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1.  Development and community-based validation of the IDEA study Instrumental Activities of Daily Living (IDEA-IADL) questionnaire 
Global Health Action  2014;7:10.3402/gha.v7.25988.
The dementia diagnosis gap in sub-Saharan Africa (SSA) is large, partly due to difficulties in assessing function, an essential step in diagnosis.
As part of the Identification and Intervention for Dementia in Elderly Africans (IDEA) study, to develop, pilot, and validate an Instrumental Activities of Daily Living (IADL) questionnaire for use in a rural Tanzanian population to assist in the identification of people with dementia alongside cognitive screening.
The questionnaire was developed at a workshop for rural primary healthcare workers, based on culturally appropriate roles and usual activities of elderly people in this community. It was piloted in 52 individuals under follow-up from a dementia prevalence study. Validation subsequently took place during a community dementia-screening programme. Construct validation against gold standard clinical dementia diagnosis using DSM-IV criteria was carried out on a stratified sample of the cohort and validity assessed using area under the receiver operating characteristic (AUROC) curve analysis.
An 11-item questionnaire (IDEA-IADL) was developed after pilot testing. During formal validation on 130 community-dwelling elderly people who presented for screening, the AUROC curve was 0.896 for DSM-IV dementia when used in isolation and 0.937 when used in conjunction with the IDEA cognitive screen, previously validated in Tanzania. The internal consistency was 0.959. Performance on the IDEA-IADL was not biased with regard to age, gender or education level.
The IDEA-IADL questionnaire appears to be a useful aid to dementia screening in this setting. Further validation in other healthcare settings in SSA is required.
PMCID: PMC4275650  PMID: 25537940
instrumental activities of daily living; validation; screening; dementia; Africa; Tanzania
2.  Factors Influencing Drug Uptake during Mass Drug Administration for Control of Lymphatic Filariasis in Rural and Urban Tanzania 
PLoS ONE  2014;9(10):e109316.
In most countries of Sub-Saharan Africa, control of lymphatic filariasis (LF) is based on annual mass drug administration (MDA) with a combination of ivermectin and albendazole. Treatment coverages are however often suboptimal for programmes to reach the goal of transmission interruption within reasonable time. The present study aimed to identify predictors and barriers to individual drug uptake during MDA implementation by the National LF Elimination Programme in Tanzania.
A questionnaire based cross sectional household survey was carried out in two rural and two urban districts in Lindi and Morogoro regions shortly after the 2011 MDA. 3279 adults (≥15 years) were interviewed about personal characteristics, socio-economic status, MDA drug uptake among themselves and their children, reasons for taking/not taking drugs, and participation in previous MDA activities for LF control.
The overall drug uptake rate was 55.1% (range of 44.5–75.6% between districts). There was no overall major difference between children (54.8%) and adults (55.2%) or between females (54.9%) and males (55.8%), but the role of these and other predictors varied to some extent between study sites. Major overall predictors of drug uptake among the interviewed adults were increasing age and history of previous drug uptake. Being absent from home during drug distribution was the main reason for not taking the drugs (50.2%) followed by clinical contraindications to treatment (10.8%), missing household visits of drug distributors (10.6%), and households not being informed about the distribution (9.0%).
Drug uptake relied more on easily modifiable provider-related factors than on individual perceptions and practices in the target population. Limited investments in appropriate timing, dissemination of accurate timing information to recipients and motivation of drug distributors to visit all households (repeatedly when residents are absent) are likely to have considerable potential for increasing drug uptake, in support of successful LF transmission elimination.
PMCID: PMC4190414  PMID: 25296034
3.  Does training on performance based financing make a difference in performance and quality of health care delivery? Health care provider’s perspective in Rungwe Tanzania 
In recent years, Performance Based Financing (PBF); a form of result based financing, has attracted a global attention in health systems in developing countries. PBF promotes autonomous health facilities, motivates and introduces financial incentives to motivate health facilities and health workers to attain pre-determined targets. To achieve this, the Tanzanian government through the Christian Social Services Commission initiated a PBF pilot project in Rungwe district, Mbeya region. Kilimanjaro Christian Medical Center was given the role of training health workers on PBF principles in Rungwe. The aim of this study was to explore health care providers’ perception on a three years training on PBF principles in a PBF pilot project at Rungwe District in Mbeya, Tanzania.
