Generalized and COVID related anxiety as risk factors for health outcomes among adolescents with HIV during COVID-19 in Tanzania.

The COVID-19 pandemic and associated prevention strategies caused widespread interruptions to care and treatment for people living with HIV. Adolescents living with HIV (AWHIV) were particularly vulnerable to poor mental and physical health during COVID-19. We assessed the burden of generalized and COVID-19-related anxiety and associations with adherence to HIV care and treatment and viral load suppression (VLS) among AWHIV during the peak of the COVID-19 pandemic in Tanzania. Methods: This cross-sectional study was conducted among AWHIV aged 15-19 years attending 10 clinics in Dar es Salaam from April 2022-February 2023. Study participants completed a self-administered questionnaire including Generalized Anxiety Disorder (GAD), COVID-19-related anxiety, and other psychosocial and physical health and support measures. HIV visit adherence, viral load and sociodemographic data were abstracted from patient health records.Analysis:: Multivariable (MV) quasibinomial and logistic regression models examined associations of Generalized and COVID-19-related anxiety with visit adherence and HIV virologic suppression (HIV VL < 50 copies/mL). Data were analyzed using R software. Results: 658 AWHIV (52% male) were included in this analysis. Most (86%) had been on antiretroviral treatment (ART) for at least four years, 55% attended at least 75% of their scheduled clinic visits, and 78% were HIV virologically suppressed. The median GAD and COVID-19-related anxiety scores were 2 (IQR: 0-5, and 26 (IQR: 13-43; respectively. Only 2% scored moderate-severe generalized anxiety (score 10-21). We found no significant associations between COVID-19-related anxiety or GAD and visit adherence. Higher GAD was inversely associated with VLS (adjusted odds ratio (AOR): 0.89 (95% CI 0.81, 0.98)). Female gender and higher quality of physical life were significantly associated with VLS. Conclusion: Low levels of generalized and COVID-19 related anxiety were reported among Tanzanian AWHIV. Integrating screening and management of generalized anxiety screening into HIV care for AWHIV could improve VLS among this population.

Incidence and determinants of perinatal mortality in five urban hospitals in Dar es Salaam, Tanzania: a cohort study with an embedded case-control analysis.

INTRODUCTION: Tanzania has one of the highest burdens of perinatal mortality, with a higher risk among urban versus rural women. To understand the characteristics of perinatal mortality in urban health facilities, study objectives were: I. To assess the incidence of perinatal deaths in public health facilities in Dar es Salaam and classify these into a) pre-facility stillbirths (absence of fetal heart tones on admission to the study health facilities) and b) intra-facility perinatal deaths before discharge; and II. To identify determinants of perinatal deaths by comparing each of the two groups of perinatal deaths with healthy newborns. METHODS: This was a retrospective cohort study among women who gave birth in five urban, public health facilities in Dar es Salaam. I. Incidence of perinatal death in the year 2020 was calculated based on routinely collected health facility records and the Perinatal Problem Identification Database. II. An embedded case-control study was conducted within a sub-population of singletons with birthweight ≥ 2000 g (excluding newborns with congenital malformations); pre-facility stillbirths and intra-facility perinatal deaths were compared with 'healthy newborns' (Apgar score ≥ 8 at one and ≥ 9 at five minutes and discharged home alive). Descriptive and logistic regression analyses were performed to explore the determinants of deaths. RESULTS: A total of 37,787 births were recorded in 2020. The pre-discharge perinatal death rate was 38.3 per 1,000 total births: a stillbirth rate of 27.7 per 1,000 total births and an intra-facility neonatal death rate of 10.9 per 1,000 live births. Pre-facility stillbirths accounted for 88.4% of the stillbirths. The case-control study included 2,224 women (452 pre-facility stillbirths; 287 intra-facility perinatal deaths and 1,485 controls), 99% of whom attended antenatal clinic (75% with more than three visits). Pre-facility stillbirths were associated with low birth weight (cOR 4.40; (95% CI: 3.13-6.18) and with maternal hypertension (cOR 4.72; 95% CI: 3.30-6.76). Intra-facility perinatal deaths were associated with breech presentation (aOR 40.3; 95% CI: 8.75-185.61), complications in the second stage (aOR 20.04; 95% CI: 12.02-33.41), low birth weight (aOR 5.57; 95% CI: 2.62-11.84), cervical dilation crossing the partograph's action line (aOR 4.16; 95% CI:2.29-7.56), and hypertension during intrapartum care (aOR 2.9; 95% CI 1.03-8.14), among other factors.  CONCLUSION: The perinatal death rate in the five urban hospitals was linked to gaps in the quality of antenatal and intrapartum care, in the study health facilities and in lower-level referral clinics. Urgent action is required to implement context-specific interventions and conduct implementation research to strengthen the urban referral system across the entire continuum of care from pregnancy onset to postpartum. The role of hypertensive disorders in pregnancy as a crucial determinant of perinatal deaths emphasizes the complexities of maternal-perinatal health within urban settings.

