survive Bleeding After Birth (HMS BAB) training as a single-component intervention in Tanzania found some positive albeit limited effect on clinical management and reduction of postpartum haemorrhage (PPH). Aim: In order to better understand these findings, and particularly the contribution of contextual factors on the observed effects, we explored health workers' perceptions of their health facilities' readiness to provide PPH care. Methods: We conducted 7 focus group discussions (FGDs) and 12 in-depth interviews (IDIs) in purposively selected intervention districts in the HMS BAB trial. FGDs and IDIs were audio-recorded, transcribed and translated verbatim. Thematic analysis, using both inductive and deductive approaches, was applied with the help of MAXQDA software. Results: Health workers perceive that their facilities have a low readiness to provide PPH care, leading to stressful situations and suboptimal clinical management. They describe inconsistencies in essential supplies, fluctuating availability of blood for transfusion, and ineffective referral system. In addition, there are challenges in collaboration, communication and leadership support, which is perceived to prevent effective management of cases within the facility as well as in referral situations. Health workers strive to provide life-saving care to women with PPH despite the perceived challenges. In some health facilities, health workers perceive supportive clinical leadership as motivating in providing good care. Conclusion: The potential positive effects of single-component interventions such as HMS BAB training on clinical outcome may be constraint by poor health facility readiness, including communication, leadership and referral processes that need to be addressed. [ABSTRACT FROM AUTHOR]

Background: Neurological disorders (ND) have a profound consequence on human productivity, quality of life and survival. There are limited data on the burden of ND in Tanzania due to insufficient coverage of civil and vital registration systems. Objectives: This study was conducted to estimate mortality of ND in all ages in Tanzania using data from the Sample Vital Registration with Verbal Autopsy (SAVVY) study. Methods: Multistage random sampling was employed to select 23 districts, 1397 census enumeration areas and 154,603 households. During the baseline survey conducted between 2011 and 2014, deaths which occurred 12 months prior to the baseline survey were documented followed by verbal autopsy interviews. Causes of death were certified using International Classification of Diseases. Results: The baseline survey enrolled a total of 650,864 residents. A total of 6645 deaths were reported to have occurred 12 months before the date of survey. Death certification was available for 5225 (79%) deaths. The leading causes of death were cerebrovascular diseases with a cause-specific mortality fraction (CSMF) of 1.64% (95% CI: 1.30–1.99) and 3.82% (95% CI: 2.92–4.72) in all ages and adults older than 50 years, respectively. Stroke accounted for 92% of all cerebrovascular deaths. Mortality of epilepsy was estimated with a CSMF of 0.94% (95% CI: 0.68–1.20); meningitis with a CSMF of 0.80% (95% CI: 0.56–1.04); cerebral palsy and other paralytic syndromes with a CSMF of 0.46% (95% CI: 0.27–0.65); and intrauterine hypoxia in neonates with a CSMF of 2.06% (95% CI: 1.12–3.01). Overall, mortality of ND was estimated with a CSMF of 4.99% (95% CI: 4.40–5.58). Conclusions: The SAVVY survey provides estimates of mortality burden of ND in Tanzania. The study provides a basis for monitoring trends of ND and contributes to advancing knowledge of the burden of diseases. Integrating morbidities measures into the SAVVY design will provide comprehensive measures of burden of ND taking into account lifetime disabilities created by ND. [ABSTRACT FROM AUTHOR]

Background: 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. Design: 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. Results: 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. Conclusion: 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. [ABSTRACT FROM AUTHOR]

