Training Curriculum, Skills, and Competencies for Global Health Leaders: Good Practices and Lessons Learned.

Objectives: This paper aims to depict unique perspectives and to compare and contrast three leadership programs for global health in order to enable other training institutions to design impactful curricula. Methods: We purposively selected three global health training programs. We used a six-step curriculum development framework to systematically compare the curriculum process across programs and to identify best practices and factors contributing to the impact of each of these programs. Findings: All three fellowship programs undertook an intentional and in-depth approach to curriculum development. Each identified competencies related to leadership and technical skills. Each defined goals, though the goals differed to align with the desired impact of the program, ranging from improving the impact of HIV programming, supporting stronger global health program implementation, and supporting the next generation of global health leaders. All programs implemented the curriculum through an onboarding phase, a delivery of core content in different formats, and a wrap-up or endline phase. During implementation, each program also utilized networking and mentoring to enhance connections and to support application of learning in work roles. Programs faced overlapping challenges and opportunities including funding, strengthening partnerships, and finding ways to engage and support alumni. Conclusions: Local ownership of programs is critical, including tailoring curricula to the needs of specific contexts. Strong partnerships and resources are needed to ensure program sustainability and impact. Key Takeaways: Global health competencies and curricula should be linked to local health system needs and contexts where learners are working.Emphasizing both individualistic and collectivist approaches to learning is important in engaging and supporting diverse global health learners.Emphasizing mentorship and opportunities to apply learning in contexts where learners are working is important in order to provide support to learners as they work to integrate what they are learning into their professional roles and activities.Partnerships and resources-including donor support-are essential to implement and sustain robust leadership curricula and to provide opportunities for experiential and didactic learning.

Public knowledge of risk factors and warning signs for cardiovascular disease among young and middle-aged adults in rural Tanzania.

BACKGROUND: Improving cardiovascular health requires public knowledge and reduction of modifiable cardiovascular disease (CVD) risk factors. This study assessed knowledge of risk factors and warning signs for CVDs among young and middle-aged adults in Morogoro, Tanzania. METHODS: We conducted a community-based survey as part of cluster randomized controlled study of community health workers (CHWs) intervention for reduction of blood pressure among young and middle-aged adults in rural Morogoro. Information on socio-demographic characteristics, knowledge of risk factors and warning signs for CVDs was collected using an interviewer administered questionaire. Knowledge was assessed using open-ended questions followed by closed-ended questions. Descriptive statistics were used to describe knowledge of risk factors and warning signs. Logistic regression analysis was used to investigate factors associated with adequate knowledge of risk factors and warning signs for CVDs. RESULTS: Two-thirds (65.7%) of the participants had heard about CVDs. The main sources of information were mainly relatives/ neighbors (64.8%) and radio (53.0%). Only 28.3% of the participants reported health care providers as source of information about CVDs. More than half of the participants (52.4%) did not mention even one risk factor spontaneously while 55.2% were unable to mention any warning sign. When asked to select from a list, 6.9% were unable to correctly identify any risk factor whereas 11.8% could not correctly identify even a single warning sign. Quarter of participants (25.4%) had good knowledge score of risk factors, 17.5% had good knowledge score of warning signs and 16.3% had overall good knowledge of both risk factors and warning signs. Residing in Ulanga, having higher education level, having ever checked blood pressure and being overweight/obese predicted adequacy of knowledge score for both risk factors and warning signs. CONCLUSION: Knowledge of risk factors and warning signs in this rural population of young and middle-aged adults was generally low. Health care providers were less likely to provide health education regarding risk factors and warning signs for CVDs. Health promotion interventions to increase population knowledge of risk factors and warning signs should be implemented for successful reduction of CVDs in Tanzania.

Prevalence, Awareness, Treatment, and Control of Hypertension among Young and Middle-Aged Adults: Results from a Community-Based Survey in Rural Tanzania.

BACKGROUND: Hypertension, which is the single most important risk factor for CVDs, is increasing at an alarming rate in most developing countries. This study estimated the prevalence, awareness, treatment, and control of hypertension among young and middle-aged adults in rural Morogoro, Tanzania. Furthermore, it explored factors associated with both prevalence and awareness of hypertension. METHODS: A cross-sectional survey was conducted as part of the cluster randomized controlled study of community health workers (CHWs) interventions for reduction of blood pressure in a randomly selected sample of young and middle-aged population in rural Morogoro. Sociodemographics, lifestyle-related factors, history of diagnosis, and treatment for hypertension were collected using a questionnaire adopted from the STEPS survey tool. Blood pressure, height, and weight were measured at home following standard procedures. Descriptive statistics were used to estimate prevalence, awareness, treatment, and control of hypertension. Multiple logistic regression models were used to assess determinants of hypertension and awareness. RESULT: The prevalence of hypertension was 29.3% (95% CI: 27.7-31.0). Among individuals with hypertension, only 34.3% were aware of their hypertension status. Only around one-third (35.4%) of those who were aware of their hypertension status were currently on antihypertensive medication. Hypertension control was attained in only 29.9% among those on medications. Older age (p < 0.001), use of raw table salt (p < 0.001), and being overweight/obese (p < 0.001) were associated with hypertension. Predictors of awareness of hypertension status were older age, being a female, higher socioeconomic status, use of raw table salt, a history of diabetes, and overweight/obesity (all p < 0.001). Alcohol drinking was associated with low awareness for hypertension status (p < 0.001). CONCLUSION: There is high prevalence of hypertension with low rates of awareness, treatment, and control among young and middle-aged adults in rural Tanzania. Community-level health promotion and screening campaigns for hypertension and other CVD risk factors should be intensified.

