Experiences of teachers and students on school closures and its consequences during the COVID-19 pandemic in Nyarugusu refugee camp, Tanzania.

Tanzania has experienced several waves of COVID-19 since it was first detected in the country. During the first wave, Tanzania took several measures to prevent wider virus transmission with school closures being one of them. All areas and institutions were targeted, including the refugee camps in Kigoma region. Despite the abundant evidence generated in relation to the effects of the pandemic and associated school closures globally, there has been a paucity of literature exploring the experiences of teachers and students in humanitarian settings. We conducted a qualitative study to explore COVID-19 related school closures in Nyarugusu refugee camp. We aimed to describe teachers' and students' experiences and perceived consequences of school closures. In-depth interviews with teachers and students were conducted in September 2020 in Burundian and Congolese schools in the context of a cluster randomised trial of EmpaTeach, a school-based violence prevention intervention. A total of 44 individuals (29 teachers and 15 students) were interviewed. A phenomenological theoretical framework was used to guide the content analysis. Findings indicated that the COVID-19 pandemic was generally seen as frightening by refugees. Study participants understood the importance of school closures to prevent transmission of the virus, but various negative consequences were reported by both teachers and students. These included perceived mental health difficulties such as stress, depression and anxiety associated with the worry of infection, idleness, and disruption of education. Participants also perceived an increase in occurrences of early marriages and unplanned pregnancies, which they thought contributed to increased school dropout. Participants identified the main causes of such outcomes as a lack of parental supervision, children's lack of restraint and poor character, and a lack of alternative teaching practices (such as online or remote learning) to keep the students busy while at home. Children were held accountable for their faults with little support from the adults. Our findings suggest that there is an urgent need to strengthen child protection programming to support children and their communities during emergencies and provides protective environments such as school and education. There is a critical need to develop preparedness plans for future pandemics to support child safety, academic development and wellbeing.

Conceptualisation of violence and discipline among students, teachers, and parents in Nyarugusu Refugee Camp, Tanzania.

BACKGROUND: Little academic research has been conducted on how people conceptualise 'violence' and 'discipline', especially in humanitarian settings. This may limit the transferability of violence prevention interventions. This paper examines the understanding of violence and discipline concepts among students, teachers, and parents in the Nyarugusu Refugee Camp in Tanzania. METHODS: A qualitative study was undertaken as part of the larger trial testing the effectiveness of the EmpaTeach intervention to prevent physical violence from teachers to students implemented in 27 schools in Nyarugusu Refugee Camp. Data from baseline and midline surveys in control schools that did not receive the intervention informed this paper where a total of 14 in-depth interviews (eight with students and six teachers) and six focus group discussions (two with teachers and four with parents from the Parent Teacher Association) were analyzed. Both audio recordings from in-depth interviews and focus group discussions were transcribed verbatim, and translated from Kiswahili to English (Congolese) and Kirundi to English (Burundian). Translated data were verified and coded using thematic analysis based on the views of students, teachers, and parents. RESULTS: Participants revealed that the same behavioural acts could be differentially classified as violence or discipline. Violence was understood in relation to the consequences of acts, which could include physical or psychological harm, or other harms which were seen as detrimental to children's futures and life chances, particularly adolescent pregnancy. Sexual acts without consent were also seen as violence. In contrast, discipline was understood according to intent, and perceived acts done towards students to correct bad behaviour. CONCLUSION: Results imply that education about the harmful consequences of behavioural acts intended as discipline, may be important for violence prevention interventions and that framing interventions in terms of positive child development could help change discipline strategies in schools.

Factors affecting caregivers' participation in support groups for people living with HIV in Tanzania.

Introduction: Support groups for people living with HIV (PLHIV) are essential for increasing adherence, retention, addressing their psychosocial needs and improving patient literacy. However, factors that influence participation of caregivers living with HIV (LHIV) in these groups are scarcely documented, particularly for those caring for orphans and vulnerable children (OVC). Methods: This study used baseline data collected between 1st October 2021 and 30th September 2022 from the PEPFAR/USAID-funded Adolescents and Children HIV Incidence Reduction, Empowerment and Virus Elimination (ACHIEVE) project in Tanzania to investigate factors that affect participation of caregivers LHIV in support groups for PLHIV. A total of 74,249 HIV-positive OVC caregivers who were already receiving antiretroviral therapy (ART) and had a confirmed care and treatment centre identification number were included in the analysis. Factors affecting group participation were identified through multilevel analysis using multivariable mixed-effects logistic regression. Results: Results showed that 84.2% of the caregivers were participants in the support groups for PLHIV. Their mean age was 36 years, and the majority (82.1%) were female. Multivariable analysis revealed that participation in the groups was more likely among caregivers living in urban areas (aOR = 1.39 [1.24, 1.55]), with primary education (aOR = 1.17 [1.07, 1.28]), and without disabilities (aOR = 0.62 [0.47, 0.82]). However, participation was less likely among widowed (aOR = 0.91 [0.84, 0.999]), single or unmarried (aOR = 0.86 [0.78, 0.95]), and those with secondary education or higher levels than never attended (aOR = 0.69 [0.60, 0.80]), moderate hunger (aOR = 0.86 [0.79, 0.93]), and those aged 30 years or older (p< 0.001). Discussion: A sizeable proportion (15.8%) of the caregivers were not in support groups for PLHIV, ranging from 12.3% among those in households with severe hunger to 29.7% among disabled ones. The study highlights the need for tailored interventions to increase participation in support groups for PLHIV, particularly for caregivers who are disabled, live in rural areas, are older, widowed, and/or unmarried, and those in poor households.