Background: Behavioral change approaches for human immunodeficiency virus (HIV) prevention in Tanzania encourage married partners to observe safe sex practices (condom use, avoidance of, or safe sex with multiple partners). To implement this advice, partners need to communicate with each other about safer sex, which is often challenging. Although social-structural factors are crucial in understanding sexual behavior, only a few studies focus on understanding safer sex dialogue in a broader social context. Design: Drawing on the WHO-Commission on the Social Determinants of Health (WHO-CSDH) framework, this study explored key social-structural constructs for studying health in the context of improving safer sex dialogue between polygamous and monogamous partners. Twenty-four in-depth interviews (IDIs) and six focus group discussions (FGDs) with 38 men and women aged 18-60 years were conducted in Ifakara town located in Kilombero district, Tanzania. The study was nested within the community health surveillance project MZIMA (Kiswahili: 'being healthy'). Partners' experiences of safer sex dialogue in polygamous and monogamous relations were investigated and the challenges to safer sex dialogue explored. Results: The study revealed that open safer sex dialogue in marriage is limited and challenged by social norms about marriage (a view that safer sex dialogue imply that partners are 'not really' married); marital status (a belief that safer sex dialogue is not practical in polygamous marriages, the elder wife should be exempted from the dialogue since she is at lower risk of engaging in extramarital affairs); relationship quality (marital conflicts, extramarital affairs, trust, and sexual dissatisfaction); and gender power relations (the notion that females' initiative to discuss condom use and HIV couple counseling and testing may lead to conflict or divorce). Conclusions: Implementing safer sex practices requires interventions beyond promotion messages. HIV prevention interventions in Tanzania should be carefully adapted to the local context including respective social norms, gender systems, marital context and relationship uncertainties as aspects that facilitate or hinder safer sex dialogue between partners. The WHO-CSDH framework could be strengthened by explicitly integrating relationship quality, marital status, and social norms as additional determinants of health. [ABSTRACT FROM AUTHOR]

Decentralization of public health planning is proposed to facilitate public participation in health issues. Health Sector Reform in Tanzania places emphasis on the participation of lower level health facilities and community in health planning process. Despite availability of policies, guidelines, and community representative organs, actual implementation of decentralization strategies is poorly achieved. This study intended to find out factors that hinder community participation in developing and implementing Comprehensive Council Health Plan (CCHP). A qualitative approach was conducted in this study with key informants from Health Facility Governing Committees (HFGC), Council Health Service Board (CHSB), and Council Health Management Team (CHMT). Data were collected using in-depth interviews. Data generated were analyzed for themes and patterns. Factors that hindered community participation included lack of awareness on the CCHP among HFGC members, poor communication and information sharing between CHMT and HFGC, unstipulated roles and responsibilities of HFGC, lack of management capacity among HFGC members, and lack of financial resources for implementing HFGC activities. The identified challenges call for policy makers to revisit the decentralization by devolution policy by ensuring that local governance structures have adequate resources as well as autonomy to participate in planning and managing CCHP in general and health facility plans in particular. [ABSTRACT FROM AUTHOR]

Background: HIV/AIDS programmes and organisations around the world use routinely updated estimates of the UNAIDS 90-90-90 targets to track progress and prioritise further programme implementation. Any bias in these estimates has the potential to mislead organisations on where gaps exist in HIV testing and treatment programmes. Objective: To measure the extent of undisclosed HIV testing history and its impact on estimating the proportion of people living with HIV (PLHIV) who know their HIV status (the 'first 90' of the UNAIDS 90-90-90 targets). Methods: We conducted a retrospective cohort study using population-based HIV serological surveillance conducted between 2010 and 2016 and linked, directly observed HIV testing records in Kisesa, Tanzania. Generalised estimating equations logistic regression models were used to detect associations with non-disclosure of HIV testing history adjusting for demographic, behavioural, and clinical characteristics. We compared estimates of the 'first 90' using self-reported survey data only and augmented estimates using information from linked records to quantify the absolute and relative impact of undisclosed HIV testing history. Results: Numbers of participants in each of the survey rounds ranged from 7171 to 7981 with an average HIV prevalence of 6.9%. Up to 33% of those who tested HIV-positive and 34% of those who tested HIV-negative did not disclose their HIV testing history. The proportion of PLHIV who reported knowing their status increased from 34% in 2010 to 65% in 2016. Augmented estimates including information from directly observed testing history resulted in an absolute impact of 6.7 percentage points and relative impact of 12.4%. Conclusions: In this population, self-reported testing history in population-based HIV serological surveys under-estimated the percentage of HIV positives that are diagnosed by a relative factor of 12%. Research should be employed in other surveillance systems that benefit from linked data to investigate how bias may vary across settings. [ABSTRACT FROM AUTHOR]

