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Background Decision making process for Official Development Assistance (ODA) for healthcare sector in low-income and middle-income countries involves multiple agencies, each with their unique power, priorities and funding mechanisms. This process at country level has not been well studied. Methods This paper developed and applied a new framework to analyze decision-making process for priority setting in Ethiopia, Nigeria, and Tanzania, and collected primary data to validate and refine the model. The framework was developed following a scoping review of published literature. Interviews were then conducted using a pre-determined interview guide developed by the research team. Transcripts were reviewed and coded based on the framework to identify what principles, players, processes, and products were considered during priority setting. Those elements were further used to identify where the potential capacity of local decision-makers could be harnessed. Results A framework was developed based on 40 articles selected from 6860 distinct search records. Twenty-one interviews were conducted in three case countries from 12 institutions. Transcripts or meeting notes were analyzed to identify common practices and specific challenges faced by each country. We found that multiple stakeholders working around one national plan was the preferred approach used for priority setting in the countries studied. Conclusions Priority setting process can be further strengthened through better use of analytical tools, such as the one described in our study, to enhance local ownership of priority setting for ODA and improve aid effectiveness.

Background Hypertensive disorders of pregnancy are important causes of maternal morbidity and mortality, as well as preterm birth, the leading cause of death for children under 5 years globally. The World Health Organization currently recommends that pregnant women receive high-dose calcium supplementation (1500–2000 mg elemental calcium) for prevention of preeclampsia in populations with low dietary calcium intake. Trials of low-dose calcium supplementation ( Methods/design We will conduct two independent trials in Bangalore, India (n = 11,000 pregnancies), and Dar es Salaam, Tanzania (n = 11,000 pregnancies). The trial designs are individually randomized, parallel group, quadruple-blind, non-inferiority trials of low-dose calcium supplementation (500 mg elemental calcium/day) as compared to standard high-dose calcium supplementation (1500 mg elemental calcium/day) among nulliparous pregnant women. Pregnant women will be enrolled in the trial before 20 weeks of gestation and will receive the randomized calcium regimen from randomization until the time of delivery. The co-primary outcomes are (i) preeclampsia and (ii) preterm birth; we will test non-inferiority of the primary outcomes for low-dose as compared to the standard high-dose supplementation regimen in each trial. The trials’ secondary outcomes include gestational hypertension, severe features of preeclampsia, pregnancy-related death, third trimester severe anemia, fetal death, stillbirth, low birthweight, small-for-gestational age birth, and infant death. Discussion The trials will provide causal evidence on the non-inferiority of low-dose as compared to the standard high-dose supplementation in India and Tanzania. A single tablet, low-dose calcium supplementation regimen may improve individual-level adherence, reduce programmatic costs, and ultimately expand implementation of routine calcium supplementation in pregnancy in populations with low dietary calcium intake. Trial registration ClinicalTrials.gov identifier: NCT03350516; registered on 22 November 2018. Clinical Trials Registry—India identifier: CTRI/2018/02/012119; registered on 23 February 2018. Tanzania Medicines and Medical Devices Authority Trials Registry identifier: TFDA0018/CTR/0010/5; registered on 20 December 2018.