Qualitative process evaluation of the EmpaTeach intervention to reduce teacher violence in schools in Nyarugusu Refugee Camp, Tanzania.

OBJECTIVE: We explored the experiences and perceptions of school staff and students with the EmpaTeach intervention to prevent teachers' violence against school students. DESIGN: This qualitative study involved in-depth interviews with 58 and 39 participants at midline and endline, respectively, with Burundian and Congolese intervention schools in Nyarugusu refugee camp. They comprised three education coordinators of primary and secondary schools, 29 EmpaTeach intervention coordinators, 14 stakeholders including headteachers and discipline teachers, 25 classroom teachers and 26 students. Thematic analysis was used to develop codes by examining the content of quotes to capture key themes in line with the key elements of the programme theory. RESULTS: Coordinators and teachers widely reported positive experiences with the EmpaTeach programme. The intervention sessions enabled teachers to reflect on their own values and experiences of corporal punishment and equipped them with useful and acceptable classroom management and alternative discipline strategies. Teachers adopted the use of counselling, praise and reward, and joint discussions with students and parents. On the other hand, several teachers reported persistent use of corporal punishment which they attributed to children's (mis)behaviours and strong beliefs that beating was a positive approach to disciplining students. CONCLUSION: The majority of coordinators and teachers widely accepted the EmpaTeach intervention as it offered useful and relevant knowledge and skills on alternative disciplinary methods. Students noticed some positive changes on the way they were being disciplined by teachers, where non-violent methods were used. Further research is needed to understand how violence prevention interventions can successfully lead to reductions in violence in fragile settings. TRIAL REGISTRATION NUMBER: NCT03745573.

Health Facility Readiness for Promoting Male Involvement in Family Planning Services in Tanzania: A Qualitative Study on Perspectives of Health Providers in Kibaha District.

Background: The successes and failures of health policies and programs to motivate men to develop interest in positive decision making and actions relating to reproductive and child health services (RCHs) in Tanzania are inadequately documented. Therefore, a study was done to explore the health facility readiness for motivating men to effectively participate in RCHs including Family Planning (FP) in Kibaha District. Methods: This was a cross-sectional qualitative study undertaken in 2014 and involving in-depth interviews (IDIs) with frontline RCH providers at selected Health Facilities (HFs) and their district coordinator. Data were transcribed verbatim, coded and evaluated thematically through a narrative analysis approach. Results: All the respondents admitted the role of men in influencing FP decisions at family and other community levels and the need for engaging them in RCHs. They all reported to have continued to note an increasing attitude and activeness of men to attend the RCH facilities available for RCHs along with their partners despite the remaining ones who still show hesitance. Family Planning interventions supported by the District Council Authority and development partners were reported to contribute in increasing the number of males coming for FP and other RCHs. Nevertheless, some shortcomings were experienced, and were reported to include some HFs providing FP services on selected week days which limit the clients who would need them any day/time; some dispensaries lacking adequate lounges or consultation room spaces for accommodating clients arriving in couples or who would be held for receiving health education in group; and the occasional stock-outs of essential FP commodities and other RCHs at some of the HFs. Conclusions: The study reveals the pleasure frontline RCHs staff had after observing an increasing trend in male involvement in such services and the support given by the government and its allied stakeholders to make this a success. However, the prevailing deficiencies relating to HF infrastructure and FP commodity supplies need to be addressed if a universal health coverage for FP and other RCHs were to be attained as policy and program-wise advocated.

Impact of household economic strengthening intervention on food security among caregivers of orphans and vulnerable children in Tanzania.

