"If I chose to listen to people, I possibly wouldn't be using family planning": Impact of external influences on women's contraceptive autonomy in rural Northwest Tanzania.

BACKGROUND: There is an increasing emphasis on promoting women's autonomy in reproductive decision-making, particularly given global efforts to increase contraceptive access and uptake. Scales to quantify autonomy have inconsistently included the effect of external influences and focused primarily on influences of partners. OBJECTIVES: This study aimed to gain greater depth in understanding how influences including and beyond a woman's partner affect her contraceptive decision-making, as well as how external influences can overlap and further complicate contraceptive decision-making. DESIGN: A phenomenological, qualitative study in which in-depth interviews were conducted in three phases from May 2021 to February 2022 with women living in northwest Tanzania who had varying histories of contraceptive use or non-use. METHODS: One-on-one, in-depth interviews were conducted in Swahili, the national language of Tanzania, by trained female interviewers. Interviews were digitally recorded, transcribed, translated into English, and independently coded by three investigators. Analysis was conducted using NVivo. The codes developed from the transcripts were grouped into overarching themes with supporting illustrative quotes. RESULTS: A total of 72 women were interviewed. Partners were the most influential in women's family planning decision-making, followed by friends, relatives, community religious leaders, and healthcare providers. Out of the 52 women with a partner who had ever used family planning, 76.9% had discussed their desire to use family planning with their partner and nearly all reported strong pressures to use or not to use family planning from partners, family, and friends. Rarely, participants stated that they were devoid of any influence. CONCLUSION: In rural Tanzania, women's decision-making about family planning was highly impacted by external influences, including not only partners but also family, friends, and community. Indicators of women's reproductive autonomy and measurements of interventions to promote contraceptive use should incorporate measures of these external influences.

Partnerships with religious leaders to promote family planning in rural Tanzania: an open-label, cluster randomised trial.

BACKGROUND: Family planning benefits maternal-child health, education, and economic wellbeing. Despite global efforts, an unsatisfied demand for family planning persists in sub-Saharan Africa. Based on previous successful partnerships, the aim of this study was to determine whether an educational intervention for religious leaders would increase community knowledge, demand for, and ultimately uptake of family planning. METHODS: In this open-label, cluster randomised trial in Tanzania, 24 communities were randomised (1:1) to intervention or control arm. Communities, defined as the catchment area of a single public health facility, were eligible if they were at least 15 km from Mwanza City and had not previously participated in a health intervention for religious leaders. Random allocations were determined by coin toss and were not revealed to clinicians at health facilities in intervention and control communities, nor to the data entry team; however, due to the nature of the intervention, masking of religious leaders in the intervention communities was not possible. All Christian religious institutions were invited to send four leaders to an educational intervention that incorporated cultural, theological, and medical teaching about family planning. The primary outcome was contraceptive uptake at the community health facility during the year post intervention versus the year before the intervention. This trial was registered at clinicaltrials.gov, NCT03594305. FINDINGS: 75 communities in three districts were assessed for eligibility. 19 communities were excluded and 56 were eligible for study inclusion and were placed in random order to be invited to participate. The first 24 communities that were invited agreed to participate and were randomly assigned to receive the educational intervention either during the trial or after trial completion. Between July 10, 2018 and Dec 11, 2021, we provided the intervention in 12 communities and compared contraceptive uptake with 12 control communities. All were followed up for 12 months. In intervention communities, contraceptive uptake increased by a factor of 1·47 (95% CI 1·41-1·53) in the post-intervention (prospective) versus pre-intervention (historical) year (geometric mean of contraceptive uptake, 466 in the prospective year vs 312 in the historical year), versus 1·24 (95% CI 1·20-1·29) in control communities (geometric mean, 521 in the prospective year vs 429 in the historical year). The rate of change in contraceptive uptake was greater in intervention communities (between-group ratio of geometric mean ratios over time, 1·19 [95% CI 1·12-1·25]; p<0·0001). The COVID-19 pandemic was associated with decreased contraceptive uptake (geometric mean, 365 during the pandemic in communities that had the majority of their prospective 12-month data collection periods occur after March 16, 2020, vs 494 before the pandemic; geometric mean ratio, 0·72 [95% CI 0·57-0·90]; p=0·0040). INTERPRETATION: This intervention offers a scalable model, leveraging influence of trusted religious leaders to increase knowledge and uptake of family planning. New strategies such as this could help to overcome setbacks that occurred during the COVID-19 pandemic. FUNDING: John Templeton Foundation and Weill Cornell Medicine Dean's Diversity and Healthcare Disparity Award. TRANSLATION: For the Kiswahili translation of the abstract see Supplementary Materials section.

