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Background: Traditional healers play a significant role in Sub-Saharan Africa's healthcare system, but little is known about their role across the cancer care continuum in this context. Given the prevalence of patients consulting healers, we aimed to elucidate their role and impact on cancer care delivery in Sub-Saharan Africa., Methods: Following the PRISMA reporting standards, all research focused on the role of traditional healers in the cancer care continuum in sub-Saharan Africa was included in this scoping review. Data sources assessed include PubMed, Cochrane Library, Embase, and CINAHL Plus with Full Text, Scopus, Sociological Abstracts, African Journals Online, African Index Medicus, and Google Scholar. Studies that lacked perspectives on the healers' role, focused solely on the actual herbal medicines, were written in non-English language, were not primary research, or the full-text was unavailable were excluded. Two reviewers performed screening and data extraction for each article, confirmed by a third reviewer., Results: One thousand four hundred seventy-one studies were identified, with 1437 screened and 191 full-texts reviewed. Of those, 158 were excluded, and 33 (comprising of 1564 healers) were included for final data extraction and analysis. Five studies (64 healers) showed their role in prevention, eleven (454 healers) in diagnosis, twenty-seven (1524 healers) in treatment, and two (25 healers) in palliative care in Sub-Saharan Africa. While some desired increased collaboration with the biomedical system and referred patients, others lacked trust and remained hesitant to provide referrals., Conclusion: Results showed that traditional healers play an important role in cancer treatment. This provides an opportunity to leverage the skills of traditional healers to improve cancer outcomes, in a way that recognizes and respects local culture. Future research focused on improving the collaboration between traditional healers and the biomedical healthcare system may lead to strengthening the referral system and early detection and treatment of cancer., Registration:  This study was registered on PROSPERO, CRD42022293055., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Objectives: To identify, measure and value the economic burden of musculoskeletal (MSK) disorders in the Kilimanjaro region, Tanzania., Design: Community-based cross-sectional survey (undertaken between January and September 2021)., Setting: Hai district, Kilimanjaro, Tanzania., Participants: Households resident in the Hai district., Methods: A two-stage cluster sampling was used to select a representative sample of all Hai district residents. Clinical screening tools were used to identify and measure MSK disorders through a tiered approach. An economic questionnaire measuring healthcare costs, out-of-pocket costs, absenteeism, presenteeism and work productivity loss was administered to those with likely MSK disorders and selected controls (individuals without MSK disorders, matched by age and gender). Resource use was valued using country-specific costs. Two-part model regressions were fitted. A descriptive analysis of catastrophic expenditure was also conducted., Main Outcome Measure: Healthcare costs, productivity costs and total costs., Results: Annual average productivity and healthcare costs were, respectively, 3.5 and 3 times higher for those with likely MSK disorders than controls. Productivity costs of individuals with MSK disorders were Int$487 vs Int$132 in the control group (difference: Int$355, 95% CI Int$222 to Int$488). Healthcare costs in those with MSK were Int$269 vs Int$88 in the control group (difference: Int$181, 95% CI Int$34 to Int$327). The difference in terms of out-of-pocket expenses was economically substantial in magnitude, although not statistically significant., Conclusion: The evidence will be used to inform policies addressing MSK disorders, by promoting the design of interventions, service provision, health promotion and awareness activities at local, regional and national level., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

The increased prevalence of non-communicable diseases (NCDs) in recent years has led many Low- and Middle-Income Countries (LMICs), including Tanzania, to develop policies to manage their burden. Musculoskeletal (MSK) conditions, such as arthritis, account for 20% of all years lived with disability in LMICs, but the NCD strategies rarely address them. There is substantial research on the disruption MSK conditions cause to people's lives within High-Income Countries, but very little is known about the lived experiences in LMICs. We investigated the experience of MSK conditions in 48 in-depth qualitative interviews with participants from the Hai District in Tanzania, East Africa, all of whom had a MSK disorder (confirmed through clinical examination as part of a broader study). We found that loss of mobility and pain associated with MSK disorders severely limits people's everyday lives and livelihoods. Help from others, mainly those within a household, is necessary for most tasks and those with limited or no support experience particular problems. We found barriers to accessing care and treatment in the form of high direct and indirect (through travel) care costs within formal health services in Tanzania. We argue for increased attention to the growing problem of MSK disorders in LMICs and that this agenda should be driven by a patient-centred approach which designs services accessible to the target population and designed to recognise their embodied expertise., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Timely diagnosis of childhood cancer, early hospital presentation and completion of treatment significantly improve outcomes. Unfortunately, in Tanzania, thousands of children die of cancer each year without ever being diagnosed or treated. To reduce childhood death from cancer, it is important to understand the social-cultural context, values and beliefs that influence healthcare-seeking behaviours among the Tanzanian