Continuous monitoring of the pandemic's impact on health service provision and mental health, COVID-19 perceptions, and compliance with prevention measures among health care providers (HCPs) can help with mitigating the pandemic's negative effects.A computer-assisted telephone interviewing (CATI) survey was conducted among 1499 HCPs in Burkina Faso (Ouagadougou), Ethiopia (Addis Ababa), Nigeria (Lagos and Ibadan), Tanzania (Dar es Salaam), and Ghana (Kintampo). Self-reported mental health, perceptions of the COVID-19 pandemic, and prevention measures available in the workplace were assessed. HCPs' responses to questions regarding the impact of COVID-19 on nine essential health services were summed into a score; high service disruption was defined as a score higher than the total average score across all sites. Modified Poisson regression was used to identify potential factors related to high service disruption.Overall, 26.9% of HCPs reported high service disruption, with considerable differences across sites (from 1.6% in Dar es Salaam to 45.0% in Addis Ababa). A considerable proportion of HCPs reported experiencing mild psychological distress (9.4%), anxiety (8.0%), and social avoidance or rejection (13.9%) due to their profession. Participants in Addis Ababa (absolute risk ratio (ARR) = 2.10; 95% confidence interval (CI) = 1.59-2.74), Lagos (ARR = 1.65; 95% CI = 1.24-2.17), and Kintampo (ARR = 2.61; 95% CI = 1.94-3.52) had a higher likelihood of reporting high service disruption compared to those in Ouagadougou. Reporting ever-testing for COVID-19 (ARR = 0.82; 95% CI = 0.69-0.97) and the presence of COVID-19 guidelines in the workplace (ARR = 0.63; 95% CI = 0.53-0.77) were both associated with lower reported health service disruption among HCPs.The COVID-19 pandemic continues to disrupt essential health services and present a challenge to HCPs' mental health, with important differences across countries and settings; interventions are needed to mitigate these negative effects of the pandemic.

The African continent has some of the world’s lowest COVID-19 vaccination rates. While the limited availability of vaccines is a contributing factor, COVID-19 vaccine hesitancy among health care providers (HCP) is another factor that could adversely affect efforts to control infections on the continent. We sought to understand the extent of COVID-19 vaccine hesitancy among HCP, and its contributing factors in Africa. We evaluated COVID-19 vaccine hesitancy among 1,499 HCP enrolled in a repeated cross-sectional telephone survey in Burkina Faso, Ethiopia, Nigeria, Tanzania and Ghana. We defined COVID-19 vaccine hesitancy among HCP as self-reported responses of definitely not, maybe, unsure, or undecided on whether to get the COVID-19 vaccine, compared to definitely getting the vaccine. We used Poisson regression models to evaluate factors influencing vaccine hesitancy among HCP. Approximately 65.6% were nurses and the mean age (±SD) of participants was 35.8 (±9.7) years. At least 67% of the HCP reported being vaccinated. Reasons for low COVID-19 vaccine uptake included concern about vaccine effectiveness, side effects and fear of receiving unsafe and experimental vaccines. COVID-19 vaccine hesitancy affected 45.7% of the HCP in Burkina Faso, 25.7% in Tanzania, 9.8% in Ethiopia, 9% in Ghana and 8.1% in Nigeria. Respondents reporting that COVID-19 vaccines are very effective (RR:0.21, 95% CI:0.08, 0.55), and older HCP (45 or older vs.20-29 years, RR:0.65, 95% CI: 0.44,0.95) were less likely to be vaccine-hesitant. Nurses were more likely to be vaccine-hesitant (RR 1.38, 95% CI: 1.00,1.89) compared to doctors. We found higher vaccine hesitancy among HCP in Burkina Faso and Tanzania. Information asymmetry among HCP, beliefs about vaccine effectiveness and the endorsement of vaccines by the public health institutions may be important. Efforts to address hesitancy should address information and knowledge gaps among different cadres of HCP and should be coupled with efforts to increase vaccine supply.

The coronavirus disease 2019 (COVID-19) pandemic has significant health and economic ramifications across sub-Saharan Africa (SSA). Data regarding its far-reaching impacts are severely lacking, thereby hindering the development of evidence-based strategies to mitigate its direct and indirect health consequences. To address this need, the Africa Research, Implementation Science, and Education (ARISE) Network established a mobile survey platform in SSA to generate longitudinal data regarding knowledge, attitudes, and practices (KAP) related to COVID-19 prevention and management and to evaluate the impact of COVID-19 on health and socioeconomic domains. We conducted a baseline survey of 900 healthcare workers, 1,795 adolescents 10 to 19 years of age, and 1,797 adults 20 years or older at six urban and rural sites in Burkina Faso, Ethiopia, and Nigeria. Households were selected using sampling frames of existing Health and Demographic Surveillance Systems or national surveys when possible. Healthcare providers in urban areas were sampled using lists from professional associations. Data were collected through computer-assisted telephone interviews from July to November 2020. Consenting participants responded to surveys assessing KAP and the impact of the pandemic on nutrition, food security, healthcare access and utilization, lifestyle, and mental health. We found that mobile telephone surveys can be a rapid and reliable strategy for data collection during emergencies, but challenges exist with response rates. Maintaining accurate databases of telephone numbers and conducting brief baseline in-person visits can improve response rates. The challenges and lessons learned from this effort can inform future survey efforts during COVID-19 and other emergencies, as well as remote data collection in SSA in general.