Perspectives of Muslim Religious Leaders to Shape an Educational Intervention About Family Planning in Rural Tanzania: A Qualitative Study.

INTRODUCTION: Uptake of effective contraceptive methods can be hindered by poor understanding and uncertainty about its compatibility with religious beliefs. We sought to understand the perspectives of Muslim religious leaders in rural Tanzania on family planning (FP) and acceptable strategies for providing FP education to leaders and their communities. METHODS: We conducted in-depth interviews with Muslim leaders from 4 communities in northwest Tanzania. Open-ended questions explored leaders' views on FP in relation to their communities, Muslim texts and teaching, and their experience as leaders. We also investigated how FP education could be provided in their communities and asked practical questions regarding seminar implementation. Interviews were conducted in Kiswahili and transcribed and translated into English. Data were coded independently by 2 investigators using NVivo 1.5.1 and analyzed thematically. RESULTS: We interviewed 17 male and 15 female Muslim leaders. All leaders supported FP as a concept in which births are spaced, interpreting this as espoused by the Qur'an and a basic right of children raised in Islam. Leaders uniformly endorsed the use of breastfeeding and the calendar method to space births but had divergent and sometimes opposing views on other methods, including condom use, oral contraceptives, and intrauterine devices. All leaders acknowledged the need for FP education among their congregants and were in favor of helping to teach an FP seminar in their communities. CONCLUSION: Our data reveal insights into how education for Muslim leaders may equip them to promote birth spacing and enhance understanding of FP in their communities in ways that are concordant with Islamic teaching. Our findings will guide the design and pilot-testing of an educational intervention for Muslim religious leaders to promote knowledge and uptake of FP in rural Tanzania.

Health providers' perspectives on contraceptive use in rural Northwest Tanzania: A qualitative study.

Objectives: In Tanzania, contraceptive use is limited, particularly in rural communities and even among women who would like to delay childbearing. This paper aims to present health providers' perspectives on populations seeking contraception and barriers that could be addressed to increase access to and uptake of contraception, given their interface with large portions of their communities. Study Design: We conducted 18 in-depth interviews with providers stationed at health dispensaries in six rural villages in northwest Tanzania. Two investigators independently coded interviews using a stepwise process to achieve consensus on prevalent topics. Results: Three topics emerged from our analysis: (1) nature of clients seeking contraception; (2) barriers to uptake of contraception; and (3) the role of secrecy in obtaining and using contraception. Health providers reported that married women with children were the most frequent users of contraception, alongside some single women, men, sex workers, and students. Barriers to contraception included lack of supplies and trained staff, misconceptions and fears, stigma, and unsupportive partners. Providers observed that contraception was often used secretly. They reported surreptitious visits and described clients' preferential use of discreet methods. Providers respected and supported clients' desires to keep visits confidential. Conclusion: Our data suggest maintaining high stocks of discreet contraceptive methods and deploying more trained staff to dispensaries could increase availability and access to contraceptives. At the community level, more education campaigns are warranted to address barriers, especially those related to stigma. Implications: Our work highlights the need for additional contraceptive methods that are easy to administer and discreet for women who must maintain secrecy. Future studies of the effectiveness of interventions and new contraceptives should obtain healthcare providers' perspectives, as they can provide important insights to service provision.

Religious Leaders as Trusted Messengers in Combatting Hypertension in Rural Tanzanian Communities.

BACKGROUND: Hypertension is a growing public health emergency in rural sub-Saharan Africa. Based on the known influence of religious leaders in rural sub-Saharan Africa and our prior research, we explored perspectives of religious leaders on hypertension and potential strategies to improve hypertension control in their communities. METHODS: We conducted 31 in-depth interviews with Christian (n = 17) and Muslim (n = 14) religious leaders in rural Tanzania. Interviews focused on religious leaders' perceptions of hypertension and how they could play a role in promoting blood pressure reduction. We used interpretative phenomenological analysis, a qualitative research method, to understand religious leaders' perspectives on, and experiences with, hypertension. RESULTS: Three main themes emerged during analysis. First, we found that perceptions about causes, treatment, and complications of hypertension are influenced by religious beliefs. Second, religious beliefs can enable engagement with hypertension care through religious texts that support the use of biomedical care. Third, religious leaders are enthusiastic potential partners for promoting hypertension control in their communities. These themes were consistent between religion and gender of the religious leaders. CONCLUSIONS: Religious leaders are eager to learn about hypertension, to share this knowledge with others and to contribute to improved health in their communities.