Background: Male involvement in pregnancy and childbirth has been shown to improve maternal and child health. Many countries have used different strategies to promote participation of men in antenatal care services. While many strategies have been employed to promote male participation in antenatal care, few have been evaluated to provide much-needed lessons to support wider adoption. Objective: This study aimed at describing strategies that were used by health providers and the community to promote male participation in antenatal care services and challenges associated with the implementation of these interventions in Southern Tanzania. Methods: We used qualitative data and analytical methods to answer the research questions. The study relied on semi-structured interviews with health providers, men and women, village and community leaders and traditional birth attendants. Data were analysed using a thematic approach. Results: The findings of this study revealed that different strategies were employed by health providers and the community in promoting participation of men in antenatal care services. These strategies included: health providers denying services to women attending antenatal care without their partners, fast-tracking service to men attending antenatal care with their partners, and providing education and community sensitisation. The implementation of these strategies was reported to have both positive and unintended consequences. Conclusions: This study concludes that despite the importance of male involvement in pregnancy and childbirth-related services, the use and promotion of the male escort policy should not inadvertently affect access to antenatal care services by pregnant women. In addition, programmes aiming for men's involvement should be implemented in ways that respect, promote and facilitate women's choices and autonomy and ensure their safety. Furthermore, there is a need for sensitisation of health providers and policymakers on what works best for involving men in pregnancy and childbirth. [ABSTRACT FROM AUTHOR]

Background: Intrapartum-related hypoxia accounts for 30% of neonatal deaths in Tanzania. This has led to the introduction and scaling-up of the Helping Babies Breathe (HBB) programme, which is a simulation-based learning programme in newborn resuscitation skills. Studies have documented ineffective ventilation of non-breathing newborns and the inability to follow the HBB algorithm among providers. Objective: This study aimed at exploring barriers and facilitators to effective bag mask ventilation, an essential component of the HBB algorithm, during actual newborn resuscitation in rural Tanzania. Methods: Eight midwives, each with more than one year's working experience in the labour ward, were interviewed individually at Haydom Lutheran Hospital, Tanzania. The audio recordings were transcribed and translated into English and analysed using qualitative content analysis. Results: Midwives reported the ability to monitor labour properly, preparing resuscitation equipment before delivery, teamwork and frequent ventilation training as the most effective factors in improving actual ventilation practices and promoting the survival of newborns. They thought that their anxiety and fear due to stress of ventilating a non-breathing baby often led to poor resuscitation performance. Additionally, they experienced difficulties assessing the baby's condition and providing appropriate clinical responses to initial interventions at birth; hence, further necessary actions and timely initiation of ventilation were delayed. Conclusions: Efforts should be focused on improving labour monitoring, birth preparedness and accurate assessment immediately after birth, to decrease intrapartum-related hypoxia. Midwives should be well prepared to treat a non-breathing baby through high-quality and frequent simulation training with an emphasis on teamwork training. [ABSTRACT FROM AUTHOR]