Impact evaluation of the TAMANI project to improve maternal and child health in Tanzania.

BACKGROUND: The Tabora Maternal and Newborn Health Initiative project was a multicomponent intervention to improve maternal and newborn health in the Tabora region of Tanzania. Components included training healthcare providers and community health workers, infrastructure upgrades, and improvements to health management. This study aimed to examine the impact of trainings on four key outcomes: skilled birth attendance, antenatal care, respectful maternity care and patient-provider communication. METHODS: Trainings were delivered sequentially at four time points between 2018 and 2019 in eight districts (two districts at a time). Cross-sectional surveys were administered to a random sample of households in all districts at baseline and after each training wave. Due to practical necessities, the original stepped wedge cluster randomised design of the evaluation was altered mid-programme. Therefore, a difference-in-differences for multiple groups in multiple periods was adopted to compare outcomes in treated districts to not yet treated districts. Risk differences were estimated for the overall average treatment effect on the treated and group/time dynamic effects. RESULTS: Respondents reported 3895 deliveries over the course of the study. The intervention was associated with a 12.9 percentage point increase in skilled birth attendance (95% CI 0.4 to 25.4), which began to increase 4 months after the end of training in each district. There was little evidence of impact on antenatal care visits, respectful treatment during delivery and patient-provider communication. CONCLUSION: Interventions to train local healthcare workers in basic and comprehensive emergency obstetric and newborn care increased skilled birth attendance but had limited impact on other pregnancy-related outcomes.

Accuracy of a smartphone application for blood pressure estimation in Bangladesh, South Africa, and Tanzania.

Undetected and unmonitored hypertension carries substantial mortality and morbidity, especially during pregnancy. We assessed the accuracy of OptiBPTM, a smartphone application for estimating blood pressure (BP), across diverse settings. The study was conducted in community settings: Gaibandha, Bangladesh and Ifakara, Tanzania for general populations, and Kalafong Provincial Tertiary Hospital, South Africa for pregnant populations. Based on guidance from the International Organization for Standardization (ISO) 81,060-2:2018 for non-invasive BP devices and global consensus statement, we compared BP measurements taken by two independent trained nurses on a standard auscultatory cuff to the BP measurements taken by a research version of OptiBPTM called CamBP. For ISO criterion 1, the mean error was 0.5 ± 5.8 mm Hg for the systolic blood pressure (SBP) and 0.1 ± 3.9 mmHg for the diastolic blood pressure (DBP) in South Africa; 0.8 ± 7.0 mmHg for the SBP and -0.4 ± 4.0 mmHg for the DBP in Tanzania; 3.3 ± 7.4 mmHg for the SBP and -0.4 ± 4.3 mmHg for the DBP in Bangladesh. For ISO criterion 2, the average standard deviation of the mean error per subject was 4.9 mmHg for the SBP and 3.4 mmHg for the DBP in South Africa; 6.3 mmHg for the SBP and 3.6 mmHg for the DBP in Tanzania; 6.4 mmHg for the SBP and 3.8 mmHg for the DBP in Bangladesh. OptiBPTM demonstrated accuracy against ISO standards in study populations, including pregnant populations, except in Bangladesh for SBP (criterion 2). Further research is needed to improve performance across different populations and integration within health systems.

Evaluation of long-lasting insecticidal net distribution through schools in Southern Tanzania.

Universal coverage with effective vector control remains the mainstay of malaria vector control in sub-Saharan Africa. Tanzania has utilized a number of mechanisms for the maintenance of long-lasting insecticidal net (LLIN) coverage over time. Schools have been identified as one potential channel for continuous distribution of LLIN. This research aims to evaluate an annual school-based LLIN distribution programme in Tanzania that began in 2013, called the School Net Programme (SNP). Following each of the first four rounds of SNP distribution, a household survey was conducted in intervention and comparison districts in Southern and Lake zones of Tanzania (N = 5083 households). Measures of ownership, access and use were compared between intervention and comparison districts. Determinants of reach were assessed in intervention districts. Population access to an LLIN increased from 63.1% (95% CI: 58.8, 67.5) to 76.5% (95% CI: 72.9, 80.0) in the intervention districts between the first and last surveys. Access also rose in the comparison districts from 51.4% (95% CI: 46.9, 55.9) to 79.8% (95% CI: 77.3, 82.0) following mass distribution and implementation of school-based distribution during the study period. LLIN use increased in intervention districts from 44.9% (95% CI: 40.5, 49.3) to 65.6% (95% CI: 59.4, 71.8) and from 57.2% (95% CI: 49.7, 64.7) to 77.4% (95% CI: 69.3, 85.5) specifically amongst primary school-aged children. Households reached by the SNP were wealthier households with children enrolled in school. The SNP in Tanzania was able to maintain population level LLIN ownership, use and access in the absence of mass distribution. The SNP successfully reached households that housed school-aged children. Alternative delivery strategies may need to be considered to reach households without children enrolled in schools that experienced fewer benefits from the programme.