Preferences for family planning education among men and women in rural, highly religious Tanzanian communities: a discrete choice experiment.

Unmet need for family planning (FP) remains prevalent worldwide. In Tanzania, 21.7% of women desire to delay pregnancy, but do not use modern contraception despite its free availability at local clinics. Our prior data suggest that this is related to complex gender and religious dynamics in rural communities. To understand how education about FP could be improved, we developed a discrete choice experiment (DCE) to rank preferences of six attributes of FP education. Results were stratified by gender. Sixty-eight women and 76 men completed interview-assisted DCEs. Participants significantly preferred education by a clinician (men = 0.62, p < .001; women = 0.38, p < .001) and education in mixed-gender groups (men = 0.55, p < .001; women = 0.26, p < .001). Women also significantly preferred education by a religious leader (0.26, p = .012), in a clinic versus church, mosque, or community centre (0.31, p = .002), and by a female educator (0.12, p = .019). Men significantly preferred a male educator (0.17, p = .015), whom they had never met (0.25, p < .001), and educating married and unmarried people separately (0.22, p = .002). Qualitative data indicate women who had not previously used contraception preferred education led by a religious leader in a church or mosque. FP education tailored to these preferences may reach a broader audience, dispel misconceptions about FP and ultimately decrease unmet need.

Design and pilot testing of a church-based intervention to address interpersonal and intrapersonal barriers to uptake of family planning in rural Tanzania: a qualitative implementation study.

BACKGROUND: Use of family planning (FP) saves the lives of mothers and children, and contributes to better economic outcomes for households and empowerment for women. In Tanzania, the overall unmet need for FP is high. This study aimed: (1) to use focus group data to construct a theoretical framework to understand the multidimensional factors impacting the decision to use FP in rural Tanzania; (2) to design and pilot-test an educational seminar, informed by this framework, to promote uptake of FP; and (3) to assess acceptability and further refine the educational seminar based on focus group data collected 3 months after the education was provided. METHODS: We performed a thematic analysis of 10 focus group discussions about social and religious aspects of FP from predominantly Protestant church attenders prior to any intervention, and afterwards from six groups of church leaders who had attended the educational seminar. RESULTS: Key interpersonal influences included lack of support from husband/partner, family members, neighbours and church communities. Major intrapersonal factors impeding FP use were lack of medical knowledge and information, misconceptions, and perceived incompatibility of FP and Christian faith. Post-seminar, leaders reported renewed intrapersonal perspectives on FP and reported teaching these perspectives to community members. CONCLUSIONS: Addressing intrapersonal barriers to FP use for leaders led them to subsequently address both intrapersonal and interpersonal barriers in their church communities. This occurred primarily by increasing knowledge and support for FP in men, family members, neighbours and church communities.

How gender and religion impact uptake of family planning: results from a qualitative study in Northwestern Tanzania.

BACKGROUND: Women in Tanzania report a high unmet need for both information about and access to family planning. Prior studies have demonstrated the complex and variable relationship between religious faith and beliefs about family planning in sub-Saharan Africa. We hypothesized that a major reason for the poor uptake of family planning in Tanzania is that women and their partners are uncertain about whether pregnancy prevention is compatible with their religious beliefs. METHODS: Twenty-four focus group discussions with 206 participants were conducted in Mwanza, Tanzania between 2016 and 2017: six groups were conducted among Christian men, six among Christian women, six among Muslim men, and six among Muslim women. Among Christians, 98% were Protestants. Focus groups were also divided by gender and religion to facilitate discussion about gender-specific and religion-specific factors influencing family planning utilization. Qualitative data were analyzed using a thematic, phenomenological approach. RESULTS: We identify two important themes regarding the intersections of religion and family planning practices. First, we report that dynamics of family planning are experienced differently based on gender, and that male authority conflicts with female embodied knowledge, leading to negotiation or covert contraceptive use. Second, religious acceptability of family planning methods is of central importance, though participants differed in their interpretations of their religion's stance on this question. Most who found family planning incompatible with their faith affirmed their responsibility to give birth to as many children as God would give them. Others found family planning to be acceptable given their moral responsibility to care for and protect their children by limiting the family size. CONCLUSIONS: Both religious tradition and gender dynamics strongly influence the uptake of family planning, with a wide range of interpretations of religious traditions affecting the perceived acceptability of family planning. Regardless of gender or religious affiliation, participants were unified by a desire to live according to religious tradition. Future efforts to improve uptake of family planning are likely to have maximal impact if they are tailored to inform, involve, and empower male heads of households, and to address questions of religious acceptability.