community., Methods: This was a cross-sectional qualitative study conducted in Mwanza, Kilimanjaro and Dar-es-Salaam regions between March and June 2021. We purposively selected community members aged ≥18 years from three rural and three urban settings to participate in seven focus group discussions (each with eight to 12 respondents). The participants were from communities without any affiliation to the treatment of children with cancer or treatment facilities. We transcribed, coded and analyzed data using a thematic-content approach with the support of NVIVO 12 software., Results: Many had heard of breast or cervical cancer; however, most were unaware of childhood cancer. Adults believe that cancer in children is caused by witchcraft and cannot be cured by modern medicines available at hospitals. These beliefs lead parents to first seek care from traditional healers, which hence delay presentation to the hospital. Other community concerns included the cost of transportation, investigation-related costs, and the long duration of treatment. These have an influence on treatment adherence leading to seeking alternative treatment, such as spiritual or traditional treatment., Conclusion: Low community awareness, late hospital presentation, and treatment abandonment remain a challenge in childhood cancer in most parts of Tanzania. Belief about childhood cancer being a result of witchcraft and superstition contributes to limited health-seeking behaviours. Cultural and contextually relevant awareness campaign interventions are needed to increase cancer knowledge in Tanzanian communities., (© 2024 Wiley Periodicals LLC.)

Introduction: Cancer-related stigma is a key driver of advanced breast cancer stage in Sub-Saharan Africa (SSA). We developed and tested the impact of a breast cancer survivor-led Stigma reduction intervention (SRI) on stigma and treatment adherence of newly diagnosed patients with breast cancer in Tanzania., Methods: Breast cancer survivors were trained on breast cancer knowledge and motivational interviewing. A total of 4 trained survivors delivered a SRI (standardized flipchart breast education talk, personal testimony, and motivational interviewing) to 30 newly diagnosed patients with breast cancer before treatment. Pre- and post-intervention knowledge surveys and stigma scale surveys were analyzed via Fisher's exact test and Wilcoxon rank-sum tests. A discussion was held with a group of survivors after the intervention period to elicit feedback on their intervention experience., Results: Among the 30 patients, breast cancer knowledge (median overall percent correct) increased from 28% (IQR: 18%-45%) to 85% (IQR: 79%-88%) (p < 0.001) and stigma (median score) decreased from 75 (IQR: 57-81) to 53 (IQR: 44-66) (p < 0.01) following the intervention. All participants were willing to pursue hospital-based treatment after undergoing the intervention. Eighty-seven percent (n = 26) initiated treatment at 8-week follow-up after the intervention. All survivors endorsed feeling empowered and valued in their role in this intervention., Conclusions: Breast cancer survivors are a powerful group to combat the lack of knowledge and stigma in community and healthcare settings. Expanding the scope and scale of this intervention holds promise for improving treatment-seeking behavior and ultimately breast cancer outcomes in SSA., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Importance: Effective communication between patients and health care teams is essential in the health care setting for delivering optimal cancer care and increasing cancer awareness. While the significance of communication in health care is widely acknowledged, the topic is largely understudied within African settings., Objective: To assess how the medical language of cancer and oncology translates into African languages and what these translations mean within their cultural context., Design, Setting, and Participants: In this multinational survey study in Africa, health professionals, community health workers, researchers, and scientists involved in cancer care and research and traditional healers were invited to participate in an online survey on a voluntary basis through online platforms. The survey provided 16 cancer and oncologic terms used in cancer diagnosis and treatment (eg, cancer, radiotherapy) to participants, mostly health care workers, who were asked to provide these terms in their local languages (if the terms existed) followed by a direct or close translation of the meaning in English. The survey was open from February to April 2023., Main Outcomes and Measures: Patterns of meaning that recurred across languages were identified using thematic analysis of 16 English-translated terms categorized into 5 themes (neutral, negative, positive, phonetic or borrowed, and unknown)., Results: A total of 107 responses (response rate was unavailable given the open and widespread distribution strategy) were collected from 32 countries spanning 44 African languages, with most participants (63 [59%]) aged 18 to 40 years; 54 (50%) were female. Translations for cancer were classified as phonetic or borrowed (34 [32%]), unknown (30 [28%]), neutral (24 [22%]), and negative (19 [18%]), with the latter category including universal connotations of fear, tragedy, incurability, and fatality. Similar elements connoting fear or tragedy were found in translations of terms such as malignant, chronic, and radiotherapy. The term radiotherapy yielded a high percentage of negative connotations (24 [22%]), with a prevailing theme of describing the treatment as being burned or burning with fire, heat, or electricity, which may potentially hinder treatment., Conclusions and Relevance: In this survey study of cancer communication and the translation of oncology terminology in African languages, the findings suggest that the terminology may contribute to fear, health disparities, and barriers to care and pose communication difficulties for health professionals. The results reinforce the need for culturally sensitive cancer terminology for improving cancer awareness and communication.