Male partner approval on the use of modern contraceptive methods: factors determining usage among couples in Kibaha district, Tanzania.

BACKGROUND: Men in developing countries play an important role in the adoption of family planning (FP), either as actual users or supporters of their partners. Notwithstanding the universal knowledge on the contraceptive methods, their approval and use have been low among men in Tanzania. This study determined the magnitude and factors that influence men to use or approve the use of modern contraceptive methods with their spouses. METHODS: A cross sectional, community-based study was conducted in Kibaha, Pwani region in 2014. A total of 365 randomly selected married and cohabiting men; aged 18 to 60 years who had at least a child below the age of 5 years were interviewed using a structured questionnaire. Descriptive statistics were performed and associations between status of men using modern FP with their partners and potential factors were tested using Chi-square and Fisher's exact tests as appropriate. Logistic regression model was fitted to determine significant factors associated with male use of the methods with their partners. RESULTS: About 60 % of men (59.7%) reported to use modern FP methods. In the bivariate analysis, education level (odds ratio (OR) = 2.6, CI = 1.4-4.8; p = 0.002); men knowledge on any contraceptive method (OR = 24.1, CI = 7.3-79.9; p < 0.001); awareness of a nearby FP clinic (OR = 6.2, CI = 3.1-12.3; p < 0.001); number of children (OR = 2, CI = 1.1-3.6; p < 0.025) and presence of a provider during clinic visit (OR = 12.0, CI = 2.26-63.7; p < 0.004) were significantly associated with the use of FP. However, in the multivariable analysis, only knowledge on FP methods (adjusted odds ratios (AOR) =26.4; CI = 7.9-88.4, p < 0.001) and number of children a man had (AOR = 1.9; CI = 1.0-3.6, p = 0.039) remained significantly associated with the use of modern FP methods. CONCLUSION: This study has shown that for men to use family planning methods with their partners, knowledge of FP methods and number of children are critical factors. Visiting a FP center alone or with a spouse, and availability of FP provider (during visit) also influence this practice. These findings emphasize a need to increase knowledge on contraception and family planning services access among men.

Effect of training community health workers and their interventions on cardiovascular disease risk factors among adults in Morogoro, Tanzania: study protocol for a cluster randomized controlled trial.

BACKGROUND: Cardiovascular diseases (CVDs) increasingly contribute to morbidity and mortality in Tanzania. Public knowledge about CVD risk factors is important for the primary prevention of CVDs and can be improved through community-based interventions delivered by community health workers (CHWs). However, evidence of the utility of CHWs in improving knowledge and CVD risk factors profile is lacking in Tanzania. This study aims at assessing the effect of training CHWs and their CVD-specific interventions for reduction of hypertension and other CVD risk factors among adults in Morogoro, Tanzania. METHODS: This study will use a mixed-methods design with both quantitative and qualitative approaches. A baseline quantitative survey will be conducted to assess knowledge, prevalence, and determinants of CVD risk factors in a random sample of 2950 adults aged 25-64 years. A cluster randomized controlled design with pre-test will be used to assess the effects of CVD-specific interventions delivered by CHWs on reduction of blood pressure and proportion of other CVD risk factors among 516 adults with raised blood pressure from 12 randomly selected villages in Morogoro, Tanzania. Focus group discussion (FGDs) will be conducted at the end of the intervention to assess perceived quality and acceptability of CVD-specific interventions delivered by CHWs. The intervention will consist of a five-day CVD-specific training to CHWs from villages randomized to the intervention. Trained CHWs will then provide home health education and healthy lifestyle promotion for prevention of CVD risk factors, counseling about hypertension screening for early identification, and referral and linkage of individuals with elevated blood pressure to health facilities. Since intensity of the intervention is key to reinforce behavior change, CHWs will visit the participants every month for the first six months, then bi-monthly thereafter up to 12 months. Except for referral of participants with raised blood pressure identified during the baseline survey, control villages will not receive any interventions delivered by CHWs. At the end of the intervention period, an end-line survey will be conducted in both intervention and control villages to evaluate changes in knowledge, blood pressure, and proportion of other CVD risk factors. DISCUSSION: The results of this study are likely to have positive policy implications for the prevention of CVD risk factors through the use of CHWs in the provision of CVD-specific interventions, especially now that the Tanzanian government is considering implementing and scaling up a nation-wide multitask CHW cadre. TRIAL REGISTRATION: PACTR Registry, PACTR201801002959401 . Registered on 10 January 2018.