Educating religious leaders to promote uptake of male circumcision in Tanzania: a cluster randomised trial.

BACKGROUND: Male circumcision is being widely deployed as an HIV prevention strategy in countries with high HIV incidence, but its uptake in sub-Saharan Africa has been below targets. We did a study to establish whether educating religious leaders about male circumcision would increase uptake in their village. METHODS: In this cluster randomised trial in northwest Tanzania, eligible villages were paired by proximity (<60 km) and the time that a free male circumcision outreach campaign from the Tanzanian Ministry of Health became available in their village. All villages received the standard male circumcision outreach activities provided by the Ministry of Health. Within the village pairs, villages were randomly assigned by coin toss to receive either additional education for Christian church leaders on scientific, religious, and cultural aspects of male circumcision (intervention group), or standard outreach only (control group). Church leaders or their congregations were not masked to random assignment. The educational intervention consisted of a 1-day seminar co-taught by a Tanzanian pastor and a Tanzanian clinician who worked with the Ministry of Health, and meetings with the study team every 2 weeks thereafter, for the duration of the circumcision campaign. The primary outcome was the proportion of male individuals in a village who were circumcised during the campaign, using an intention-to-treat analysis that included all men in the village. This trial is registered with ClinicalTrials.gov, number NCT 02167776. FINDINGS: Between June 15, 2014, and Dec 10, 2015, we provided education for church leaders in eight intervention villages and compared the outcomes with those in eight control villages. In the intervention villages, 52·8% (30 889 of 58 536) of men were circumcised compared with 29·5% (25 484 of 86 492) of men in the eight control villages (odds ratio 3·2 [95% CI, 1·4-7·3]; p=0·006). INTERPRETATION: Education of religious leaders had a substantial effect on uptake of male circumcision, and should be considered as part of male circumcision programmes in other sub-Saharan African countries. This study was conducted in one region in Tanzania; however, we believe that our intervention is generalisable. We equipped church leaders with knowledge and tools, and ultimately each leader established the most culturally-appropriate way to promote male circumcision. Therefore, we think that the process of working through religious leaders can serve as an innovative model to promote healthy behaviour, leading to HIV prevention and other clinically relevant outcomes, in a variety of settings. FUNDING: Bill & Melinda Gates Foundation, National Institutes of Health, and the Mulago Foundation.

'The body we leave behind': a qualitative study of obstacles and opportunities for increasing uptake of male circumcision among Tanzanian Christians.

OBJECTIVES: Male circumcision (MC) reduces HIV infection by approximately 60% among heterosexual men and is recommended by the WHO for HIV prevention in sub-Saharan Africa. In northwest Tanzania, over 60% of Muslims but less than 25% of Christian men are circumcised. We hypothesised that the decision to circumcise may be heavily influenced by religious identity and that specific religious beliefs may offer both obstacles and opportunities to increasing MC uptake, and conducted focus group discussions to explore reasons for low rates of MC among Christian church attenders in the region. DESIGN: Qualitative study using focus group discussions and interpretative phenomenological analysis. SETTING: Discussions took place at churches in both rural and urban areas of the Mwanza region of northwest Tanzania. PARTICIPANTS: We included 67 adult Christian churchgoers of both genders in a total of 10 single-gender focus groups. RESULTS: Christians frequently reported perceiving MC as a Muslim practice, as a practice for the sexually promiscuous, or as unnecessary since they are taught to focus on 'circumcision of the heart'. Only one person had ever heard MC discussed at church, but nearly all Christian parishioners were eager for their churches to address MC and felt that MC could be consistent with their faith. CONCLUSIONS: Christian religious beliefs among Tanzanian churchgoers provide both obstacles and opportunities for increasing uptake of MC. Since half of adults in sub-Saharan Africa identify themselves as Christians, addressing these issues is critical for MC efforts in this region.