About 2 billion people worldwide suffer moderate or severe forms of food insecurity, calling for correctional measures involving economic strengthening interventions. This study assessed the impact of household economic strengthening (HES) intervention on food security among caregivers of orphans and vulnerable children (OVC) in Tanzania. The study was longitudinal in design, based on OVC caregivers' baseline (2017-2018) and midline (2019) data from the USAID Kizazi Kipya project. Food security, the outcome, was measured using the Household Hunger Scale (HHS) in three categories: little to no hunger (food secure), moderate hunger, and severe hunger. Membership in the USAID Kizazi Kipya-supported economic strengthening intervention (i.e. WORTH Yetu) was the main independent variable. Data analysis involved generalized estimating equation (GEE) for multivariate analysis. With mean age of 50.3 years at baseline, the study analyzed 132,583 caregivers, 72.2% of whom were female. At midline, 7.6% of all caregivers enrolled at baseline were members in WORTH Yetu. Membership in WORTH Yetu was significantly effective in reducing household hunger among the caregivers: severe hunger dropped from 9.4% at baseline to 4.1% at midline; moderate hunger dropped from 65.9% at baseline to 62.8% at midline; and food security (i.e., little to no hunger households) increased from 25.2% at baseline to 33.1% at midline. In the multivariate analysis, membership in WORTH Yetu reduced the likelihood of severe hunger by 47% (OR = 0.53, 95% CI 0.48-0.59), and moderate hunger by 21% (OR = 0.79, 95% CI 0.76-0.83), but increased the likelihood of food security by 45% (OR = 1.45, 95% CI 1.39-1.51). The USAID Kizazi Kipya's model of household economic strengthening for OVC caregivers was effective in improving food security and reducing household hunger in Tanzania. This underscores the need to expand WORTH Yetu coverage. Meanwhile, these results indicate a potential of applying the intervention in similar settings to address household hunger.

Accelerating caregivers' HIV status disclosure to community-based lay social welfare volunteers in Tanzania.

BACKGROUND: HIV status disclosure facilitates access to HIV-related prevention and treatment services and increases opportunities for social support, HIV risk reduction with partners, and index testing for sexual partners or children. This study assessed the effect of a program model of community-based social welfare volunteers on HIV status disclosure among caregivers of orphans and vulnerable children (OVC). METHODS: This was a longitudinal study, which was based on OVC caregivers who were beneficiaries of the USAID Kizazi Kipya project in Tanzania. They were enrolled (baseline) by community social welfare volunteers during 2017-2018, received services, and reassessed at midline in 2019. Caregivers who reported having been HIV tested, were asked to voluntarily report the status in order for the volunteers to establish and provide needed services. Those who reported their HIV status as negative or positive were grouped as "disclosed", and those who knew their status but did not report it were documented as "undisclosed". McNemar's tests compared disclosure rates at baseline and midline. Multivariable analysis was conducted using generalized estimating equation (GEE). RESULTS: The study analyzed 140,664 caregivers (72% female) from 81 district councils of Tanzania. Their mean age at enrollment was 47.4 years. Overall, 81.3% of the caregivers disclosed their HIV status to the project staff at baseline; this increased significantly to 96.1% at midline (p < 0.001). Disclosure at baseline varied significantly by sociodemographic characteristic (p < 0.05), with higher disclosure in females, among urban residents, and higher educated caregivers. However, the observed disclosure variations by sociodemographic characteristics at baseline disappeared at midline and disclosure reached around 96% across the characteristics (p > 0.05). In the multivariable analysis, caregivers' likelihood of HIV status disclosure was nearly 6 times higher at midline than at baseline, when baseline characteristics were adjusted for (OR = 5.76, 95% CI 5.59-5.94, p < 0.001). There were 26,329 caregivers who did not disclose their HIV status at baseline (i.e., 0% diclosure rate at baseline), but 94.7% (n = 24,933) had disclosed by midline, and their disclosure trend was rapidly increasing as their duration of exposure to the project increased. CONCLUSIONS: This study detected an increased caregivers' HIV status disclosure to the USAID Kizazi Kipya project staff by 14.8%, from 81.3% at baseline to 96.1% at midline within an average project exposure period of 1.4 years. The observed loss of sociodemographic differences in HIV status disclosure rate at midline implies that community-based interventions may be well-positioned to successfully address and eliminate sociodemographic barriers to service uptake and consequently improve services coverage and health outcomes.

Hunger and Adherence to Antiretroviral Therapy: Learning From HIV Positive Caregivers of Orphans and Vulnerable Children in Tanzania.