A comparative analysis of determinants of low birth weight and stunting among under five children of adolescent and non-adolescent mothers using 2015/16 Tanzania Demographic and Health Survey (TDHS).

BACKGROUND: Tanzania is one of the Sub-Saharan African country with nearly 12 out of 60 million people being adolescent. The prevalence of child marriage is higher with one out of every three girls being married before reaching their 18th birthday, 5 % being married by the age of 15, and 31% by the age of 18 years. Literature shows early pregnancy is associated with Low Birth Weight (LBW) and stunting among children under 5 years. This paper explores variation and factors associated with low birth weight and stunting among children born by adolescent and non-adolescent mothers. METHODS: Data from 13,266 women with children under 5 years collected as part of the 2015/2016 TDHS was re-analyzed using STATA version 14 software while accounting for survey design. A total of 6385 women (of which 7.2% were adolescent) and 8852 women (of which 6.7% were adolescent) were involved in the analysis of child birth weight and stunting respectively. Descriptive statistics stratified by maternal age was conducted with LBW and stunting as outcome variables followed by logistic regressions models controlling for confounding variables. RESULTS: The proportion of obese or overweight adolescent and non-adolescent mothers was 11.8 and 36.5% respectively. Antenatal care (ANC) attendance, areas of residence and social economic status were very similar in the two maternal age groups. Non- adolescent mothers had reduced odds of giving birth to LBW babies compared to adolescent mothers (Adjusted Odds Ratio (AOR) = 0.34; 95% CI: 0.22-0.50). Maternal undernutrition (AOR = 2.29; 95% CI: 1.43-3.67), being divorced, separated or widowed (AOR = 1.76; 95% CI: 1.24-2.50) and having at least four ANC visits (AOR = 0.64; 95% CI: 0.49-0.83) were significantly associated with reduced odds of having a LBW. Child stunting was not associated with maternal age. Maternal high socioeconomic status (AOR = 0.69; 95% CI: 0.57-0.84) and maternal obesity or overweight (AOR = 0.77; 95% CI: 0.64-0.92) were negatively associated with stunting. Child birth weight, sex, and age were significantly associated with stunting. CONCLUSION: Maternal age was a predictor of LBW but not stunting. ANC attendance and not living with a spouse increase the risk of LBW babies. Stunting was associated with low maternal body mass index (BMI), low socioeconomic status, child birth weight, gender, and age. A multi-sectoral approach is needed to address child nutrition problems with teenagers 'specific intervention that offer emotional support, and health education during pregnancies for improving immediate and later life child birth outcomes.

Factors affecting non-coverage of measles-rubella vaccination among children aged 9-59 months in Tanzania.

Globally, measles remains a major cause of child mortality, and rubella is the leading cause of birth defects among all infectious diseases. In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan that set a target to eliminate Measles-Rubella (MR) in five of the six World Health Organization (WHO) regions by 2020. This was cross-sectional study employed both quantitative and qualitative research methods. The sample size was calculated to provide overall, age- and sex-specific coverage estimates for MR vaccine among children aged between 9 and 59 months at the national level. Using desired precision of ±5% with an expected coverage of 95%, a total of 15,235 households were required. The age of children, a child who had received the MR vaccine before the campaign, household wealth quintile, the age of caregivers, and their marital status were associated with non-coverage of MR vaccination among children aged 9-59 months in Tanzania. Nationally, an estimated 88.2% (95% CI: 87.3-89%) of children aged 9-59 months received the MR campaign dose, as assessed by caregivers' recall. These estimates revealed slightly higher coverage in Zanzibar 89.6% (95% CI: 84.7-93%) compared to Mainland Tanzania 88.1% (95% CI 87.2-88.9%). These associated factors revealed causes of unvaccinated children and may be some of the reasons for Tanzania's failure to meet the MR campaign target of 95 percent vaccination coverage. Thus, vaccine development must increase programmatic oversight in order to improve immunization activities and communication strategies in Tanzanian areas with low MR coverage.

Effectiveness of integrated nutrition interventions on childhood stunting: a quasi-experimental evaluation design.