Capability wellbeing can potentially provide a holistic outcome for health economic evaluation and the capability approach seems promising for African countries. As yet there is no work that has explored the evaluative space needed for health and care decision making at the whole population level and procedures that merely translate existing measures developed in the global north to contexts in the global south risk embedding structural inequalities. This work seeks to elicit the concepts within the capability wellbeing evaluative space for general adult populations in Tanzania and Malawi. Semi-structured interviews with 68 participants across Tanzania and Malawi were conducted between October 2021 and July 2022. Analysis used thematic coding frames and the writing of analytic accounts. Interview schedules were common across the two country settings, however data collection and analysis were conducted independently by two separate teams and only brought together once it was clear that the data from the two countries was sufficiently aligned for a single analysis. Eight common attributes of capability wellbeing were found across the two countries: financial security; basic needs; achievement and personal development; attachment, love and friendship; participation in community activities; faith and spirituality; health; making decisions without unwanted interference. These attributes can be used to generate outcome measures for use in economic evaluations comparing alternative health interventions. By centring the voices of Tanzanians and Malawians in the construction of attributes that describe a good life, the research can facilitate greater equity within economic evaluations across different global settings., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Cancer stigma presents a critical barrier to care seeking, contributing to delayed presentation and poor cancer outcomes worldwide. The burden of cancer in Tanzania is on the rise, with cancer being the third-leading cause of death in the country. Despite rising incidence and poor outcomes of cancer, cancer-related stigma interventions have received low prioritization. There is a need for sound research that focuses on understanding attitudes driving stigma, its impact on care-seeking and treatment adherence, and intervention models to reduce stigma. We used a cross-sectional qualitative study design. We administered three open-ended qualitative questions to 140 adults newly diagnosed with cancer in Moshi, Tanzania. The questions explored common attitudes toward people with cancer, the perceived impact of cancer-related stigma on care engagement, and ideas for reducing cancer stigma. Patients were recruited during routine appointments at the Cancer Center at Kilimanjaro Christian Medical Center. Data were analyzed using a team-based, applied thematic approach and NVivo 12 software. All participants described stigma as a significant challenge for treatment and receiving support from their social networks. Perceptions of financial burden, misconceptions about cancer, such as the belief that it is contagious, and fear of death, were common attitudes driving cancer stigma. Most participants feared that symptoms would prevent them from being able to work and that the cost of cancer care would drive away loved ones. Stigma was not a ubiquitous response, as some participants reported increased care and social support from family members after a cancer diagnosis. Experiences of stigma contributed to feelings of shame, fear of burdening the family, reduced resources to access treatment, and disengagement from care. Common substitutes to medical therapies included religious interventions and traditional medicine, perceived as less expensive and less stigmatizing. Many participants felt they would benefit from improved financial support, professional counseling, and education for families and communities to reduce stigmatizing attitudes and enhance social support. There is a need for intervention studies focused on improving cancer literacy, community advocacy to reduce cancer stigma, and increasing emotional and practical support for people with cancer and their families. There is also a clear need for policy efforts to make cancer care more affordable and accessible to reduce the financial burden on patients and families., Competing Interests: I have read the journal’s policy, and the authors of this manuscript have the following competing interests: Dr. Knettel is a scientific advisor for Cancer Support Community. Nosayaba Osazuwa-Peters is a scientific advisor for Navigating Cancer. The other authors have no competing interests, financial or otherwise, to report regarding this research., (Copyright: © 2024 Mwobobia et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Musculoskeletal disorders, experienced as joint pain, are a significant global health problem, but little is known about how joint pain is categorised and understood in Tanzania. Understanding existing conceptualisations of and responses to joint pain is important to ensure both research and interventions are equitable and avoid biomedical imposition., Methods: Rapid ethnographic appraisal was conducted in a periurban and rural community in Kilimanjaro, documenting language used to describe joint pain, ideas about causes, understandings of who experiences such pain, the impacts pain has and how people respond to it. We conducted 66 interviews with community leaders, traditional healers, community members and pharmacists.Photographs