The association between hunger and adherence to antiretroviral therapy (ART) is less known especially in vulnerable populations receiving HIV care and treatment services. Caregivers of orphans and vulnerable children (OVC) are vulnerable and likely to experience hunger due to additional economic pressure in caring for OVC. Using data from the community-based, USAID-funded Kizazi Kipya project, this study assesses the association between hunger and ART adherence among caregivers of OVC in Tanzania. HIV positive caregivers enrolled in the project from January to July 2017 were analyzed. The outcome variable was adherence to ART, defined as "not having missed any ART dose in the last 30 days," and household hunger, measured using the Household Hunger Scale (HHS), was the main independent variable. Data analysis included multivariable logistic regression. The study analyzed 11,713 HIV positive caregivers who were on ART at the time of enrollment in the USAID Kizazi Kipya project in 2017. Aged 48.2 years on average, 72.9% of the caregivers were female. While 34.6% were in households with little to no hunger, 59.4 and 6.0% were in moderate hunger and severe hunger households, respectively. Overall, 90.0% of the caregivers did not miss any ART dose in the last 30 days. ART adherence rates declined as household hunger increased (p < 0.001). Multivariable analysis showed that the odds of adhering to ART was significantly lower by 42% among caregivers in moderate hunger households than those in little to no hunger households (OR = 0.58, 95% CI 0.50-0.68). The decline increased to 47% among those in severe hunger households (OR = 0.53, 95% CI 0.41-0.69). Hunger is an independent and a significant barrier to ART adherence among caregivers LHIV in Tanzania. Improving access to adequate food as part of HIV care and treatment services is likely to improve ART adherence in this population.

Correlates of Uptake of Antiretroviral Therapy in HIV-Positive Orphans and Vulnerable Children Aged 0-14 Years in Tanzania.

BACKGROUND: In 2018, only 65% of Tanzanian children aged 0-14 years living with human immunodeficiency virus (HIV) were on treatment, suggesting that challenges exist. This study explores factors associated with uptake of antiretroviral therapy (ART) among HIV-positive orphans and vulnerable children (OVC). METHODS: Data are from the USAID Kizazi Kipya project that aims to increase the uptake of HIV/AIDS and other health and social services by OVC and their caregivers. HIV-positive OVC aged 0-14 years who were enrolled in the project from January 2017 to September 2018 were analyzed. ART status (off ART or on ART) was the outcome variable. Multivariate analysis was performed using multilevel logistic regression. RESULTS: Of the 10,047 HIV-positive OVC aged 0-14 years analyzed, 93.5% were currently on ART at enrollment. In the multivariate analysis, OVC with male caregivers were 4-times more likely than those with female caregivers to be on ART (OR=4.03, 95% CI=1.49-10.90). OVC with HIV-positive caregivers were 12-times more likely than those with HIV-negative caregivers to be on ART (OR=12.0, 95% CI=3.81-37.70). OVC with caregivers who did not disclose their HIV status were 74% less likely to be on ART than OVC of HIV-negative caregivers (OR=0.26, 95% CI=0.08-0.90). OVC living in urban areas were more than 5-times as likely as their rural counterparts to be on ART (OR=5.55, 95% CI=2.21-14.0). CONCLUSION: The majority of the OVCLHIV in the current study were currently on ART (93.5%) at enrollment. However, uptake of ART by the OVC was dependent on factors external to themselves. Advancing ART uptake may require targeting OVC of female caregivers, OVC of HIV-negative caregivers, as well as OVC of caregivers of undisclosed HIV statu, and rural areas.

ART use and associated factors among HIV positive caregivers of orphans and vulnerable children in Tanzania.

BACKGROUND: Utilization of antiretroviral therapy (ART) is crucial for better health outcomes among people living with the human immunodeficiency virus (PLHIV). Nearly 30% of the 1.6 million PLHIV in Tanzania are not on treatment. Since HIV positive status is the only eligibility criterion for ART use, it is critical to understand the obstacles to ART access and uptake to reach universal coverage of ART among PLHIV. For the caregivers of orphans and vulnerable children (OVC) LHIV and not on ART, attempts to identify them and ensure that they initiate and continue using ART is critical for their wellbeing and their ability to care for their children. METHODS: Data are from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya project that aims at scaling up the uptake of HIV/AIDS and other health and social services by orphans and vulnerable children (OVC) and their caregivers. HIV positive caregivers of OVC who were enrolled in the USAID Kizazi Kipya project between January 2017 and June 2018 were included in this cross-sectional study. The caregivers were drawn from 11 regions: Arusha, Iringa, Katavi, Kigoma, Mara, Mbeya, Morogoro, Ruvuma, Simiyu, Singida, and Tanga. The outcome variable was ART status (either using or not), which was enquired of each OVC caregiver LHIV at enrollment. Data analysis involved multivariable analysis using random-effects logistic regression to identify correlates of ART use. RESULTS: In total, 74,999 caregivers living with HIV with mean age of 44.4 years were analyzed. Of these, 96.4% were currently on ART at enrollment. In the multivariable analysis, ART use was 30% lower in urban than in rural areas (adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.61-0.81). Food security improved the odds of being on ART (OR = 1.29, 95% CI 1.15-1.45). Disabled caregivers were 42% less likely than non-disabled ones to be on ART (OR = 0.58, 95% CI 0.45-0.76). Male caregivers with health insurance were 43% more likely than uninsured male caregivers to be on ART (OR = 1.43, 95% CI 1.11-1.83). Caregivers aged 40-49 years had 18% higher likelihood of being on ART than the youngest ones. Primary education level was associated with 26% increased odds of being on ART than no education (OR = 1.26, 95% CI 1.13-1.41). CONCLUSIONS: Although nearly all the caregivers LHIV in the current study were on ART (96.4%), more efforts are needed to achieve universal coverage. The unreached segments of the population LHIV, even if small, may lead to worse health outcomes, and also spur further spread of the HIV epidemic due to unachieved viral suppression. Targeting caregivers in urban areas, food insecure households, who are uninsured, and those with mental or physical disability can improve ART coverage among caregivers LHIV.