BACKGROUND: Although malnutrition particularly stunting is recognized as multi-causal, there has been limited integrated nutrition interventions to reduce its burden in children under-fives and those existing are not well evaluated. This study tested the effectiveness of provision of health and nutrition education and promotion of home gardening in child stunting. METHODS: The study used a quasi-experimental evaluation design. Two rounds of household surveys were done to assess changes in behaviors (uptake of Antenatal Care services and child feeding practices) and stunting among children under-5 years. The sample size was calculated to detect a 10% percent absolute baseline-to-end-line change in stunting. A two-stage stratified sampling process was used to sample 896 and 1736 households at each round of data collection in the intervention and control districts respectively. Mothers delivered in the past 24 months preceding the survey and all children under-5 years residing in selected households were eligible. The difference in difference (DID) analysis was used to estimate effect of the interventions. All ethical clearances were obtained from relevant authorities prior to data collection. RESULTS: A total of 3467 and 4145 children under 5 years were recruited at baseline and endline respectively. The proportional of stunted children decreases from 35.9 to 34.2% in intervention and from 29.3 to 26.8% in the control sites. Overall, no statistically significant stunting reduction was observed between intervention and control sites. However, a significant effect was observed in intermediate outcomes; Uptake of iron folic acid (DID: 5.2%, (95% CI: 1.7-8.7), p = 0.003), health facility delivery (DID: 6.5%, (95% CI: 1.8-11.2), p = 0.006), pre-lacteal feeding (DID: - 5.9%, (95%CI: - 9.2, - 2.5), p = 0.001), breast feeding within 1 h after birth (DID: 7.8%, (95%CI: 2.2-13.4), p = 0.006) and exclusive breast feeding in children under 6 months (DID:20.3%, (95% CI: 10.5-30.1), p = 0.001). CONCLUSION: The 3 years program did not result in significant evidence of stunting reduction, but the observed effect on health and nutrition behavioural indicators are at the causal pathways to improved child nutritional outcomes in the long run. Implementation of these integrated packages over a longer duration is needed to witness significant reduction in the prevalence of stunting.

The consequences of declining population access to insecticide-treated nets (ITNs) on net use patterns and physical degradation of nets after 22 months of ownership.

BACKGROUND: As insecticide-treated nets (ITNs) wear out and are disposed, some household members are prioritized to use remaining ITNs. This study assessed how nets are allocated within households to individuals of different age categories as ITNs are lost or damaged and as new ITNs are obtained. The study also explored how ITN allocation affects ITN durability. METHODS: A cross-sectional household survey and ITN durability study was conducted among 2,875 households across Tanzania to determine the proportion of nets that remain protective (serviceable) 22 months after net distribution aiming for universal coverage. Allocation of study nets within houses, and re-allocation of ITNs when new universal replacement campaign (URC) nets arrived in study households in Musoma District, was also assessed. RESULTS: Some 57.0% (95% CI 53.9-60.1%) of households had sufficient ITNs for every household member, while 84.4% (95% CI 82.4-86.4%) of the population had access to an ITN within their household (assuming 1 net covers every 2 members). In households with sufficient nets, 77.5% of members slept under ITNs. In households without sufficient nets, pregnant women (54.6%), children < 5 years (45.8%) and adults (42.1%) were prioritized, with fewer school-age children 5-14 years (35.9%), youths 15-24 years (28.1%) and seniors > 65 years (32.6%) sleeping under ITNs. Crowding ([Formula: see text] 3 people sleeping under nets) was twice as common among people residing in houses without sufficient nets for all age groups, apart from children < 5. Nets were less likely to be serviceable if: [Formula: see text] 3 people slept under them (OR 0.50 (95% CI 0.40-0.63)), or if nets were used by school-age children (OR 0.72 (95% CI 0.56-0.93)), or if the net product was Olyset®. One month after the URC, only 23.6% (95% CI 16.7-30.6%) of the population had access to a URC ITN in Musoma district. Householders in Musoma district continued the use of old ITNs even with the arrival of new URC nets. CONCLUSION: Users determined the useful life of ITNs and prioritized pregnant women and children < 5 to serviceable ITNs. When household net access declines, users adjust by crowding under remaining nets, which further reduces ITN lifespan. School-age children that commonly harbour gametocytes that mediate malaria transmission are compelled to sleep under unserviceable nets, crowd under nets or remain uncovered. However, they were accommodated by the arrival of new nets. More frequent ITN delivery through the school net programme in combination with mass distribution campaigns is essential to maximize ITN effectiveness.

Adherence to Iron-Folic Acid Supplementation and Associated Factors among Pregnant Women in Kasulu Communities in North-Western Tanzania.