Improving feeding and growth of HIV-positive children through nutrition training of frontline health workers in Tanga, Tanzania.

BACKGROUND: Nutrition training can boost competence of health workers to improve children's feeding practices. In this way, child undernutrition can be ameliorated in general populations. However, evidence is lacking on efficacy of such interventions among Human Immunodeficiency Virus (HIV)-positive children. We aimed to examine the efficacy of a nutrition training intervention to improve midlevel providers' (MLPs) nutrition knowledge and feeding practices and the nutrition statuses of HIV-positive children in Tanga, Tanzania. METHODS: This cluster-randomized controlled trial was conducted in 16 out of 32 care and treatment centers (CTCs) in Tanga. Eight CTCs were assigned to the intervention arm and a total of 16 MLPs received nutrition training and provided nutrition counseling and care to caregivers of HIV-positive children. A total of 776 pairs of HIV-positive children and their caregivers were recruited, of whom 397 were in the intervention arm. Data were analyzed using instrumental variable random effects regression with panel data to examine the efficacy of the intervention on nutrition status through feeding practices. RESULTS: Mean nutrition knowledge scores were higher post-training compared to pre-training among MLPs (37.1 vs. 23.5, p < 0.001). A mean increment weight gain of 300 g was also observed at follow-up compared to baseline among children of the intervention arm. Feeding frequency and dietary diversity improved following the intervention and a 6 months follow-up (p < 0.001). An increase in each unit of feeding frequency and dietary diversity were associated with a 0.15-unit and a 0.16-unit respectively decrease in the child underweight (p < 0.001). CONCLUSIONS: Nutrition training improved nutrition knowledge among MLPs caring for HIV-positive children attending CTCs in Tanga, Tanzania. Caregivers' feeding practices also improved, which in turn led to a modest weight gain among HIV-positive children. To sustain weight gain, efforts should be made to also improve households' food security and caregivers' education in addition to inservice nutrition trainings. The protocol was registered on 15/02/2013, before the recruitment at ISRCTN trial registry with the trial registration number: ISRCTN65346364.

High magnitude of under nutrition among HIV infected adults who have not started ART in Tanzania--a call to include nutrition care and treatment in the test and treat model.

BACKGROUND: Undernutrition among people living with HIV (PLWHIV) can be ameliorated if nutrition specific and sensitive interventions are integrated into their HIV care and treatment centers (CTC). Integrated care is lacking despite expansion of antiretroviral therapy (ART) coverage, representing a substantial missed opportunity. This research aims to examine nutritional status and associated risk factors among HIV-positive adults prior to ART initiation in Tanzania in order to characterize existing gaps and inform early integration of nutrition care into CTC. METHODS: We analyzed data from 3993 pre-ART adults living with HIV enrolled in CTCs within the Trial of Vitamin (TOV3) and progression of HIV/AIDS study in Dar es salaam, Tanzania. The primary outcome for this analysis was undernutrition, measured as body mass index (BMI) below 18.5 kg/m2. We conducted descriptive analyses of baseline characteristics and utilized multiple logistic regression to determine independent factors associated with pre-ART undernutrition. RESULTS: Undernutrition was prevalent in about 27.7% of pre-ART adults, with a significantly higher magnitude among males compared to females (30% vs. 26.6%, p < 0.025). Severe undernutrition (BMI < 16.0 kg/m2) was prevalent in one in four persons, with a trend toward higher magnitudes among females (26.2% vs. 21.1% p = 0.123). Undernutrition was also more prevalent among younger adults (p < 0.001), those with lower wealth quintiles (p = 0.003), and those with advanced HIV clinical stage (p < 0.001). Pre-ART adults presented with poor feeding practices, hallmarked by low dietary diversity scores and infrequent consumption of proteins, vegetables, and fruits. After adjusting for confounders and important co-variates, pre-ART undernutrition was associated with younger age, low wealth indices, advanced clinical stage, and low dietary diversity. CONCLUSIONS: One in every four pre-ART PLWHIV presented with undernutrition in Dar es salaam, Tanzania. Risk factors for undernourishment included younger age, lower household income, advanced HIV clinical stage, and lower dietary diversity score. Knowledge of the prevalence and prevailing risk factors for undernutrition among pre-ART PLWHIV should guide targeted, early integration of nutrition interventions into routine HIV care and treatment in high-prevalence, low-income settings such as Tanzania.

Profile, knowledge, and work patterns of a cadre of maternal, newborn, and child health CHWs focusing on preventive and promotive services in Morogoro Region, Tanzania.