were taken and included in fieldnotes to supplement the interview data and develop thick descriptions. Data were analysed by constant comparison using QDA Miner software., Results: Across the sample, dominant concepts of joint pain were named ugonjwa wa baridi , cold disease; ugonjwa wa uzee , old age disease; rimatizim , disease of the joints; and g auti , gout. Causes mentioned included exposure to the cold, old age, alcohol and red meat consumption, witchcraft, demons and injuries/falls. Age, gender and occupation were seen as important factors for developing joint pain. Perceived impacts of joint pain included loss of mobility, economic and family problems, developing new health conditions, death, reduction in sexual functioning and negative self-perceptions. Responses to joint pain blended biomedical treatments, herbal remedies, consultations with traditional healers and religious rituals., Conclusions: Conceptualisations of and responses to joint pain in the two communities were syncretic, mixing folk and biomedical practices. Narratives about who is affected by joint pain mirror emerging epidemiological findings, suggesting a strong 'lay epidemiology' in these communities. Anthropological methods can support the decolonisation of global health by decentring the imposition of English language biomedicine and pursuing synthetic, dignified languages of care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

In Tanzania, there are high rates of suicidal thoughts and behavior among people living with HIV (PLWH), yet few instruments exist for effective screening and referral. To address this gap, we developed and validated Swahili translations of the Columbia Suicide Severity Rating Scale (C-SSRS) Screen Version and two accompanying scales assessing self-efficacy to avoid suicidal action and reasons for living. We administered a structured survey to 80 PLWH attending two HIV clinics in Moshi, Tanzania. Factor analysis of the items revealed four subscales: suicide intensity, self-efficacy to avoid suicide, fear and social concern about suicide, and family and spirituality deterrents to suicide. The area under the receiver operating curve showed only suicide intensity, and fear and social concern met the prespecified cutoff of ≥0.7 in accurately identifying patients with a plan and intent to act on suicidal thoughts. This study provides early evidence that brief screening of intensity of suicidality in the past month, assessed by the C-SSRS Screen Version, is a strong, resource-efficient strategy for identifying suicide risk in the Tanzanian setting. Patients who report little fear of dying and low concern about social perceptions of suicide may also be at increased risk., Competing Interests: The authors declare none., (© The Author(s) 2023.)

Objective: Suicidal ideation is strikingly common among people living with HIV (PLWH) worldwide, leading to higher burden of disease, poor HIV care engagement, and loss of life. In low- and middle-income countries such as Tanzania, mental health resources are scarce, requiring innovative strategies for treatment. We describe the protocol for a clinical trial of a three-session telehealth counseling intervention to reduce suicidality and improve HIV care engagement in Tanzania., Methods: In a pilot randomized controlled trial, we will assess the feasibility, acceptability, and potential efficacy of a new telehealth intervention, termed "IDEAS for Hope". A total of 60 PLWH will be enrolled from two HIV clinics in the Kilimanjaro region and connected to telehealth counsellors based at a large regional hospital. Participants will be ≥18 years old and speak either Kiswahili or English. Patient screening will occur during routine HIV clinical care to identify PLWH experiencing suicidal ideation. Baseline surveys will be administered upon enrollment and participants will be randomized 1:1 to receive either IDEAS for Hope or the comparison condition, a brief safety planning session. All participants will receive an additional referral for psychiatric treatment. Follow-up assessment will occur at three months. IDEAS for Hope is informed by a Motivational Interviewing-enhanced safety planning intervention (MI-SafeCope) and our formative work in Tanzania. The model consists of Four Pillars: living healthy with HIV, managing HIV stigma, seeking social support, and meeting basic needs. Together, these mechanisms serve as a foundation for developing a sense of safety and hope for the future. Outcome measures will include intervention feasibility, acceptability, participant suicidality, and HIV care engagement., Significance: Innovative, telehealth-based counseling represents a promising treatment for suicidality among PLWH in low-resource settings. Results from this pilot trial will inform intervention refinement and parameter estimates for a future clinical trial powered to evaluate effectiveness., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Knettel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: Taenia solium (T. solium) neurocysticercosis (NCC) affects the central nervous system and is associated with 30% of acquired epilepsy in some endemic areas. Epilepsy is a stigmatizing disease in many societies and people with epilepsy (PWE) and their families experience discrimination. This study aimed to explore the knowledge, perceptions, and experiences of epilepsy among PWE and their caregivers attending mental health clinics., Methods: In T. solium endemic areas of Tanzania, PWE and their caregivers attending