INTRODUCTION: Pregnant women are at a high risk of anaemia, with iron-folate deficiency being the most common cause of anaemia among pregnant women. Despite the well-known importance of iron and folic acid supplementation (IFAS) during pregnancy, adherence to these supplements is relatively low and associated factors were not well identified in the study area. This study is aimed at investigating adherence to IFAS and associated factors among pregnant women in Kasulu district, north-western Tanzania. METHODS: A health facility cross-sectional survey with a mixed-method approach was conducted in Kasulu district from March to April 2019. A structured questionnaire was given to 320 women with children aged 0-6 months to assess factors associated with adherence to IFAS among pregnant women. Data were entered into SPSS version 22.0 for analysis. Binary logistic regression was further employed to determine the factors associated with adherence to IFAS. Focus group discussions were done with 19 pregnant women and 15 mothers of children aged 0-6 months to obtain more clarifications on the factors associated with adherence to IFAS. Furthermore, in-depth interviews were done with six health care providers to explore their perceptions of IFAS. RESULTS: Out of the 320 respondents of the survey, 20.3% (n = 65) adhered to IFAS. Factors associated with adherence to IFAS among pregnant women included time to start ANC (AOR = 3.72, 95% CI: 1.42, 9.79), knowledge of anaemia (AOR = 3.84, 95% CI: 1.335, 10.66), counseling on the importance of the iron-folic acid (AOR = 3.86, 95% CI: 1.42, 10.50), IFAS given during clinical visit (AOR = 15.72, 95% CI: 5.34, 46.31), number of meals consumed (AOR = 3.44, 95% CI: 1.28, 9.21), number of children (AOR = 3.462, 95% CI: 1.035, 11.58), and distance to health facility (AOR = 0.34, 95% CI: 0.131, 0.886). Qualitative findings revealed that delayed first ANC visit, lack of remainder for pregnant women to take IFAS, low awareness about the negative effects of anaemia, low of knowledge of IFAS and management of side effects, negative beliefs about the use of IFAS, and follow-up mechanism were major reasons for poor adherence. CONCLUSION: Adherence to iron-folic acid supplementation during pregnancy was low. Strengthening systems for creating reminding mechanism, raising community awareness through educational programs to pregnant women and health providers could improve adherence to IFAS.

Determinants of Home Delivery among Women Aged 15-24 Years in Tanzania.

BACKGROUND: The United Nation's Sustainable Development Goal number 3 aims at reducing the maternal mortality rate by less than 70/100,000 live births globally and 216/100,000 live births in developing regions by 2030. Despite several interventions in Tanzania, maternal mortality has increased from 454/100,000 live births in 2010 to 556/100,000 live births in 2015. Home delivery and maternal young age contribute to maternal deaths. Reducing home deliveries among women aged 15-24 years may likely decrease the prevalence of maternal deaths in Tanzania. This study investigated the determinants of home delivery among women aged 15- 24 years in rural and mainland districts of Tanzania. METHODS: This study uses a mixed-methods approach using data collected as part of the evaluation of government and UNICEF interventions in 13 districts of Tanzania mainland from October and November 2011. Results from the secondary analysis were supplemented by qualitative data collected between February and April 2019 from four rural districts: Bagamoyo, Tandahimba, Magu, and Moshi. RESULTS: A total of 409 adolescents and young women who delivered one year before the quantitative data collection were included in the final analysis. A quarter of them gave birth at home. Having at least four antenatal care (ANC) visits (OR=0.23, 95% CI: 0.12-0.41, p<0.01), planning place of delivery (OR=0.22, 95% CI: 0.14-0.36 p<0.01), and knowledge of the danger signs during pregnancy (OR=0.36, 95% CI: 0.22-0.57, p<0.01) were significantly associated with the place of delivery. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Maternal level of education, number of ANC visits attended, planned place of delivery, and knowledge of danger signs during pregnancy were the determinants of the choice of place of delivery among women aged 15-24 years in Tanzania. Understanding these risk factors is important in designing programs and interventions to reduce maternal deaths from women of this age group which contributes about 18% of all maternal deaths in Tanzania.

Sustaining LLIN coverage with continuous distribution: the school net programme in Tanzania.

Most malaria-endemic countries have struggled in the past decade to establish effective national-scale continuous distribution mechanisms for long-lasting insecticidal nets (LLINs). Since the implementation of the Tanzania National Voucher Scheme in 2004 and mass-distribution campaigns in 2009-2011 and 2015-2016, Tanzania has been committed to finding new and innovative ways of achieving and maintaining universal bed net coverage. Planning for the School Net Programme (SNP) began in 2011 and in 2013, the country piloted a SNP in three regions. Nets were distributed annually to children attending schools in selected primary and secondary grades. Intra-family re-distribution was assumed, and hence the family as a whole, rather than just the children themselves, were the targeted beneficiaries. The programme has since expanded to 14 regions and has seen six rounds of annual distribution. In its fifth year, 3 million nets were distributed at a cost of USD 3.64 per net and USD 0.60 per person-year of protection (including the net). ITN access and use were maintained at a high level (~ 50-75%) over the first 4 years of distribution within selected evaluation areas, even in the absence of a mass distribution event. Net distribution through primary schools has proven to be a feasible and effective strategy for maintaining consistently high coverage in Tanzania.