BACKGROUND: Despite impressive decreases in under-five mortality, progress in reducing maternal and neonatal mortality in Tanzania has been slow. We present an evaluation of a cadre of maternal, newborn, and child health community health worker (MNCH CHW) focused on preventive and promotive services during the antenatal and postpartum periods in Morogoro Region, Tanzania. Study findings review the effect of several critical design elements on knowledge, time allocation, service delivery, satisfaction, and motivation. METHODS: A quantitative survey on service delivery and knowledge was administered to 228 (of 238 trained) MNCH CHWs. Results are compared against surveys administered to (1) providers in nine health centers (n = 88) and (2) CHWs (n = 53) identified in the same districts prior to the program's start. Service delivery outputs were measured by register data and through a time motion study conducted among a sub-sample of 33 randomly selected MNCH CHWs. RESULTS: Ninety-seven percent of MNCH CHWs (n = 228) were interviewed: 55% male, 58% married, and 52% with secondary school education or higher. MNCH CHWs when compared to earlier CHWs were more likely to be unmarried, younger, and more educated. Mean MNCH CHW knowledge scores were <50% for 8 of 10 MNCH domains assessed and comparable to those observed for health center providers but lower than those for earlier CHWs. MNCH CHWs reported covering a mean of 186 households and were observed to provide MNCH services for 5 h weekly. Attendance of monthly facility-based supervision meetings was nearly universal and focused largely on registers, yet data quality assessments highlighted inconsistencies. Despite program plans to provide financial incentives and bicycles for transport, only 56% of CHWs had received financial incentives and none received bicycles. CONCLUSIONS: Initial rollout of MNCH CHWs yields important insights into addressing program challenges. The social profile of CHWs was not significantly associated with knowledge or service delivery, suggesting a broader range of community members could be recruited as CHWs. MNCH CHW time spent on service delivery was limited but comparable to the financial incentives received. Service delivery registers need to be simplified to reduce inconsistencies and yet expanded to include indicators on the timing of antenatal and postpartum visits.

Motivation and satisfaction among community health workers in Morogoro Region, Tanzania: nuanced needs and varied ambitions.

BACKGROUND: In 2012, the Ministry of Health and Social Welfare (MOHSW), Tanzania, approved national guidelines and training materials for community health workers (CHWs) in integrated maternal, newborn and child health (Integrated MNCH), with CHWs trained and deployed across five districts of Morogoro Region soon after. To inform future scale up, this study assessed motivation and satisfaction among these CHWs. METHODS: A survey of all CHWs trained by the Integrated MNCH Programme was conducted in the last quarter of 2013. Motivation and satisfaction were assessed using a five-point Likert scale with 29 and 27 items based on a literature review and discussions with CHW programme stakeholders. Exploratory factor analysis was conducted to identify motivation and satisfaction determinants. RESULTS: Out of 238 eligible CHWs, 96 % were included in the study. Findings showed that respondents were motivated to become CHWs due to altruism (work on MNCH, desire to serve God, work hard) and intrinsic needs (help community, improve health, pride) than due to external stimuli (monetary incentives, skill utilization, community respect or hope for employment). CHWs were satisfied by relationships with health workers and communities, job aids and the capacity to provide services. CHWs were dissatisfied with the lack of transportation, communication devices and financial incentives for carrying out their tasks. Factors influencing motivation and satisfaction did not differ across CHW socio-demographic characteristics. Nonetheless, older and less educated CHWs were more likely to be motivated by altruism, intrinsic needs and skill utilization, community respect and hope for employment. Less educated CHWs were more satisfied with service and quality factors and more wealthy CHWs satisfied with job aids. CONCLUSION AND RECOMMENDATIONS: A combination of financial and non-financial incentives is required to support motivation and satisfaction among CHWs. Although CHWs joined mainly due to their altruistic nature, they became discontented with the lack of monetary compensation, transportation and communication support received. With the planned rollout of the national CHW cadre, improved understanding of CHWs as a heterogeneous group with nuanced needs and varied ambitions is vital for ensuring sustainability.

Poor nutrition status and associated feeding practices among HIV-positive children in a food secure region in Tanzania: a call for tailored nutrition training.

METHODS: We conducted this mixed-method study among 748 children aged 6 months-14 years attending 9 of a total of 32 care and treatment centers in Tanga region, Tanzania. We collected quantitative data using a standard questionnaire and qualitative data through seven focus group discussions (FGDs). RESULTS: HIV-positive children had high magnitudes of undernutrition. Stunting, underweight, wasting, and thinness were prevalent among 61.9%, 38.7%, 26.0%, and 21.1% of HIV-positive children, respectively. They also had poor feeding practices: 88.1% were fed at a frequency below the recommendations, and 62.3% had a low level of dietary diversity. Lower feeding frequency was associated with stunting (ß = 0.11, p = 0.016); underweight (ß = 0.12, p = 0.029); and thinness (ß = 0.11, p = 0.026). Lower feeding frequency was associated with low wealth index (ß = 0.06, p<0.001), food insecurity (ß =  -0.05, p<0.001), and caregiver's education. In the FGDs, participants discussed the causal relationships among the key associations; undernutrition was mainly due to low feeding frequency and dietary diversity. Such poor feeding practices resulted from poor nutrition knowledge, food insecurity, low income, and poverty. CONCLUSION: Feeding practices and nutrition status were poor among HIV-positive children even in food rich areas. Improving feeding frequency may help to ameliorate undernutrition. To improve it, tailored interventions should target children of poor households, the food insecure, and caregivers who have received only a low level of education.