Relationship Between Food Insufficiency and HIV Infection Among Caregivers of Orphans and Vulnerable Children in Tanzania.

BACKGROUND: Although Tanzania experiences a general decline in HIV prevalence, some populations such as caregivers of orphans may be at a higher risk than the general population, suggesting that infection pathways still need further exploration. This study examines how food insufficiency relates to HIV infection among caregivers of orphans and vulnerable children (OVC) in Tanzania. DATA AND METHODS: Data are from a community-based, USAID-funded Kizazi Kipya project that aims at increasing the uptake of HIV services, as well as other health and social services by OVC and their caregivers in Tanzania. Caregivers who were enrolled in the project from January to July 2017 in seven regions of Tanzania, and had reported their HIV status to the project, were included in the analysis. While HIV status was the outcome, the main independent variable was food insufficiency which was assessed using the Household Hunger Scale (HHS). Using Stata (version 14.0; StataCorp LP, College Station, TX, USA), data analysis involved multilevel mixed-effects logistic regression.. RESULTS: Of the 47,617 caregivers analyzed (73.7% females), 61.8% and 4.6% were experiencing moderate and severe hunger, respectively. The overall HIV prevalence among the caregivers was 28.3%. Nevertheless, the prevalence was as high as 34.2% among caregivers in severe hunger households. Multivariate analysis revealed an increasing likelihood of being HIV positive as hunger increased (moderate hunger: OR=1.10, 95%CI: 1.03-1.18; severe hunger: OR=1.51, 95%CI: 1.32-1.74). These observations were adjusted for marital status, age, sex, education, place of residence, family size, disability status, and health insurance. CONCLUSION: Food insufficiency is associated with a higher likelihood of HIV infection among OVC caregivers in Tanzania, suggesting that improving access to adequate food has a potential to reduce HIV risks among them. Furthermore, food insufficiency could be considered an important criterion for targeting HIV testing and treatment services to expand coverage.

Determinants of undisclosed HIV status to a community-based HIV program: findings from caregivers of orphans and vulnerable children in Tanzania.

BACKGROUND: HIV status disclosure facilitates receipt of HIV prevention and treatment services. Although disclosure to sexual partners, family members or friends has been extensively studied, disclosure to community-based HIV programs is missing. This study assesses the magnitude of, and factors associated with undisclosed HIV status to a community-based HIV prevention program among caregivers of orphans and vulnerable children (OVC) in Tanzania. METHODS: Data are from the USAID-funded Kizazi Kipya project that seeks to increase uptake of HIV, health, and social services by OVC and their caregivers in Tanzania. Data on OVC caregivers who were enrolled in the project during January-March 2017 in 18 regions of Tanzania were analyzed. Caregivers included were those who had complete information on their HIV status disclosure, household socioeconomic status, and sociodemographic characteristics. HIV status was self-reported, with undisclosed status representing all those who knew their HIV status but did not disclose it. Multilevel mixed-effects logistic regression, with caregivers' HIV status disclosure being the outcome variable was conducted. RESULTS: The analysis was based on 59,683 OVC caregivers (mean age = 50.4 years), 71.2% of whom were female. Of these, 37.2% did not disclose their HIV status to the USAID Kizazi Kipya program at the time of enrollment. Multivariate analysis showed that the likelihood of HIV status non-disclosure was significantly higher among: male caregivers (odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.16-1.28); unmarried (OR = 1.12, 95% CI 1.03-1.23); widowed (OR = 1.12, 95% CI 1.07-1.18); those without health insurance (OR = 1.36, 95% CI 1.28-1.45); age 61 + years (OR = 1.72, 95% CI 1.59-1.88); those with physical or mental disability (OR = 1.14, 95% CI 1.04-1.25); and rural residents (OR = 1.58, 95% CI 1.34-1.86). HIV status non-disclosure was less likely with higher education (p < 0.001); and with better economic status (p < 0.001). CONCLUSION: While improved education, economic strengthening support and expanding health insurance coverage appear to improve HIV status disclosure, greater attention may be required for men, unmarried, widowed, rural residents, and the elderly populations for their higher likelihood to conceal HIV status. This is a clear missed opportunity for timely care and treatment services for those that may be HIV positive. Further support is needed to support disclosure in this population.