Assessment of the impact of availability and readiness of malaria services on uptake of intermittent preventive treatment in pregnancy (IPTp) provided during ANC visits in Tanzania.

BACKGROUND: Intermittent preventive treatment during pregnancy (IPTp) is a highly-recommended intervention to prevent maternal and neonatal complications associated with malaria infection. Despite fairly high antenatal care (ANC) coverage in Tanzania, low IPTp uptake rates represent a gap in efforts to decrease complications attributed to malaria in pregnancy. The objective of this study was to examine if availability, readiness and managing authority are associated with uptake of IPTp during ANC. METHODS: Data for this analysis come from a cross-sectional survey, the Tanzania Service Provision Assessment conducted between 2014 and 2015. Principal component analysis was used to create scores for availability of malaria services and readiness for the provision of services. Generalized estimating equation models with logit link and the binomial distribution assessed factors that impact the uptake of IPTp by pregnant women attending ANC. RESULTS: Higher fraction of women in their third trimester than second (68% versus 49%, OR = 2.6; 95% CI (2.1-3.3)), had received at least one dose of IPTp. There was a wide variation in the availability and readiness of malaria services provision and diagnostic tools by managing authorities. Public facilities were more likely than private to offer malaria rapid diagnostic test, and more providers at public facilities than private diagnosed and/or treated malaria. Women who attended facilities where direct observation therapy was practiced were more likely to have received at least one dose of IPTp (64% versus 46% who received none; p < 0.001). Women who attended ANC at a facility with a high readiness score were more likely to take IPTp than those attending facilities with low readiness scores (OR = 2.1; 95% CI (1.4-3.3)). Reported stock out on the day of interview was negatively associated with IPTp uptake (OR 0.09; 95% CI 0.07-0.1). CONCLUSION: Readiness of health facilities to provide malaria related services, the number of ANC visits and gestational age were associated with uptake of IPTp among women attending ANC. There are disparities in malaria service availability and readiness across geographical location and managing authorities. These findings could be used to assist the malaria programme and policymakers to appropriately decide when planning for malaria service deliveries and interventions.

An assessment of the malaria-related knowledge and practices of Tanzania's drug retailers: exploring the impact of drug store accreditation.

BACKGROUND: Since 2003 Tanzania has upgraded its approximately 7000 drug stores to Accredited Drug Dispensing Outlets (ADDOs), involving dispenser training, introduction of record keeping and enhanced regulation. Prior to accreditation, drug stores could officially stock over-the-counter medicines only, though many stocked prescription-only antimalarials. ADDOs are permitted to stock 49 prescription-only medicines, including artemisinin combination therapies and one form of quinine injectable. Oral artemisinin monotherapies and other injectables were not permitted at any time. By late 2011 conversion was complete in 14 of 21 regions. We explored variation in malaria-related knowledge and practices of drug retailers in ADDO and non-ADDO regions. METHODS: Data were collected as part of the Independent Evaluation of the Affordable Medicines Facility - malaria (AMFm), involving a nationally representative survey of antimalarial retailers in October-December 2011. We randomly selected 49 wards and interviewed all drug stores stocking antimalarials. We compare ADDO and non-ADDO regions, excluding the largest city, Dar es Salaam, due to the unique characteristics of its market. RESULTS: Interviews were conducted in 133 drug stores in ADDO regions and 119 in non-ADDO regions. Staff qualifications were very similar in both areas. There was no significant difference in the availability of the first line antimalarial (68.9% in ADDO regions and 65.2% in non-ADDO regions); both areas had over 98% availability of non-artemisinin therapies and below 3.0% of artemisinin monotherapies. Staff in ADDO regions had better knowledge of the first line antimalarial than non-ADDO regions (99.5% and 91.5%, p = 0.001). There was weak evidence of a lower price and higher market share of the first line antimalarial in ADDO regions. Drug stores in ADDO regions were more likely to stock ADDO-certified injectables than those in non-ADDO regions (23.0% and 3.9%, p = 0.005). CONCLUSIONS: ADDO conversion is frequently cited as a model for improving retail sector drug provision. Drug stores in ADDO regions performed better on some indicators, possibly indicating some small benefits from ADDO conversion, but also weaknesses in ADDO regulation and high staff turnover. More evidence is needed on the value-added and value for money of the ADDO roll out to inform retail policy in Tanzania and elsewhere.

Measuring Patient Adherence to Malaria Treatment: A Comparison of Results from Self-Report and a Customised Electronic Monitoring Device.