Nutrition training improves health workers' nutrition knowledge and competence to manage child undernutrition: a systematic review.

BACKGROUND: Medical and nursing education lack adequate practical nutrition training to fit the clinical reality that health workers face in their practices. Such a deficit creates health workers with poor nutrition knowledge and child undernutrition management practices. In-service nutrition training can help to fill this gap. However, no systematic review has examined its collective effectiveness. We thus conducted this study to examine the effectiveness of in-service nutrition training on health workers' nutrition knowledge, counseling skills, and child undernutrition management practices. METHODS: We conducted a literature search on nutrition interventions from PubMed/MEDLINE, CINAHL, EMBASE, ISI Web of Knowledge, and World Health Organization regional databases. The outcome variables were nutrition knowledge, nutrition-counseling skills, and undernutrition management practices of health workers. Due to heterogeneity, we conducted only descriptive analyses. RESULTS: Out of 3910 retrieved articles, 25 were selected as eligible for the final analysis. A total of 18 studies evaluated health workers' nutrition knowledge and showed improvement after training. A total of 12 studies with nutrition counseling as the outcome variable also showed improvement among the trained health workers. Sixteen studies evaluated health workers' child undernutrition management practices. In all such studies, child undernutrition management practices and competence of health workers improved after the nutrition training intervention. CONCLUSION: In-service nutrition training improves quality of health workers by rendering them more knowledge and competence to manage nutrition-related conditions, especially child undernutrition. In-service nutrition training interventions can help to fill the gap created by the lack of adequate nutrition training in the existing medical and nursing education system. In this way, steps can be taken toward improving the overall nutritional status of the child population.

Efficacy of in-service nutrition training for mid-level providers to improve feeding practices among HIV-positive children in Tanga, Tanzania: study protocol for a cluster randomized controlled trial.

BACKGROUND: Feeding practices and child undernutrition can be improved when trained health workers provide proper nutrition counseling to caregivers. However, this important management component is difficult to achieve in countries where trained health workers are limited; Tanzania is no exception. In rural and semi-urban areas, mid-level providers (MLPs) are left to manage diseases such as HIV/AIDS.Training health workers in nutrition has been shown to be an effective intervention among HIV-negative children elsewhere, but no studies have been conducted among HIV-positive children. Furthermore, in Tanzania and other countries with MLPs, no evidence currently exists demonstrating an improvement in nutrition among children who receive health services given by MLPs. This study thus aims to examine the efficacy of nutrition training of MLPs on feeding practices and the nutrition status of HIV-positive children in Tanga, Tanzania. METHODS/DESIGN: We will conduct a cluster randomized controlled trial in care and treatment centers (CTCs) in Tanga, Tanzania. The CTCs will be the unit of randomization. We will select 16 CTCs out of 32 for this study, of which we will randomly assign 8 to the intervention arm and 8 to the control arm by coin flipping. From the selected CTCs we will attempt to recruit a total of 800 HIV-positive children aged 6 months to 14 years, half of whom will be receiving care and/or treatment in the CTCs of the intervention arm, and the other half of whom will be receiving care and/or treatment in the CTCs of the control arm (400 children in each condition).We will provide nutrition training to MLPs of the CTCs selected for the intervention arm. In this intervention, we will use the World Health Organization guidelines on nutrition training of health workers for HIV-positive children aged 6 months to 14 years. The trained MLPs will then provide tailored nutrition counseling to caregivers of children being treated at the 8 CTCs of the intervention arm. We will measure nutrition status and child feeding practices monthly for a total of six months. CONCLUSIONS: Results of this trial will help expanding undernutrition interventions among HIV-positive children in Tanzania and other countries. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN65346364.

Sources of community health worker motivation: a qualitative study in Morogoro Region, Tanzania.