Background: Previous research has shown that men who have sex with men (MSM) avoid formal healthcare services because of the fear of discrimination as homosexuality is illegal and stigmatized in Tanzania. Instead, self-treatment by medications obtained directly from pharmacies or drugstores may be common when MSM experience symptoms of suspected sexually transmitted infections (STIs) related to sexual activity with men. Objective: To explore MSM’s perceptions and experiences of seeking treatment and advice from pharmacists and drugstore workers in Dar es Salaam, Tanzania, with regards to their sexual health and STI-related problems. Materials and Methods: 15 in-depth interviews were conducted with MSM with experience of seeking assistance relating to their sexual health at pharmacies and drugstores in Dar es Salaam in 2016. A qualitative manifest and latent content analysis was applied to the collected data. Results: Four themes related to different aspects of MSM’s perceptions and experiences of pharmacy care emerged from the analysis: (1)Balancing threats against need for treatmentreflected informants’ struggles concerning risks and benefits of seeking assistance at pharmacies and drugstores; (2)Identifying strategies to access required servicesdescribed ways of approaching a pharmacist when experiencing a sexual health problem; (3)Seeing pharmacists as a first choice of carefocused on informants’ reasons for preferring contact with pharmacies/drugstores rather than formal healthcare services; and (4)Lacking reliable services at pharmaciesindicated what challenges existed related to pharmacy care. Conclusions: MSM perceived the barriers for accessing assistance for STI and sexual health problems at pharmacies and drugstores as low, thereby facilitating their access to potential treatment. However, the results further revealed that MSM at times received inadequate drugs and consequently inadequate treatment. Multi-facetted approaches are needed, both among MSM and drugstore, pharmacy, and healthcare workers, to improve knowledge of MSM sexual health, STI treatment, and risks of antibiotic resistance. [ABSTRACT FROM PUBLISHER]

Background: In most low-income countries, many women with high-risk pregnancies and complications do not reach the referral hospitals despite the provision of referral advice. Objective: To explore how antenatal maternal referral advice is understood and handled in a rural Tanzanian community. Methods: Individual in-depth interviews were conducted with six women who did not go to hospital and 13 people who were involved in the referral advice. Narrative analysis was used to describe and create meanings out of the decision-making process. Results: In all interviews, not following the referral advice was greatly influenced by close family members. Three main traits of how referral advice was understood emerged: convinced referral is not necessary, accepting referral advice but delayed by others, and passive and moving with the wind. The main reasons given for declining the referral advice included discrediting midwives’ advice, citing previous successful deliveries despite referral advice; being afraid of undergoing surgery; lack of support for care of siblings at home; and high costs incurred during referral. Conclusions: Declining maternal referral advice centred around the pregnant women’s position and their dependence on the family members around them, with a decreased ability to show autonomy. If they were socially and economically empowered, women could positively influence decision making during maternal referrals. [ABSTRACT FROM PUBLISHER]

Background: Men play an important role in maternal health. The postpartum period is a critical stage, yet there is a scarcity of research that explores men’s involvement during this stage. Objective: The aim of the study was to explore male partners’ perceptions of the cultural practices during postpartum care in rural Tanzania. Methods: Fourteen focus group discussions were conducted with 93 men, with an age range of 19–65 years, in August 2013. The study was conducted in the Kongwa District, located in the Dodoma region in central Tanzania. Qualitative data were digitally recorded, transcribed verbatim and analyzed using content analysis. Results: Four categories emerged, namely: ‘Men as providers and, occasionally, care takers’, ‘Men as decision makers’, ‘Diverse perceptions of sexual abstinence’ and ‘Barriers for men in using/accompanying partners to use reproductive and child healthcare services’. The cross-category theme ‘Men during postpartum: remaining powerful but excluded’ refers to how men are in a powerful position above women in different aspects of life. Elderly women played an important role in caring for postpartum mothers and their newborns, but men were the ones making the final decision about where to seek care. Traditional practices isolated men from their partners for a certain period, and enforced sexual abstinence for the women during the postpartum period. However, cultural norms permitted men to engage in extramarital relations. Reproductive and child healthcare services were perceived by men as not welcoming the male partners, and local gender norms discouraged men from accompanying their partners to seek services. Conclusions: In this study, we found that men perceived their role during the postpartum period as financial providers, decision makers and, occasionally, care givers. Men also held diverse perceptions with regard to sexual abstinence and felt excluded from participating in maternal healthcare services. [ABSTRACT FROM PUBLISHER]