BACKGROUND: Self-report is the most common and feasible method for assessing patient adherence to medication, but can be prone to recall bias and social desirability bias. Most studies assessing adherence to artemisinin-based combination therapies (ACTs) have relied on self-report. In this study, we use a novel customised electronic monitoring device--termed smart blister packs--to examine the validity of self-reported adherence to artemether-lumefantrine (AL) in southern Tanzania. METHODS: Smart blister packs were designed to look identical to locally available AL blister packs and to record the date and time each tablet was removed from packaging. Patients obtaining AL at randomly selected health facilities and drug stores were followed up at home three days later and interviewed about each dose of AL taken. Blister packs were requested for pill count and extraction of smart blister pack data. RESULTS: Data on adherence from both self-report verified by pill count and smart blister packs were available for 696 of 1,204 patients. There was no difference between methods in the proportion of patients assessed to have completed treatment (64% and 67%, respectively). However, the percentage taking the correct number of pills for each dose at the correct times (timely completion) was higher by self-report than smart blister packs (37% vs. 24%; p<0.0001). By smart blister packs, 64% of patients completing treatment did not take the correct number of pills per dose or did not take each dose at the correct time interval. CONCLUSION: Smart blister packs resulted in lower estimates of timely completion of AL and may be less prone to recall and social desirability bias. They may be useful when data on patterns of adherence are desirable to evaluate treatment outcomes. Improved methods of collecting self-reported data are needed to minimise bias and maximise comparability between studies.

Are Tanzanian patients attending public facilities or private retailers more likely to adhere to artemisinin-based combination therapy?

BACKGROUND: Artemisinin combination therapy (ACT) is first-line treatment for malaria in most endemic countries and is increasingly available in the private sector. Most studies on ACT adherence have been conducted in the public sector, with minimal data from private retailers. METHODS: Parallel studies were conducted in Tanzania, in which patients obtaining artemether-lumefantrine (AL) at 40 randomly selected public health facilities and 37 accredited drug dispensing outlets (ADDOs) were visited at home and questioned about doses taken. The effect of sector on adherence, controlling for potential confounders was assessed using logistic regression with a random effect for outlet. RESULTS: Of 572 health facility patients and 450 ADDO patients, 74.5% (95% CI: 69.8, 78.8) and 69.8% (95% CI: 64.6, 74.5), respectively, completed treatment and 46.0% (95% CI: 40.9, 51.2) and 34.8% (95% CI: 30.1, 39.8) took each dose at the correct time ('timely completion'). ADDO patients were wealthier, more educated, older, sought care later in the day, and were less likely to test positive for malaria than health facility patients. Controlling for patient characteristics, the adjusted odds of completed treatment and of timely completion for ADDO patients were 0.65 (95% CI: 0.43, 1.00) and 0.69 (95% CI: 0.47, 1.01) times that of health facility patients. Higher socio-economic status was associated with both adherence measures. Higher education was associated with completed treatment (adjusted OR = 1.68, 95% CI: 1.20, 2.36); obtaining AL in the evening was associated with timely completion (adjusted OR = 0.35, 95% CI: 0.19, 0.64). Factors associated with adherence in each sector were examined separately. In both sectors, recalling correct instructions was positively associated with both adherence measures. In health facility patients, but not ADDO patients, taking the first dose of AL at the outlet was associated with timely completion (adjusted OR = 2.11, 95% CI: 1.46, 3.04). CONCLUSION: When controlling for patient characteristics, there was some evidence that the adjusted odds of adherence for ADDO patients was lower than that for public health facility patients. Better understanding is needed of which patient care aspects are most important for adherence, including the role of effective provision of advice.

Availability and price of malaria rapid diagnostic tests in the public and private health sectors in 2011: results from 10 nationally representative cross-sectional retail surveys.

OBJECTIVES: To describe the state of the public and private malaria diagnostics market shortly after WHO updated its guidelines for testing all suspected malaria cases prior to treatment. METHODS: Ten nationally representative cross-sectional cluster surveys were conducted in 2011 among public and private health facilities, community health workers and retail outlets (pharmacies and drug shops) in nine countries (Tanzania mainland and Zanzibar surveyed separately). Eligible outlets had antimalarials in stock on the day of interview or had stocked antimalarials in the past 3 months. RESULTS: Three thousand four hundred and thirty-nine rapid diagnostic test (RDT) products from 39 manufacturers were audited among 12,197 outlets interviewed. Availability was typically highest in public health facilities, although availability in these facilities varied greatly across countries, from 15% in Nigeria to >90% in Madagascar and Cambodia. Private for-profit sector availability was 46% in Cambodia, 20% in Zambia, but low in other countries. Median retail prices for RDTs in the private for-profit sector ranged from $0.00 in Madagascar to $3.13 in Zambia. The reported number of RDTs used in the 7 days before the survey in public health facilities ranged from 3 (Benin) to 50 (Zambia). CONCLUSIONS: Eighteen months after WHO updated its case management guidelines, RDT availability remained poor in the private sector in sub-Saharan Africa. Given the ongoing importance of the private sector as a source of fever treatment, the goal of universal diagnosis will not be achievable under current circumstances. These results constitute national baselines against which progress in scaling-up diagnostic tests can be assessed.