The role of community participation for sustainable integrated neglected tropical diseases and water, sanitation and hygiene intervention programs: A pilot project in Tanzania.

Strategies aimed at reducing the prevalence of neglected tropical diseases (NTDs) in Tanzania including those attributed to water, sanitation and hygiene (WASH) problems have been largely top-down in nature. They have focused on strengthening the governance of NTD-WASH programs by integrating different vertical disease programs and improving the efficiency of report-generation. In this paper, we argue for community participation as an effective strategy for developing sustainable village health governance. We present the results of a pilot undertaken between November 2015 and April 2016 in which we adopted a mixed methods case study approach to implement an Enhanced Development Governance (EDG) model using existing village governance structures. Our results show that the EDG model was associated with a statistically significant reduction in the prevalence of schistosomiasis and diarrhoea, and has led to an increase in awareness of WASH interventions for sustaining gains in NTD control. We identify five key social processes enacted by the EDG model that have led to improved health benefits related to frequency of meetings and attendance, promotion of health and sanitation awareness, income-generating activities, self-organising capabilities, and interaction between village bodies. These findings hold important implications for conceptualising the role of community participation in sustaining NTD-WASH intervention programs and for sensitising institutional and policy reform.

Contributing to the debate on categorising shared sanitation facilities as 'unimproved': An account based on field researchers' observations and householders' opinions in three regions, Tanzania.

BACKGROUND: Health risks associated with poor sanitation behaviours continue to be reported mostly from low-income countries (LICs). Reports show that various factors limit many people from accessing and using improved latrines, forcing some to opt for sharing latrines with neighbours, others practicing open defecation. Meanwhile, debate prevails on whether shared latrines should be categorised as unimproved according to WHO/UNICEF-JMP criteria. We contribute to this debate based on results from a study undertaken in three regions, Tanzania. MATERIALS AND METHODS: Data were collected through observations in 1,751 households with latrines, coupled with collection of opinions from heads of such households regarding the latrine-sharing practices. Bivariate and multivariate logistic regression analyses were performed to assess associations between the outcome and possible predictor variables. RESULTS: Of all 1,751 latrines, 14.6% were shared. Among the shared latrines, 74.2% were found being generally clean as compared to 69.2% of the non-shared ones. Comparing the shared and non-shared latrines, the non-shared latrines were significantly less likely to be found with floors built with permanent materials (OR = 0.73, 95% CI: 0.55, 0.98); washable floors (OR = 0.69; 95% CI: 0.51, 0.93); and lockable doors (OR = 0.73; 95% CI: 0.56, 0.95). Shared latrines were less likely to have floors with faecal matter, functional handwashing facilities (HWFs), HWFs with running water, and roofs; albeit the differences in all these scenarios were not statistically significant. Respondents expressed desire for improved latrines, but also did not find it wrong to share latrines if cleanliness was maintained. CONCLUSION: Having an 'improved' latrine remains important as JMP recommends, but based on our study findings, we argue that possessing a non-shared latrine neither guarantees safety to its users nor its categorisation as 'improved'. Instead, the state of the latrine, the construction technology used and the behaviours of the users may be more important.

Biosocial Determinants of Persistent Schistosomiasis among Schoolchildren in Tanzania despite Repeated Treatment.

Schistosomiasis is a parasitic disease endemic to Tanzania and other countries of the global south, which is currently being addressed through preventive chemotherapy campaigns. However, there is growing recognition that chemotherapy strategies will need to be supplemented to sustainably control and eventually eliminate the disease. There remains a need to understand the factors contributing to continued transmission in order to ensure the effective configuration and implementation of supplemented programs. We conducted a cross-sectional questionnaire, to evaluate the biosocial determinants facilitating the persistence of schistosomiasis, among 1704 Tanzanian schoolchildren residing in two districts undergoing a preventive chemotherapeutic program: Rufiji and Mkuranga. A meta-analysis was carried out to select the diagnostic questions that provided a likelihood for predicting infection status. We found that self-reported schistosomiasis continues to persist among the schoolchildren, despite multiple rounds of drug administration.Using mixed effects logistic regression modeling, we found biosocial factors, including gender, socio-economic status, and water, sanitation, and hygiene (WASH)-related variables, were associated with this continued schistosomiasis presence. These findings highlight the significant role that social factors may play in the persistence of disease transmission despite multiple treatments, and support the need not only for including integrated technical measures, such as WASH, but also addressing issues of poverty and gender when designing effective and sustainable schistosomiasis control programs.