This was an explorative qualitative study, which took place at Rungwe PBF pilot area in October 2012. Twenty six (26) participants were purposively selected. Six took part in- depth interviews (IDIs) and twenty (20) in the group discussions. Both the IDIs and the GDs explored the perceived benefit and challenges of implementing PBF in their workplace. Data were manually analyzed using content analysis approach.
Overall informants had positive perspectives on PBF training. Most of the health facilities were able to implement some of the PBF concepts in their work places after the training, such as developing job descriptions for their staff, creating quarterly business plans for their facilities, costing for their services and entering service agreement with the government, improved record keeping, customer care and involving community as partners in running their facilities. The most common principle of paying individual performance bonuses was mentioned as a major challenge due to inadequate funding and poor design of Rungwe PBF pilot project.
Despite poor design and inadequate funding, our findings have shown some promising results after PBF training in the study area. The findings have highlighted the potential of PBF to act as leverage for initiating innovative and proactive actions, which may motivate health personnel performance and quality of care in the study setting with minimal support. However, key policy issues at the national level should be addressed in order to exploit this opportunity.
PMCID: PMC4234322  PMID: 24708628
Performance based financing; PBF pilot project; Rungwe; Tanzania
4.  Social representation and practices related to dementia in Hai District of Tanzania 
BMC Public Health  2014;14:260.
With the increasing number of people surviving into old age in Africa, dementia is becoming an important public health problem. Understanding the social dynamics of dementia in resource-poor settings is critical for developing effective interventions. We explored the socio-cultural beliefs surrounding dementia and the life experience of people with dementia (PWD) and their caregivers in the Hai District of Kilimanjaro, Tanzania.
Cross-sectional qualitative design. Forty one PWD were purposively sampled from the Hai District of Kilimanjaro. Twenty five paired interviews with PWD and with caregivers, and 16 with caregivers alone, were conducted. Interviews were tape recorded, transcribed verbatim and analyzed using content analysis approach.
Forty one PWD (26 females), aged 70 years and older, were recruited but due to speech difficulties only 25 participated in the interviews. Married were 13, widow in 22 and widower 6. The majority, 33/41 were illiterate. PWD and carers perceived memory problems as a normal part of ageing. Dementia was commonly referred as "ugonjwa wa uzeeni" (disease of old people) or memory loss disease. The majority of PWD 13/12 and carers 7/16 did not know what dementia is or what causes it. Dementia was felt to be associated with stroke, high blood pressure, diabetes, old age, curse/witchcraft and life stress. Half of the participants had used modern care and alternative care such as herbs, prayers or traditional healers. Caregivers complained about the burden of caring for PWD and suggested that community organizations should be involved in addressing the problem.
Knowledge about dementia is low and the symptoms are accepted as a problem of old age. PWD and carers demonstrate pluralistic behaviour in seeking help from modern care, prayers and traditional healers. The disease adds significant burden to family members. Family and caregivers need more education on early recognition of symptoms and cost effective management of dementia at family level. Faith-based organizations could play an important role in dementia interventions. At a national level effective policy and improvement of the health care system to address the needs of PWD and their families are imperative.
PMCID: PMC3994576  PMID: 24642112
Dementia; Social-cultural; Beliefs; Life experience
5.  Feasibility of introducing compulsory community health fund in low resource countries: views from the communities in Liwale district of Tanzania 
In 1995, Tanzania introduced the voluntary Community Health Fund (CHF) with the aim of ensuring universal health coverage by increasing financial investment in the health sector. The uptake of the CHF is low, with an enrolment of only 6% compared to the national target of 75%. Mandatory models of community health financing have been suggested to increase enrolment and financial capacity. This study explores communities’ views on the introduction of a mandatory model, the Compulsory Community Health Fund (CCHF) in the Liwale district of Tanzania.
A cross-sectional study which involved 387 participants in a structured face to face survey and 33 in qualitative interviews (26 in focus group discussions (FGD) and 7 in in-depth interviews (IDI). Structured survey data were analyzed using SPSS version 16 to produce descriptive statistics. Qualitative data were analyzed using content analysis.
387 people completed a survey (58% males), mean age 38 years. Most participants (347, 89.7%) were poor subsistence farmers and 229 (59.2%) had never subscribed to any form of health insurance scheme. The idea of a CCHF was accepted by 221 (57%) survey participants. Reasons for accepting the CCHF included: reduced out of pocket expenditure, improved quality of health care and the removal of stigma for those who receive waivers at health care delivery points. The major reason for not accepting the CCHF was the poor quality of health care services currently offered. Participants suggested that enrolment to the CCHF be done after harvesting when the population were more likely to have disposable income, and that the quality care of care and benefits package be improved.