BACKGROUND: There is a renewed interest in community health workers (CHWs) in Tanzania, but also a concern that low motivation of CHWs may decrease the benefits of investments in CHW programs. This study aimed to explore sources of CHW motivation to inform programs in Tanzania and similar contexts. METHODS: We conducted semi-structured interviews with 20 CHWs in Morogoro Region, Tanzania. Interviews were digitally recorded, transcribed, and coded prior to translation and thematic analysis. The authors then conducted a literature review on CHW motivation and a framework that aligned with our findings was modified to guide the presentation of results. RESULTS: Sources of CHW motivation were identified at the individual, family, community, and organizational levels. At the individual level, CHWs are predisposed to volunteer work and apply knowledge gained to their own problems and those of their families and communities. Families and communities supplement other sources of motivation by providing moral, financial, and material support, including service fees, supplies, money for transportation, and help with farm work and CHW tasks. Resistance to CHW work exhibited by families and community members is limited. The organizational level (the government and its development partners) provides motivation in the form of stipends, potential employment, materials, training, and supervision, but inadequate remuneration and supplies discourage CHWs. Supervision can also be dis-incentivizing if perceived as a sign of poor performance. CONCLUSIONS: Tanzanian CHWs who work despite not receiving a salary have an intrinsic desire to volunteer, and their motivation often derives from support received from their families when other sources of motivation are insufficient. Policy-makers and program managers should consider the burden that a lack of remuneration imposes on the families of CHWs. In addition, CHWs' intrinsic desire to volunteer does not preclude a desire for external rewards. Rather, adequate and formal financial incentives and in-kind alternatives would allow already-motivated CHWs to increase their commitment to their work.

Effectiveness of nutrition training of health workers toward improving caregivers' feeding practices for children aged six months to two years: a systematic review.

BACKGROUND: Nutrition training of health workers can help to reduce child undernutrition. Specifically, trained health workers might contribute to this end through frequent nutrition counseling of caregivers. This may improve child-feeding practices and thus reduce the risk of undernutrition among children of counseled caregivers. Although studies have shown varied impacts of health workers' nutrition training on child feeding practices, no systematic review of the effectiveness of such intervention has yet been reported. Therefore, we conducted this study to examine the effectiveness of nutrition training for health workers on child feeding practices including feeding frequency, energy intake, and dietary diversity among children aged six months to two years. METHODS: We searched the literature for published randomized controlled trials (RCTs) and cluster RCTs using medical databases including PubMed/MEDLINE, CINAHL, EMBASE, and ISI Web of Knowledge, and through WHO regional databases. Our intervention of interest was nutrition training of health workers. We pooled the results of the selected trials, evaluated them using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria, and calculated the overall effect size of the intervention in meta-analyses. RESULTS: Ten RCTs and cluster RCTs out of 4757 retrieved articles were eligible for final analyses. Overall, health workers' nutrition training improved daily energy intake of children between six months and two years of age. The pooled evidence from the three studies reporting mean energy intake per day revealed a standardized mean difference (SMD) of 0.76, 95% CI (0.63-0.88). For the two studies with median energy intake SMD was 1.06 (95% CI 0.87-1.24). Health workers' nutrition training also improved feeding frequency among children aged six months to two years. The pooled evidence from the three studies reporting mean feeding frequency showed an SMD of 0.48 (95% CI 0.38-0.58). Regarding dietary diversity, children in intervention groups were more likely to consume more diverse diets compared to their counterparts. CONCLUSION AND RECOMMENDATIONS: Nutrition training for health workers can improve feeding frequency, energy intake, and dietary diversity of children aged six months to two years. Scaling up of nutrition training for health workers presents a potential entry point to improve nutrition status among children.

Ready to Use Therapeutic Foods (RUTF) improves undernutrition among ART-treated, HIV-positive children in Dar es Salaam, Tanzania.

BACKGROUND: HIV/AIDS is associated with an increased burden of undernutrition among children even under antiretroviral therapy (ART). To treat undernutrition, WHO endorsed the use of Ready to Use Therapeutic Foods (RUTF) that can reduce case fatality and undernutrition among ART-naïve HIV-positive children. However, its effects are not studied among ART-treated, HIV-positive children. Therefore, we examined the association between RUTF use with underweight, wasting, and stunting statuses among ART-treated HIV-positive children in Dar es Salaam, Tanzania. METHODS: This cross-sectional study was conducted from September-October 2010. The target population was 219 ART-treated, HIV-positive children and the same number of their caregivers. We used questionnaires to measure socio-economic factors, food security, RUTF-use, and ART-duration. Our outcome variables were underweight, wasting, and stunting statuses. RESULTS: Of 219 ART-treated, HIV-positive children, 140 (63.9%) had received RUTF intervention prior to the interview. The percentages of underweight and wasting among non-RUTF-receivers were 12.4% and 16.5%; whereas those of RUTF-receivers were 3.0% (P = 0.006) and 2.8% (P = 0.001), respectively. RUTF-receivers were less likely to have underweight (Adjusted Odd Ratio (AOR) =0.19, CI: 0.04, 0.78), and wasting (AOR = 0.24, CI: 0.07, 0.81), compared to non RUTF-receivers. Among RUTF receivers, children treated for at least four months (n = 84) were less likely to have underweight (P = 0.049), wasting (P = 0.049) and stunting (P < 0.001). CONCLUSIONS: Among HIV-positive children under ART, the provision of RUTF for at least four months was associated with low proportions of undernutrition status. RUTF has a potential to improve undernutrition among HIV-positive children under ART in the clinical settings in Dar es Salaam, Tanzania.

