Cluster randomized trial of comprehensive gender-based violence programming delivered through the HIV/AIDS program platform in Mbeya Region, Tanzania: Tathmini GBV study.

The Tathmini GBV study was a cluster randomized trial to assess the impact of a comprehensive health facility- and community-based program delivered through the HIV/AIDS program platform on reduction in gender-based violence and improved care for survivors. Twelve health facilities and surrounding communities in the Mbeya Region of Tanzania were randomly assigned to intervention or control arms. Population-level effects were measured through two cross-sectional household surveys of women ages 15-49, at baseline (n = 1,299) and at 28 months following program scale-out (n = 1,250). Delivery of gender-based violence services was assessed through routine recording in health facility registers. Generalized linear mixed effects models and analysis of variance were used to test intervention effects on population and facility outcomes, respectively. At baseline, 52 percent of women reported experience of recent intimate partner violence. The odds of reporting experience of this violence decreased by 29 percent from baseline to follow-up in the absence of the intervention (time effect OR = 0.71, 95% CI: 0.57-0.89). While the intervention contributed an additional 15 percent reduction, the effect was not statistically significant. The program, however, was found to contribute to positive, community-wide changes including less tolerance for certain forms of violence, more gender equitable norms, better knowledge about gender-based violence, and increased community actions to address violence. The program also led to increased utilization of gender-based violence services at health facilities. Nearly three times as many client visits for gender-based violence were recorded at intervention (N = 1,427) compared to control (N = 489) facilities over a 16-month period. These visits were more likely to include provision of an HIV test (55.3% vs. 19.6%, p = .002). The study demonstrated the feasibility and impact of integrating gender-based violence and HIV programming to combat both of these major public health problems. Further opportunities to scale out GBV prevention and response strategies within HIV/AIDS service delivery platforms should be pursued. Trial Registration: Pan African Clinical Trials Registry No. PACTR201802003124149.

Parents' experiences of reporting child sexual abuse in urban Tanzania.

This article reports parental experiences of legally reporting child sexual abuse in Tanzania. Based on in-depth interviews, four types of sexual abuse incidents are portrayed. Each evokes different reactions from parents and the community. An incident characterized as the innocent child was associated with a determination to seek justice. The forced-sex youth elicited feelings of parental betrayal of their child. The consenting curious youth resulted in uncertainty of how to proceed, while the transactional-sex youth evoked a sense of parental powerlessness to control the child because of low economic status. Differentiating between types of sexual abuse incidents may increase awareness of the complexities of child sexual abuse reporting. Education on laws regulating sexual offenses and a functional national child protection system are needed to address child sexual abuse complexities and safeguard the rights of children in Tanzania.

Child sexual abuse: community concerns in urban Tanzania.

The aim of this study was to explore community perceptions about child sexual abuse in Tanzania. Thirteen focus group discussions were conducted with adult community members. The core category, children's rights challenged by lack of agency, was supported by eight categories. Aware but distressed portrayed feelings of hopelessness, lack of trust in the healthcare and legal systems reflected perceived malpractice, decreased respect for children's rights referred to poor parental care and substance abuse, myths justifying CSA illustrated cultural beliefs to rationalize child sexual abuse, disclosure threatened by fear of stigma and discrimination aligned the manifestations that prevent disclosure, actions driven by economic circumstances described the economical dependence of victims, urging a change in procedures reflected informants' wish to ally with local governance and pressure groups, and willingness to act indicated the community's role in supporting victims. The study showed how lack of agency calls for efforts to increase children's human rights at all levels.

Factors for change in maternal and perinatal audit systems in Dar es Salaam hospitals, Tanzania.

BACKGROUND: Effective maternal and perinatal audits are associated with improved quality of care and reduction of severe adverse outcome. Although audits at the level of care were formally introduced in Tanzania around 25 years ago, little information is available about their existence, performance, and practical barriers to their implementation. This study assessed the structure, process and impacts of maternal and perinatal death audit systems in clinical practice and presents a detailed account on how they could be improved. METHODS: A cross sectional descriptive study was conducted in eight major hospitals in Dar es Salaam in January 2009. An in-depth interview guide was used for 29 health managers and members of the audit committees to investigate the existence, structure, process and outcome of such audits in clinical practice. A semi-structured questionnaire was used to interview 30 health care providers in the maternity wards to assess their awareness, attitude and practice towards audit systems. The 2007 institutional pregnancy outcome records were reviewed. RESULTS: Overall hospital based maternal mortality ratio was 218/100,000 live births (range: 0 - 385) and perinatal mortality rate was 44/1000 births (range: 17 - 147). Maternal and perinatal audit systems existed only in 4 and 3 hospitals respectively, and key decision makers did not take part in audit committees. Sixty percent of care providers were not aware of even a single action which had ever been implemented in their hospitals because of audit recommendations. There were neither records of the key decision points, action plan, nor regular analysis of the audit reports in any of the facilities where such audit systems existed. CONCLUSIONS: Maternal and perinatal audit systems in these institutions are poorly established in structure and process; and are less effective to improve the quality of care. Fundamental changes are urgently needed for successful audit systems in these institutions.

Perceptions of child sexual abuse-a qualitative interview study with representatives of the socio-legal system in urban Tanzania.

Through in-depth interviews, this study explored perceptions and experiences of key players handling child sexual offense cases in Dar es Salaam, Tanzania. The informants included public police investigators, magistrates, legal workers, and social workers working with nongovernmental organizations. The interviews were recorded, transcribed verbatim, and analyzed using qualitative content analysis. Five themes emerged summarizing factors associated with sexual offenses, including community passivity, legal system weaknesses, legal framework inadequacy, and key players' vulnerabilities. Addressing the identified weaknesses may promote justice, while changes in attitudes and norms are needed for the prevention of sexual offenses to children.

Management of severely ill children at first-level health facilities in sub-Saharan Africa when referral is difficult.

OBJECTIVES: To quantify the main reasons for referral of infants and children from first-level health facilities to referral hospitals in sub-Saharan Africa and to determine what further supplies, equipment, and legal empowerment might be needed to manage such children when referral is difficult. METHODS: In an observational study at first-level health facilities in Uganda, the United Republic of Tanzania, and Niger, over 3-5 months, we prospectively documented the diagnoses and severity of diseases in children using the standardized Integrated Management of Childhood Illness (IMCI) guidelines. We reviewed the facilities for supplies and equipment and examined the legal constraints of health personnel working at these facilities. FINDINGS: We studied 7195 children aged 2-59 months, of whom 691 (9.6%) were classified under a severe IMCI classification that required urgent referral to a hospital. Overall, 226 children had general danger signs, 292 had severe pneumonia or very severe disease, 104 were severely dehydrated, 31 had severe persistent diarrhoea, 207 were severely malnourished, and 98 had severe anaemia. Considerably more ill were 415 young infants aged one week to two months: nearly three-quarters of these required referral. Legal constraints and a lack of simple equipment (suction pumps, nebulizers, and oxygen concentrators) and supplies (nasogastric tubes and 50% glucose) could prevent health workers from dealing more appropriately with sick children when referral was not possible. CONCLUSION: When referral is difficult or impossible, some additional supplies and equipment, as well as provision of simple guidelines, may improve management of seriously ill infants and children.