Improving access to malaria medicine through private-sector subsidies in seven African countries.

Improving access to quality-assured artemisinin combination therapies (ACTs) is an important component of malaria control in low- and middle-income countries. In 2010 the Global Fund to Fight AIDS, Tuberculosis, and Malaria launched the Affordable Medicines Facility--malaria (AMFm) program in seven African countries. The goal of the program was to decrease malaria morbidity and delay drug resistance by increasing the use of ACTs, primarily through subsidies intended to reduce costs. We collected data on price and retail markups on antimalarial medicines from 19,625 private for-profit retail outlets before and 6-15 months after the program's implementation. We found that in six of the AMFm pilot programs, prices for quality-assured ACTs decreased by US$1.28-$4.34, and absolute retail markups on these therapies decreased by US$0.31-$1.03. Prices and markups on other classes of antimalarials also changed during the evaluation period, but not to the same extent. In all but two of the pilot programs, we found evidence that prices could fall further without suppliers' losing money. Thus, concerns may be warranted that wholesalers and retailers are capturing subsidies instead of passing them on to consumers. These findings demonstrate that supranational subsidies can dramatically reduce retail prices of health commodities and that recommended retail prices communicated to a wide audience may be an effective mechanism for controlling the market power of private-sector antimalarial retailers and wholesalers.

Cluster randomized trial of text message reminders to retail staff in tanzanian drug shops dispensing artemether-lumefantrine: effect on dispenser knowledge and patient adherence.

Artemisinin combination therapies are available in private outlets, but patient adherence might be compromised by poor advice from dispensers. In this cluster randomized trial in drug shops in Tanzania, 42 of 82 selected shops were randomized to receive text message reminders about what advice to provide when dispensing artemether-lumefantrine (AL). Eligible patients purchasing AL at shops in both arms were followed up at home and questioned about each dose taken. Dispensers were interviewed regarding knowledge of AL dispensing practices and receipt of the malaria-related text messages. We interviewed 904 patients and 110 dispensers from 77 shops. Although there was some improvement in dispenser knowledge, there was no difference between arms in adherence measured as completion of all doses (intervention 68.3%, control 69.8%, p [adjusted] = 0.6), or as completion of each dose at the correct time (intervention 33.1%, control 32.6%, p [adjusted] = 0.9). Further studies on the potential of text messages to improve adherence are needed.

Has Tanzania embraced the green leaf? Results from outlet and household surveys before and after implementation of the Affordable Medicines Facility-malaria.

BACKGROUND: The Affordable Medicines Facility-malaria (AMFm) is primarily an artemisinin combination therapy (ACT) subsidy, aimed at increasing availability, affordability, market share and use of quality-assured ACTs (QAACTs). Mainland Tanzania was one of eight national scale programmes where AMFm was introduced in 2010. Here we present findings from outlet and household surveys before and after AMFm implementation to evaluate its impact from both the supply and demand side. METHODS: Outlet surveys were conducted in 49 randomly selected wards throughout mainland Tanzania in 2010 and 2011, and data on outlet characteristics and stocking patterns were collected from outlets stocking antimalarials. Household surveys were conducted in 240 randomly selected enumeration areas in three regions in 2010 and 2012. Questions about treatment seeking for fever and drugs obtained were asked of individuals reporting fever in the previous two weeks. RESULTS: The availability of QAACTs increased from 25.5% to 69.5% among all outlet types, with the greatest increase among pharmacies and drug stores, together termed specialised drug sellers (SDSs), where the median QAACT price fell from $5.63 to $0.94. The market share of QAACTs increased from 26.2% to 42.2%, again with the greatest increase in SDSs. Household survey results showed a shift in treatment seeking away from the public sector towards SDSs. Overall, there was no change in the proportion of people with fever obtaining an antimalarial or ACT from baseline to endline. However, when broken down by treatment source, ACT use increased significantly among clients visiting SDSs. DISCUSSION: Unchanged ACT use overall, despite increases in QAACT availability, affordability and market share in the private sector, reflected a shift in treatment seeking towards private providers. The reasons for this shift are unclear, but likely reflect both persistent stockouts in public facilities, and the increased availability of subsidised ACTs in the private sector.