The quality of antenatal care in rural Tanzania: what is behind the number of visits?

BACKGROUND: Antenatal care (ANC) provides an important opportunity for pregnant women with a wide range of interventions and is considered as an important basic component of reproductive health care. METHODS: In 2008, severe maternal morbidity audit was established at Saint Francis Designated District Hospital (SFDDH), in Kilombero district in Tanzania, to ascertain substandard care and implement interventions. In addition, a cross-sectional descriptive study was carried out in 11 health facilities within the district to assess the quality of ANC and underlying factors in a broader view. RESULTS: Of 363 severe maternal morbidities audited, only 263 (72%) ANC cards were identified. Additionally, 121 cards (with 299 ANC visits) from 11 facilities were also reviewed. Hemoglobin and urine albumin were assessed in 22% - 37% and blood pressure in 69% - 87% of all visits. Fifty two (20%) severe maternal morbidities were attributed to substandard ANC, of these 39 had severe anemia and eclampsia combined. Substandard ANC was mainly attributed to shortage of staff, equipment and consumables. There was no significant relationship between assessment of essential parameters at first ANC visit and total number of visits made (Spearman correlation coefficient, r = 0.09; p = 0.13). Several interventions were implemented and others were proposed to those in control of the health system. CONCLUSIONS: This article reflects a worrisome state of substandard ANC in rural Tanzania resulting from inadequate human workforce and material resources for maternal health, and its adverse impacts on maternal wellbeing. These results suggest urgent response from those in control of the health system to invest more resources to avert the situation in order to enhance maternal health in this country.

Birth preparedness and complication readiness among women in Mpwapwa district, Tanzania.

Avoidable mortality and morbidity remains a formidable challenge in many developing countries like Tanzania. Birth preparedness and complication readiness by mothers are critical in reducing morbidities and mortalities due to these complications. The aim of this study was to assess knowledge and practices with respect to birth preparedness and complication readiness among women in Mpwapwa district in Tanzania. A total of 600 women who became pregnant and or gave birth two years preceding the survey were interviewed. Among them 587 (97.8%) attended antenatal clinic (ANC) at least once during their last pregnancy. Two thirds of those who attended ANC made four or more visits. The median gestation age at booking for antenatal care was 16 weeks. However, 73.9% the women booked after 16 weeks of gestation. Two thirds of the women were 20-34 years old and had at least primary education level. Three hundred and forty six (57.7%) had parity between two and four. Only 14.8% of the women knew three or more obstetric danger signs. The obstetric danger signs most commonly known included vaginal bleeding during pregnancy (19%), foul smelling vaginal discharge (15%) and baby stops moving (14.3%). The majority (86.2%) of the women had decisions made on place of delivery, a person to make final decision, a person to assist during delivery, someone to take care of the family and a person to escort her to health facility. Majority (68.1%) of the women planned to be delivered by skilled attendant. One third of the women planned to deliver at home in the absence of a skilled birth attendant. In the bivariate analysis, age of the woman, education, marital status, number of ANC visits and knowing ≥3 obstetric danger signs were associated with birth preparedness and complication readiness. In multivariate logistic regression analysis, women with primary education and above were twice more likely to be prepared and ready for birth and complications. Women who knew ≥3 obstetric danger signs were 3 times more likely to be prepared for birth and complications. In conclusion, women with higher level of education and those who knew obstetric complications were more prepared for birth and complications. Further studies are recommended to find out why women do not prepare for birth or complications especially that need blood transfusion.

Birth Preparedness and Complication Readiness among Women in Mpwapwa District; Tanzania

Abstract:Avoidable mortality and morbidity remains a formidable challenge in many developing countries like Tanzania. Birth preparedness and complication readiness by mothers are critical in reducing morbidities and mortalities due to these complications. The aim of this study was to assess knowledge and practices with respect to birth preparedness and complication readiness among women in Mpwapwa district in Tanzania. A total of 600 women who became pregnant and or gave birth two years preceding the survey were interviewed. Among them 587 (97.8) attended antenatal clinic (ANC) at least once during their last pregnancy. Two thirds of those who attended ANC made four or more visits. The median gestation age at booking for antenatal care was 16 weeks. However; 73.9 the women booked after 16 weeks of gestation. Two thirds of the women were 20-34years old and had at least primary education level. Three hundred and forty six (57.7) had parity between two and four. Only 14.8 of the women knew three or more obstetric danger signs. The obstetric danger signs most commonly known included vaginal bleeding during pregnancy (19); foul smelling vaginal discharge (15) and baby stops moving (14.3). The majority (86.2) of the women had decisions made on place of delivery; a person to make final decision; a person to assist during delivery; someone to take care of the family and a person to escort her to health facility. Majority (68.1) of the women planned to be delivered by skilled attendant. One third of the women planned to deliver at home in the absence of a skilled birth attendant. In the bivariate analysis; age of the woman; education; marital status; number of ANC visits and knowing ?3 obstetric danger signs were associated with birth preparedness and complication readiness. In multivariate logistic regression analysis; women with primary education and above were twice more likely to be prepared and ready for birth and complications. Women who knew ?3 obstetric danger signs were 3 times more likely to be prepared for birth and complications. In conclusion; women with higher level of education and those who knew obstetric complications were more prepared for birth and complications. Further studies are recommended to find out why women do not prepare for birth or complications especially that need blood transfusion

Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania.

BACKGROUND: Although clinical audit is an important instrument for quality care improvement, the concept has not yet been adequately taken on board in rural settings in most resource limited countries where the problem of maternal mortality is immense. Maternal mortality and morbidity audit was established at Saint Francis Designated District Hospital (SFDDH) in rural Tanzania in order to generate information upon which to base interventions. METHODS: Methods are informed by the principles of operations research. An audit system was established, all patients fulfilling the inclusion criteria for maternal mortality and severe morbidity were reviewed and selected cases were audited from October 2008 to July 2010. The causes and underlying factors were identified and strategic action plans for improvement were developed and implemented. RESULTS: There were 6572 deliveries and 363 severe maternal morbidities of which 36 women died making institutional case fatality rate of 10%. Of all morbidities 341 (94%) had at least one area of substandard care. Patients, health workers and administration related substandard care factors were identified in 50% - 61% of women with severe morbidities. Improving responsiveness to obstetric emergencies, capacity building of the workforce for health care, referral system improvement and upgrading of health centres located in hard to reach areas to provide comprehensive emergency obstetric care (CEmOC) were proposed and implemented as a result of audit. CONCLUSIONS: Our findings indicate that audit can be implemented in rural resource limited settings and suggest that the vast majority of maternal mortalities and severe morbidities can be averted even where resources are limited if strategic interventions are implemented.

Undernutrition among HIV-positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough.

BACKGROUND: The prevalence of HIV/AIDS has exacerbated the impact of childhood undernutrition in many developing countries, including Tanzania. Even with the provision of antiretroviral therapy, undernutrition among HIV-positive children remains a serious problem. Most studies to examine risk factors for undernutrition have been limited to the general population and ART-naive HIV-positive children, making it difficult to generalize findings to ART-treated HIV-positive children. The objectives of this study were thus to compare the proportions of undernutrition among ART-treated HIV-positive and HIV-negative children and to examine factors associated with undernutrition among ART-treated HIV-positive children in Dar es Salaam, Tanzania. METHODS: From September to October 2010, we conducted a cross-sectional survey among 213 ART-treated HIV-positive and 202 HIV-negative children in Dar es Salaam, Tanzania. We measured the children's anthropometrics, socio-demographic factors, food security, dietary habits, diarrhea episodes, economic status, and HIV clinical stage. Data were analyzed using both univariate and multivariate methods. RESULTS: ART-treated HIV-positive children had higher rates of undernutrition than their HIV-negative counterparts. Among the ART-treated HIV-positive children, 78 (36.6%) were stunted, 47 (22.1%) were underweight, and 29 (13.6%) were wasted. Households of ART-treated HIV-positive children exhibited lower economic status, lower levels of education, and higher percentages of unmarried caregivers with higher unemployment rates. Food insecurity was prevalent in over half of ART-treated HIV-positive children's households. Furthermore, ART-treated HIV-positive children were more likely to be orphaned, to be fed less frequently, and to have lower body weight at birth compared to HIV-negative children.In the multivariate analysis, child's HIV-positive status was associated with being underweight (AOR = 4.61, 95% CI 1.38-15.36 P = 0.013) and wasting (AOR = 9.62, 95% CI 1.72-54.02, P = 0.010) but not with stunting (AOR = 0.68, 95% CI 0.26-1.77, P = 0.428). Important factors associated with underweight status among ART-treated HIV-positive children included hunger (AOR = 9.90, P = 0.022), feeding frequency (AOR = 0.02, p < 0.001), and low birth weight (AOR = 5.13, P = 0.039). Factors associated with wasting among ART-treated HIV-positive children were diarrhea (AOR = 22.49, P = 0.001) and feeding frequency (AOR = 0.03, p < 0.001). CONCLUSION: HIV/AIDS is associated with an increased burden of child underweight status and wasting, even among ART-treated children, in Dar es Salaam, Tanzania. In addition to increasing coverage of ART among HIV-positive children, interventions to ameliorate poor nutrition status may be necessary in this and similar settings. Such interventions should aim at promoting adequate feeding patterns, as well as preventing and treating diarrhea.