Acceptability of malaria rapid diagnostic tests administered by village health workers in Pangani District, North eastern Tanzania.

BACKGROUND: Malaria continues to top the list of the ten most threatening diseases to child survival in Tanzania. The country has a functional policy for appropriate case management of malaria with rapid diagnostic tests (RDTs) from hospital level all the way to dispensaries, which are the first points of healthcare services in the national referral system. However, access to these health services in Tanzania is limited, especially in rural areas. Formalization of trained village health workers (VHWs) can strengthen and extend the scope of public health services, including diagnosis and management of uncomplicated malaria in resource-constrained settings. Despite long experience with VHWs in various health interventions, Tanzania has not yet formalized its involvement in malaria case management. This study presents evidence on acceptability of RDTs used by VHWs in rural northeastern Tanzania. METHODS: A cross-sectional study using quantitative and qualitative approaches was conducted between March and May 2012 in Pangani district, northeastern Tanzania, on community perceptions, practices and acceptance of RDTs used by VHWs. RESULTS: Among 346 caregivers of children under 5 years old, no evidence was found of differences in awareness of HIV rapid diagnostic tests and RDTs (54 vs. 46 %, p = 0.134). Of all respondents, 92 % expressed trust in RDT results, 96 % reported readiness to accept RDTs by VHWs, while 92 % expressed willingness to contribute towards the cost of RDTs used by VHWs. Qualitative results matched positive perceptions, attitudes and acceptance of mothers towards the use of RDTs by VHWs reported in the household surveys. Appropriate training, reliable supplies, affordability and close supervision emerged as important recommendations for implementation of RDTs by VHWs. CONCLUSION: RDTs implemented by VHWs are acceptable to rural communities in northeastern Tanzania. While families are willing to contribute towards costs of sustaining these services, policy decisions for scaling-up will need to consider the available and innovative lessons for successful universally accessible and acceptable services in keeping with national health policy and sustainable development goals.

Determinants of demand for condoms to prevent HIV infections among barmaids and guesthouse workers in two districts, Tanzania.

BACKGROUND: Condoms are scientifically recommended as potential products for preventing infections attributable to human immuno-deficiency viruses (HIV). However, evidence on factors leading to their inadequate use in developing countries is still scanty. This paper reports an exploratory study of factors constraining condoms use in Tanzania from the perspectives of barmaids, guest-house workers and retailers. METHODS: Data were collected in two districts-Mpwapwa in Dodoma Region and Mbeya Rural in Mbeya Region-between October and December 2011, using structured interviews with 238 individuals including barmaids, guesthouse workers and 145 retailers. Data analysis was performed using STATA 11 software. RESULTS: Awareness about condoms was high among all study groups. Male condoms were more popular and available than female ones. A considerable proportion of the barmaids and guesthouses were disappointed with condoms being promoted and distributed to young children and disliked condom use during sexual intercourse. Accessibility of condoms was reported as being lowered by condom prices, shortage of information concerning their availability; short supply of condoms; some people shying away to be watched by children or adult people while purchasing condoms; retailers' using bad languages to condom customers; occasionally condom shops/kiosks found closed when they are urgently needed; and prevailing social perception of condoms to have low/no protective efficacy. Regression analysis of data from barmaids and guesthouse-workers indicated variations in the degree of condom acceptability and methods used to promote condoms among respondents with different demographic characteristics. CONCLUSION: A combination of psychosocial and economic factors was found contributing to lower the demand for and actual use of condoms in study communities. Concerted measures for promoting condom use need to address the demand challenges and making operational research an integral element of monitoring and evaluation of the launched interventions, hence widening the evidence for informed policy decisions.

Knowledge of occupational exposure to HIV: a cross sectional study of healthcare workers in Tumbi and Dodoma hospitals, Tanzania.