The CHF is acceptable to the most of study participants and feasible in rural Tanzania as an alternative mechanism to finance health care for the rural poor. Community members are willing to join the scheme provided they are well informed, involved in the design and implementation, and assured quality health care. Strong political will and a supportive environment are key ingredients for the success of the CCHF.
PMCID: PMC3750583  PMID: 23924271
Compulsory community health funds; Community’s views; Feasibility; Acceptability
6.  Determinants of antiretroviral therapy adherence in northern Tanzania: a comprehensive picture from the patient perspective 
BMC Public Health  2012;12:716.
To design effective, tailored interventions to support antiretroviral therapy (ART) adherence, a thorough understanding of the barriers and facilitators of ART adherence is required. Factors at the individual and interpersonal level, ART treatment characteristics and health care factors have been proposed as important adherence determinants.
To identify the most relevant determinants of adherence in northern Tanzania, in-depth interviews were carried out with 61 treatment-experienced patients from four different clinics. The interviews were ad-verbatim transcribed and recurrent themes were coded.
Coding results showed that the majority of patients had basic understanding of adherence, but also revealed misconceptions about taking medication after alcohol use. Adherence motivating beliefs were the perception of improved health and the desire to live like others, as well as the desire to be a good parent. A de-motivating belief was that stopping ART after being prayed for was an act of faith. Facilitators of adherence were support from friends and family, and assistance of home based care (HBC) providers. Important barriers to ART adherence were the use of alcohol, unavailability of food, stigma and disclosure concerns, and the clinics dispensing too few pills. Strategies recommended by the patients to improve adherence included better Care and Treatment Centre (CTC) services, recruitment of patients to become Home Based Care ( HBC) providers, and addressing the problem of stigma through education.
This study underscores the importance of designing tailored, patient-centered adherence interventions to address challenges at the patient, family, community and health care level.
PMCID: PMC3488585  PMID: 22935331
7.  Measuring adherence to antiretroviral therapy in northern Tanzania: feasibility and acceptability of the Medication Event Monitoring System 
BMC Public Health  2011;11:92.
An often-used tool to measure adherence to antiretroviral therapy (ART) is the Medication Event Monitoring System (MEMS), an electronic pill-cap that registers date and time of pill-bottle openings. Despite its strengths, MEMS-data can be compromised by inaccurate use and acceptability problems due to its design. These barriers remain, however, to be investigated in resource-limited settings. We evaluated the feasibility and acceptability of using MEMS-caps to monitor adherence among HIV-infected patients attending a rural clinic in Tanzania's Kilimanjaro Region.
Eligible patients were approached and asked to use the MEMS-caps for three consecutive months. Thereafter, qualitative, in-depth interviews about the use of MEMS were conducted with the patients. MEMS-data were used to corroborate the interview results.
Twenty-three of the 24 patients approached agreed to participate. Apart from MEMS-use on travel occasions, patients reported no barriers regarding MEMS-use. Unexpectedly, the MEMS-bottle design reduced the patients' fear for HIV-status disclosure. Patients indicated that having their behavior monitored motivated them to adhere better. MEMS-data showed that most patients had high levels of adherence and there were no bottle-openings that could not be accounted for by medication intake. Non-adherence in the days prior to clinic visits was common and due to the clinic dispensing too few pills.
MEMS-bottle use was readily accepted by patients. Although the MEMS-bottle was used accurately by most patients, patients need to be more explicitly instructed to continue MEMS-use when travelling. Even HIV-clinics with sufficient staff and free medication may impose structural adherence barriers by supplying an insufficient amount of pills.
PMCID: PMC3042941  PMID: 21306643
8.  Effectiveness of community based safe motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania 
In Tanzania, maternal mortality ratio remains unacceptably high at 578/100,000 live births. Despite a high coverage of antenatal care (96%), only 44% of deliveries take place within the formal health services. Still, "Ensure skilled attendant at birth" is acknowledged as one of the most effective interventions to reduce maternal deaths. Exploring the potential of community-based interventions in increasing the utilization of obstetric care, the study aimed at developing, testing and assessing a community-based safe motherhood intervention in Mtwara rural District of Tanzania.