mental health clinics were identified and their informed consent was sought prior to study participation. In-depth interviews were conducted in Swahili language and analyzed thematically. The coding was undertaken by two independent researchers using NVivo (Version 12, QSR International)., Results: Thirty-eight participants were interviewed. Three themes were identified during the analysis, namely, knowledge about epilepsy; perception of epilepsy; and experience with epilepsy among PWE and their caregivers. Participants commonly defined epilepsy as a "falling disease," perceived to be caused by witchcraft, and were unaware of the association between T. solium and epilepsy. Stigmatization of epilepsy was reported as a problem. Reported treatment patterns after the initial onset of epilepsy varied widely; however, patients usually began treatment with traditional healing methods, and only later opted for biomedical treatment. Patients had generally poor adherence to antiseizure medication, which could be caused by inadequate knowledge or irregular supply., Significance: Level of knowledge about epilepsy was low, and NCC was not mentioned as a cause of epilepsy among participants. Epilepsy was generally perceived to be the result of witchcraft, evil spirits, or curses. Health education is needed, including an explanation of the model of T. solium transmission and the insistence on hygiene measures. This could reduce the number of new infections with T. solium, improve access to prompt biomedical treatment, and improve the lives of PWE., (© 2023 The Authors. Epilepsia Open published by Wiley Periodicals LLC on behalf of International League Against Epilepsy.)

Background: The current Coronavirus disease pandemic reveals political and structural inequities of the world's poorest people who have little or no access to health care and yet the largest burdens of poor health. This is in parallel to a more persistent but silent global health crisis, antimicrobial resistance (AMR). We explore the fundamental challenges of health care in humans and animals in relation to AMR in Tanzania., Methods: We conducted 57 individual interviews and focus groups with providers and patients in high, middle and lower tier health care facilities and communities across three regions of Tanzania between April 2019 and February 2020. We covered topics from health infrastructure and prescribing practices to health communication and patient experiences., Results: Three interconnected themes emerged about systemic issues impacting health. First, there are challenges around infrastructure and availability of vital resources such as healthcare staff and supplies. Second, health outcomes are predicated on patient and provider access to services as well as social determinants of health. Third, health communication is critical in defining trusted sources of information, and narratives of blame emerge around health outcomes with the onus of responsibility for action falling on individuals., Conclusion: Entanglements between infrastructure, access and communication exist while constraints in the health system lead to poor health outcomes even in 'normal' circumstances. These are likely to be relevant across the globe and highly topical for addressing pressing global health challenges. Redressing structural health inequities can better equip countries and their citizens to not only face pandemics but also day-to-day health challenges., (© 2022. The Author(s).)

Background: Early access to diagnosis is crucial for effective management of any disease including tuberculosis (TB). We investigated the barriers and opportunities to maximise uptake and utilisation of molecular diagnostics in routine healthcare settings., Methods: Using the implementation of WHO approved TB diagnostics, Xpert Mycobacterium tuberculosis /rifampicin (MTB/RIF) and Line Probe Assay (LPA) as a benchmark, we evaluated the barriers and how they could be unlocked to maximise uptake and utilisation of molecular diagnostics., Results: Health officers representing 190 districts/counties participated in the survey across Kenya, Tanzania and Uganda. The survey findings were corroborated by 145 healthcare facility (HCF) audits and 11 policy-maker engagement workshops. Xpert MTB/RIF coverage was 66%, falling behind microscopy and clinical diagnosis by 33% and 1%, respectively. Stratified by HCF type, Xpert MTB/RIF implementation was 56%, 96% and 95% at district, regional and national referral hospital levels. LPA coverage was 4%, 3% below culture across the three countries. Out of 111 HCFs with Xpert MTB/RIF, 37 (33%) used it to full capacity, performing ≥8 tests per day of which 51% of these were level five (zonal consultant and national referral) HCFs. Likewise, 75% of LPA was available at level five HCFs. Underutilisation of Xpert MTB/RIF and LPA was mainly attributed to inadequate-utilities, 26% and human resource, 22%. Underfinancing was the main reason underlying failure to acquire molecular diagnostics. Second to underfinancing was lack of awareness with 33% healthcare administrators and 49% practitioners were unaware of LPA as TB diagnostic. Creation of a national health tax and decentralising its management was proposed by policy-makers as a booster of domestic financing needed to increase access to diagnostics., Conclusion: Our findings suggest higher uptake and utilisation of molecular diagnostics at tertiary level HCFs contrary to the WHO recommendation. Country-led solutions are crucial for unlocking barriers to