BACKGROUND: Insufficient knowledge on blood-borne pathogens has been identified as a factor that influences occupational exposure to needle stick and sharps injuries. The objective of this study was to assess healthcare workers' knowledge on occupational exposure to HIV. METHODS: A cross sectional survey was conducted at Tumbi designated regional hospital and Dodoma regional hospital, Tanzania in February 2012. A self-administered questionnaire was used to capture information on knowledge of occupational exposure to HIV infection. RESULTS: A total of 401 healthcare workers responded to a self-administered questionnaire. High proportion of healthcare workers (96.3%) understood that they are at risk of occupational exposure to HIV. The majority of healthcare workers trained on post exposure prophylaxis procedure and use of personal protective equipment were clinicians (87.1% and 71.4% respectively) and nurses (81.8% and 74.6% respectively). Over a quarter of the healthcare workers were not aware of whom to contact in the event of occupational exposure. One third of healthcare workers did not have comprehensive knowledge on causes of occupational HIV transmission and did not know when post exposure prophylaxis is indicated. Healthcare workers not trained on the use of person protective equipment were less likely to have comprehensive knowledge on occupational exposure to HIV (OR = 0.5; 95% CI 0.3 - 0.9). Knowledge on causes of occupational exposure varied with the cadre of healthcare workers. Nurses were more likely to have comprehensive knowledge on occupational exposure to HIV than non-clinical staff (OR = 2.6; 95% CI 1.5 - 4.5). CONCLUSION: A substantial proportion of studied healthcare workers had little knowledge on occupational exposure to HIV and was not aware of a contact person in the event of occupational exposure to HIV. Training on post exposure prophylaxis and infection prevention and control including the use of person protective equipment provided to nurses and clinicians should be extended to other clinical and non-clinical hospital staff.

Psychosocial, behavioural and health system barriers to delivery and uptake of intermittent preventive treatment of malaria in pregnancy in Tanzania - viewpoints of service providers in Mkuranga and Mufindi districts.

BACKGROUND: Intermittent preventive treatment of malaria in pregnancy (IPTp) using sulphurdoxine-pyrimethamine (SP) is one of key malaria control strategies in Africa. Yet, IPTp coverage rates across Africa are still low due to several demand and supply constraints. Many countries implement the IPTp-SP strategy at antenatal care (ANC) clinics. This paper reports from a study on the knowledge and experience of health workers (HWs) at ANC clinics regarding psychosocial, behavioural and health system barriers to IPTp-SP delivery and uptake in Tanzania. METHODS: Data were collected through questionnaire-based interviews with 78 HWs at 28 ANC clinics supplemented with informal discussions with current and recent ANC users in Mkuranga and Mufindi districts. Qualitative data were analysed using a qualitative content analysis approach. Quantitative data derived from interviews with HWs were analysed using non-parametric statistical analysis. RESULTS: The majority of interviewed HWs were aware of the IPTp-SP strategy's existence and of the recommended one month spacing of administration of SP doses. Some HWs were unsure of that it is not recommended to administer IPTp-SP and ferrous/folic acid concurrently. Others were administering three doses of SP per client following instruction from a non-governmental agency while believing that this was in conflict with national guidelines. About half of HWs did not find it appropriate for the government to recommend private ANC providers to provide IPTp-SP free of charge since doing so forces private providers to recover the costs elsewhere. HWs noted that pregnant women often register at clinics late and some do not comply with the regularity of appointments for revisits, hence miss IPTp and other ANC services. HWs also noted some amplified rumours among clients regarding health risks and treatment failures of SP used during pregnancy, and together with clients' disappointment with waiting times and the sharing of cups at ANC clinics for SP, limit the uptake of IPTp-doses. CONCLUSION: HWs still question SP's treatment advantages and are confused about policy ambiguity on the recommended number of IPTp-SP doses and other IPTp-SP related guidelines. IPTp-SP uptake is further constrained by pregnant women's perceived health risks of taking SP and of poor service quality.

Health facility-based data on women receiving sulphadoxine-pyrimethamine during pregnancy in Tanzania: lessons to learn from a cross-sectional survey in Mkuranga and Mufindi districts and other national survey reports.

BACKGROUND: A study of health facility (HF) data on women receiving sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria during pregnancy (IPTp) was carried out at antenatal care clinics in Mkuranga and Mufindi districts. METHODS: A review of health management information system (HMIS) registers, interviews with health-care workers (HWs) and district and national level malaria control program managers corroborated by inter-temporal assessment through observations at HF levels. Statistical data were analyzed in Excel and interpreted in triangulation with qualitative data from interviews and observations. RESULTS: Data indicated that IPTp doses administered to women were inadequate and partly inconsistent. HMIS registers lacked space for IPT records, forcing HWs to manipulate their record-keeping. The proportion/number of IPTp recipients in related to the supply of SP for free delivery, to women's attendance behaviours, showed variation by quarter and year of reporting. CONCLUSION: It is impossible to achieve rational health service planning when the HMIS is weak. Whilst it is acknowledged that the HMIS is already overloaded, concerted measures are urgently needed to accommodate data on new interventions and other vertical programs if malaria programs are to achieve their goals.