Background: Causes, magnitude and consequences of traumatic spinal cord injury depend largely on geography, infrastructure, socioeconomic and cultural activities of a given region. There is a scarcity of literature on profile of traumatic spinal cord injury to inform prevention and rehabilitation of this health condition in African rural settings, particularly Tanzania. Objective: To describe the incidence, etiology and clinical outcomes of traumatic spinal cord injury and issues related to retrospective study in underdeveloped setting. Methods: Records for patients with traumatic spinal cord injury for five consecutive years (2010–2014) were obtained retrospectively from the admission wards and health records archives of the Kilimanjaro Christian Medical Center. Sociodemographic, cause, complications and patients’ condition on discharge were recorded and analyzed descriptively. Results: The admission books in the wards registered 288 new traumatic spinal cord injury cases from January 2010 to December 2014. Of the 288 cases registered in the books, 224 were males and 64 females with mean age 39.1(39.1 ± 16.3) years and the majority of individuals 196(68.1%) were aged between 16 and 45 years. A search of the hospital archives provided 213 full patient records in which the leading cause of injury was falls 104(48.8%) followed by road traffic accidents 73(34.3%). Cervical 81(39.9%) and lumbar 71(34.74%) spinal levels were the most affected. The annual incidence for the Kilimanjaro region (population 1,640,087) was estimated at more than 26 persons per million population. The most documented complications were pressure ulcers 42(19.7%), respiratory complications 32(15.0%) and multiple complications 28(13.1%). The mean length of hospital stay was 64.2 ± 54.3 days and the mortality rate was 24.4%. Conclusion: Prevention of traumatic spinal cord injury in North-east Tanzania should consider falls (particularly from height) as the leading cause, targeting male teenagers and young adults. Pressure ulcers, respiratory complications, in-hospital mortality and availability of wheelchairs should be addressed. [ABSTRACT FROM PUBLISHER]

Background: Hypertension is a public health problem, and yet few people are aware of it and even fewer access effective treatment. With the ongoing demographic transition in many parts of Sub-Saharan Africa, people are changing from rural, manual work to urban lifestyles, hence the risk of hypertension increases. Objective: This study aimed at determining the prevalence, awareness and risk factors associated with hypertension in North West Tanzania. Design: A community-based cross-sectional study was conducted among adults in Magu District in 2013. Information on socio-demographic, economic and lifestyle characteristics, medical conditions, and risk factors for hypertension were collected according to the WHO Steps survey tool. Measurements of blood pressure, blood sugar, pulse rate, and anthropometry were taken. Multivariate logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (95% CI) for factors associated with hypertension (Blood pressure ≥140/90mm/Hg). Frequencies and percentages were used to determine the awareness, and treatment among hypertensive participants. Results: Among 9678 participants, the prevalence of hypertension was 8.0% and pre-hypertension 36.2%. There was a higher prevalence of hypertension at older ages, among females (8.2%) compared to males (7.7%), and among urban dwellers (10.1%) compared to rural residents (6.8%). Overweight, obese, and diabetic individuals had a higher risk of hypertension while HIV positive participants had a lower risk of hypertension (OR = 0.56; 95% CI 0.39 – 0.79). Among participants with hypertension, awareness was less than 10%. Conclusion: By integrating blood pressure screening into our long-standing community HIV screening program, we were able to identify many previously undiagnosed cases of hypertension and pre-hypertension. Age, residence, overweight and obesity were the major associated factors for hypertension. Awareness and treatment rates are very low indicating the need for programs to improve awareness, and treatment of hypertension. [ABSTRACT FROM PUBLISHER]