This community-based intervention was designed as a pre-post comparison study, covering 4 villages with a total population of 8300. Intervention activities were implemented by 50 trained safe motherhood promoters (SMPs). Their tasks focused on promoting early and complete antenatal care visits and delivery with a skilled attendant. Data on all 512 deliveries taking place from October 2004 to November 2006 were collected by the SMPs and cross-checked with health service records. In addition 242 respondents were interviewed with respect to knowledge on safe motherhood issues and their perception of the SMP's performance. Skilled delivery attendance was our primary outcome; secondary outcomes included antenatal care attendance and knowledge on Safe Motherhood issues.
Deliveries with skilled attendant significantly increased from 34.1% to 51.4% (ρ < 0.05). Early ANC booking (4 to 16 weeks) rose significantly from 18.7% at baseline to 37.7% in 2005 and 56.9% (ρ < 0.001) at final assessment. After two years 44 (88%) of the SMPs were still active, 79% of pregnant women were visited. Further benefits included the enhancement of male involvement in safe motherhood issues.
The study has demonstrated the effectiveness of community-based safe motherhood intervention in promoting the utilization of obstetric care and a skilled attendant at delivery. This improvement is attributed to the SMPs' home visits and the close collaboration with existing community structures as well as health services.
PMCID: PMC2858713  PMID: 20359341
9.  Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets 
Almost two decades since the initiation of the Safe motherhood Initiative, Maternal Mortality is still soaring high in most developing countries. In 2000 WHO estimated a life time risk of a maternal death of 1 in 16 in Sub- Saharan Africa while it was only 1 in 2800 in developed countries. This huge discrepancy in the rate of maternal deaths is due to differences in access and use of maternal health care services. It is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality. For this reason, the proportion of births attended by skilled health personnel is one of the indicators used to monitor progress towards the achievement of the MDG-5 of improving maternal health.
Cross sectional study which employed quantitative research methods.
We interviewed 974 women who gave birth within one year prior to the survey. Although almost all (99.8%) attended ANC at least once during their last pregnancy, only 46.7% reported to deliver in a health facility and only 44.5% were assisted during delivery by a skilled attendant. Distance to the health facility (OR = 4.09 (2.72–6.16)), discussion with the male partner on place of delivery (OR = 2.37(1.75–3.22)), advise to deliver in a health facility during ANC (OR = 1.43 (1.25–2.63)) and knowledge of pregnancy risk factors (OR 2.95 (1.65–5.25)) showed significant association with use of skilled care at delivery even after controlling for confounding factors.
Use of skilled care during delivery in this district is below the target set by ICPD + of attaining 80% of deliveries attended by skilled personnel by 2005. We recommend the following in order to increase the pace towards achieving the MDG targets: to improve coverage of health facilities, raising awareness for both men and women on danger signs during pregnancy/delivery and strengthening counseling on facility delivery and individual birth preparedness.
PMCID: PMC2222241  PMID: 18053268
10.  Knowledge about safe motherhood and HIV/AIDS among school pupils in a rural area in Tanzania 
The majority of adolescents in Africa experience pregnancy, childbirth and enter motherhood without adequate information about maternal health issues. Information about these issues could help them reduce their pregnancy related health risks. Existing studies have concentrated on adolescents' knowledge of other areas of reproductive health, but little is known about their awareness and knowledge of safe motherhood issues. We sought to bridge this gap by assessing the knowledge of school pupils regarding safe motherhood in Mtwara Region, Tanzania.
We used qualitative and quantitative descriptive methods to assess school pupils' knowledge of safe motherhood and HIV/AIDS in pregnancy. An anonymous questionnaire was used to assess the knowledge of 135 pupils ranging in age from 9 to 17 years. The pupils were randomly selected from 3 primary schools. Underlying beliefs and attitudes were assessed through focus group interviews with 35 school children. Key informant interviews were conducted with six schoolteachers, two community leaders, and two health staffs.
Knowledge about safe motherhood and other related aspects was generally low. While 67% of pupils could not mention the age at which a girl may be able to conceive, 80% reported it is safe for a girl to be married before she reaches 18 years. Strikingly, many school pupils believed that complications during pregnancy and childbirth are due to non-observance of traditions and taboos during pregnancy. Birth preparedness, important risk factors, danger signs, postpartum care and vertical transmission of HIV/AIDS and its prevention measures were almost unknown to the pupils.
Poor knowledge of safe motherhood issues among school pupils in rural Tanzania is related to lack of effective and coordinated interventions to address reproductive health and motherhood. For long-term and sustained impact, school children must be provided with appropriate safe motherhood information as early as possible through innovative school-based interventions.
PMCID: PMC1868762  PMID: 17456230

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