increase access to diagnostics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Early diagnosis and timely treatment are key elements of a successful healthcare system. We assessed the role of socioeconomic and cultural norms in accelerating or decelerating uptake and utilisation of health technologies into policy and practice., Setting: Secondary and tertiary level healthcare facilities (HCFs) in three East African countries. Level of HCF was selected based on the WHO recommendation for implantation of tuberculosis (TB) molecular diagnostics., Participants: Using implementation of TB diagnostics as a model, we purposively selected participants (TB patients, carers, survivors, healthcare practitioners, community members, opinion leaders and policy-makers) based on their role as stakeholders. In-depth interviews, key informant interviews and focus group discussions were held to collect the data between 2016 and 2018. The data were transcribed, translated, coded and analysed by thematic-content analysis., Results: A total of 712 individuals participated in the study. Socioeconomic and cultural factors such as poverty, stigma and inadequate knowledge about causes of disease and available remedies, cultural beliefs were associated with low access and utilisation of diagnostic and treatment tools for TB. Poverty made people hesitate to seek formal healthcare resulting in delayed diagnosis and resorting to self-medication and cheap herbal alternatives. Fear of stigma made people hide their sickness and avoid reporting for follow-up treatment visits. Inadequate knowledge and beliefs were fertile ground for aggravated stigma and believing that diseases like TB are caused by spirits and thus cured by spiritual rituals or religious prayers. Cultural norms were also the basis of gender-based imbalance in accessing care, 'I could not go to hospital without my husband's permission', TB survivor., Conclusion: Our findings show that socioeconomic and cultural factors are substantial 'roadblocks' to accelerating the uptake and utilisation of diagnostic and treatment tools. Resolving these barriers should be given equal attention as is to health system barriers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Uncertainty about the causes of death (COD) in low- and middle-income countries (LMICs) has been recognized as a constraint to global health and development. Although complete diagnostic autopsy (CDA) is the best way to assess COD, it is uncommon in LMICs because of low investment priority and assumptions about poor acceptability. Social science research was conducted from May 2016 through July 2017 to examine issues related to acceptability of CDAs in northern Tanzania where autopsy was being offered in two referral hospitals to assess COD associated with febrile illness. Initial formative research entailed 29 key informant interviews, seven observations of burial practices, and four group discussions. In-depth interviews were conducted with families of deceased, including nine families that accepted and 11 families that refused CDA. The formative research identified concepts related to death, understandings of CDA, and cultural practices and psychosocial considerations associated with death that informed the authorization process. Most families who accepted CDA cited the desire to get clarity regarding the COD as a primary reason for acceptance. An unexpected finding was that CDA is perceived as a means to determine witchcraft involvement, a common explanation for COD and a common reason for postmortem acceptance. Death resulting from chronic illness or conditions presumed to have a clinical diagnosis were reasons for CDA to be viewed as unnecessary. The timing, way families were approached, and content of information shared during authorization influenced acceptance and refusal of CDA. Findings show that CDAs can be acceptable in settings where traditional disease models prevail.

Infectious diseases are a leading cause of mortality in low- and middle-income countries (LMICs) despite effective treatments. To study the sociocultural and health system barriers to care, we conducted a qualitative social autopsy study of patients who died from febrile illness in northern Tanzania. From December 2016 through July 2017, we conducted in-depth interviews in Arusha and Kilimanjaro regions with a purposive sample of 20 family members of patients who had died at two regional referral hospitals. Of the deceased patients included in this study, 14 (70%) were adults and 10 (50%) were female. Patients identified their religion as Catholic (12, 60%), Lutheran (six, 30%), and Muslim (two, 10%), and their ethnicity as Chagga (14, 70%) and Sambaa (two, 10%), among others. Family members reported both barriers to and facilitators of receiving health care. Barriers included a perceived lack of capacity of local health facilities, transportation barriers, and a lack of formal referrals to higher levels of care. Family members also reported the cost of health care as a barrier. However, one facilitator of care was access to financial resources via families' social networks-a phenomenon we refer to as social capital. Another facilitator of care was families' proactive engagement with the health system. Our results suggest that further investment in lower level health facilities may improve care-seeking and referral patterns and that future research into the role of social capital is needed to fully understand the effect of socioeconomic factors on healthcare utilization in LMICs.