Background: Women’s responses to partner violence are influenced by a complex constellation of factors including: psychological attachment to the partner; context of the abuse; and structural factors, all of which shape available options for women outside of the relationship. Objective: To describe women’s responses to physical partner violence; and to understand the role of women’s economic resources on their responses. Methods: Cross-sectional data from Dar es Salaam and Mbeya, Tanzania. Multivariate logistic regression was used to explore the relationship between women’s economic resources and their responses to violence. Results: In both sites, among physically abused women, over one-half experienced severe violence; approximately two-thirds had disclosed the violence; and approximately 40% had sought help. Abused women were more likely to have sought help from health services, the police and religious leaders in Dar es Salaam, and from local leaders in Mbeya. Economic resources did not facilitate women’s ability to leave violent partners in Dar es Salaam. In Mbeya, women who jointly owned capital assets were less likely to have left. In both sites, women’s sole ownership of capital assets facilitated help-seeking. Conclusion: Although support services are being scaled-up in Tanzania, efforts are needed to increase the acceptability of accessing such services. [ABSTRACT FROM PUBLISHER]

Background: In order to improve the health and survival of mothers/newborns, the quality and attendance rates of postpartum care (PPC) must be increased, particularly in low-resource settings. Objective: To describe outcomes of a collegial facilitation intervention to improve PPC in government-owned health institutions in a low-resource suburb in Dar es Salaam, Tanzania. Methods: A before-and-after evaluation of an intervention and comparison group was conducted using mixed methods (focus group discussions, questionnaires, observations, interviews, and field-notes) at health institutions. Maternal and child health aiders, enrolled nurse midwives, registered nurse midwives, and medical and clinical officers participated. A collegial facilitation intervention was conducted and healthcare providers were organized in teams to improve PPC at their workplaces. Facilitators defined areas of improvement with colleagues and met regularly with a supervisor for support. Results: The number of mothers visiting the institution for PPC increased in the intervention group. Some care actions were noted in more than 80% of the observations and mothers reported high satisfaction with care. In the comparison group, PPC continued to be next to non-existent. The healthcare providers’ knowledge increased in both groups but was higher in the intervention group. Thet-test showed a significant difference in knowledge between the intervention and comparison groups and between before and after the intervention in both groups. The difference of differences for knowledge was 1.3. The providers perceived the intervention outcomes to include growing professional confidence/knowledge, improved PPC quality, and mothers’ positive response. The quality grading was based on the national guidelines and involved nine experts and showed that none of the providers reached the level of good quality of care. Conclusions: The participatory facilitation intervention contributed to improved quality of PPC, healthcare providers’ knowledge and professional confidence, awareness of PPC among mothers, and increased PPC attendance. [ABSTRACT FROM PUBLISHER]

The implementation of new technology can interrupt established workflows in health care settings. The Quality of Maternal Care (QUALMAT) project has introduced an electronic clinical decision support system (eCDSS) for antenatal care (ANC) and delivery in rural primary health care facilities in Africa. This study was carried out to investigate the influence of the QUALMAT eCDSS on the workflow of health care workers in rural primary health care facilities in Ghana and Tanzania. A direct observation, time-and-motion study on ANC processes was conducted using a structured data sheet with predefined major task categories. The duration and sequence of tasks performed during ANC visits were observed, and changes after the implementation of the eCDSS were analyzed. In 24 QUALMAT study sites, 214 observations of ANC visits (144 in Ghana, 70 in Tanzania) were carried out at baseline and 148 observations (104 in Ghana, 44 in Tanzania) after the software was implemented in 12 of those sites. The median time spent combined for all centers in both countries to provide ANC at baseline was 6.5 min [interquartile range (IQR) =4.0–10.6]. Although the time spent on ANC increased in Tanzania and Ghana after the eCDSS implementation as compared to baseline, overall there was no significant increase in time used for ANC activities (0.51 min, p=0.06 in Ghana; and 0.54 min, p=0.26 in Tanzania) as compared to the control sites without the eCDSS. The percentage of medical history taking in women who had subsequent examinations increased after eCDSS implementation from 58.2% (39/67) to 95.3% (61/64) p<0.001 in Ghana but not in Tanzania [from 65.4% (17/26) to 71.4% (15/21) p=0.70]. The QUALMAT eCDSS does not increase the time needed for ANC but partly streamlined workflow at sites in Ghana, showing the potential of such a system to influence quality of care positively. [ABSTRACT FROM AUTHOR]

Maternal health care provision remains a major challenge in developing countries. There is agreement that the provision of quality clinical services is essential if high rates of maternal death are to be reduced. However, despite efforts to improve access to these services, a high number of women in Tanzania do not access them. The aim of this study is to explore women's views about the maternal health services (pregnancy, delivery, and postpartum period) that they received at health facilities in order to identify gaps in service provision that may lead to low-quality maternal care and increased risks associated with maternal morbidity and mortality in rural Tanzania. We gathered qualitative data from 15 focus group discussions with women attending a health facility after child birth and transcribed it verbatim. Qualitative content analysis was used for analysis. 'Three categories emerged that reflected women's perceptions of maternal health care services: "mothers perceive that maternal health services are beneficial," "barriers to accessing maternal health services" such as availability and use of traditional birth attendants (TBAs) and the long distances between some villages, and "ambivalence regarding the quality of maternal health services" reflecting that women had both positive and negative perceptions in relation to quality of health care services offered'. Mothers perceived that maternal health care services are beneficial during pregnancy and delivery, but their awareness of postpartum complications and the role of medical services during that stage were poor. The study revealed an ambivalence regarding the perceived quality of health care services offered, partly due to shortages of material resources. Barriers to accessing maternal health care services, such as the cost of transport and the use of TBAs, were also shown. These findings call for improvement on the services provided. Improvements should address, accessibility of services, professionals' attitudes and stronger promotion of the importance of postpartum check-ups, both among health care professionals and women. [ABSTRACT FROM AUTHOR]

In sub-Saharan Africa, the prevalence of HIV among married and cohabiting couples is substantial. Information about the underlying social drivers of HIV transmission in couples is critical for the development of structural approaches to HIV prevention, but not readily available. We explored the association between social drivers, practices, and HIV status among stable couples in Ifakara, Tanzania. Using a cross-sectional design, we analyzed data from a sample of 3,988 married or cohabiting individuals, aged 15 years and older from the MZIMA adult health community cohort study of 2013. Sociodemographic factors (sex, income, age, and education), gender norms (perceived acceptability for a wife to ask her partner to use a condom when she knows he is HIV positive), marriage characteristics (being in a monogamous or a polygamous marriage, being remarried), sexual behavior practices (lifetime number of sexual partners and concurrent sexual partners), health system factors (ever used voluntary HIV counseling and testing), and lifestyle patterns (alcohol use) were used to explore the odds of being HIV positive, with 95% confidence intervals. Prevalence of HIV/AIDS was 6.7% (5.9% males and 7.1% females). Gender norms, that is, perception that a woman is not justified to ask her husband to use a condom even when she knows he has a disease (adjusted odds ratio AOR=1.51, 95% CI 1.06–2.17), marital characteristics, that is, being remarried (AOR=1.49, 95% CI 1.08–2.04), and sexual behavior characteristics, that is, lifetime number of sexual partners (2–4: AOR=1.47, 95% CI 1.02–2.11; 5+: AOR=1.61, 95% CI 1.05–2.47) were the main independent predictors of HIV prevalence. Among married or cohabiting individuals, the key social drivers/practices that appeared to make people more vulnerable for HIV are gender norms, marriage characteristics (being remarried), and sexual behavior practices (lifetime number of sexual partners). Married and cohabiting couples are an important target group for HIV prevention efforts in Tanzania. In addition to individual interventions, structural interventions are needed to address the gender norms, remarriage, and sexual practices that shape differential vulnerability to HIV in stable couples. [ABSTRACT FROM AUTHOR]