IntroductionSecondary schools have the transformative potential to advance adolescent nutrition and provide a unique entry point for nutrition interventions to reach adolescents and their families and communities. Integrated school nutrition interventions offer promising pathways towards improving adolescent nutrition status, food security and building sustainable skill sets.Methods and analysisThe Meals, Education, and Gardens for In-School Adolescents (MEGA) project aims to implement and evaluate an integrated, school-based nutrition intervention package among secondary schools in the Chamwino District of Dodoma, Tanzania. MEGA is a cluster-randomised controlled trial, including six public secondary schools assigned to three different arms. Two schools will receive the full intervention package, including school meals, school gardens, nutrition education and community workshops. Two schools will receive the partial intervention package, including the school garden, nutrition education and community workshops. Two schools will serve as the controls and will not receive any intervention. The intervention will be implemented for one academic year. Baseline and end-line quantitative data collection will include 750 adolescents and 750 parents. The domains of outcomes for adolescents will include haemoglobin concentrations, anthropometry, educational outcomes and knowledge, attitudes and practices regarding nutrition, agriculture and health. The domains of outcomes for parents will include knowledge, attitudes and practices of nutrition, agriculture and health. End-line focus group discussions will be conducted among selected adolescents, parents and teachers to assess the facilitators and barriers associated with the intervention.Ethics and disseminationThis study was approved by the Institutional Review Board at Harvard T.H. Chan School of Public Health (approval number: IRB20-1623), the Institutional Research Review Committee at the University of Dodoma (approval number: MA.84/261/02) and the Tanzania National Institute for Medical Research (approval number: NIMR/HO/R.8a/Vol. IX/3801). A manuscript with the research findings will be developed for publication. Local dissemination meetings will be held with key stakeholders.Trial registration numberNCT04788303.; ClinicalTrials.gov Identifier.

UNSTRUCTURED Background: Two billion people in low- and middle-income countries (LMICs) are deficient in key nutrients. Nutritional deficiencies worsen during pregnancy, causing adverse outcomes for the mother and the fetus, with consequences after pregnancy. These effects may be mitigated by providing micronutrient supplementation to women during pregnancy and lactation. However, the impact of micronutrient supplementation during pregnancy on maternal and infant nutritional status is unclear in the context of LMICs. The purpose of this systematic review and meta-analysis is to determine the effects of single, double, or multiple micronutrient supplements during pregnancy or lactation for women on maternal and infant nutritional status in LMICs. Methods: Randomized controlled trials of single or combinations of micronutrients assessing effects on maternal and infant nutritional status will be included. MEDLINE (through PubMed), EMBASE, CENTRAL (through Cochrane Library), and the WHO library database will be used to identify relevant published studies. Cochrane Risk of Bias Tool will be used to assess the risk of bias in included studies. The selection of studies, data extraction, and risk of bias will be done independently by two reviewers. A narrative summary will be provided of all the included studies. Meta-analyses will be performed whenever possible, and the heterogeneity of effects will be evaluated using I2, subgroup analyses, and meta-regression. The certainty of the evidence for each outcome will be assessed using the GRADE approach (Grading of Recommendation, Assessment, Development, and Evaluation). Discussion: This review will provide evidence on which to base policy and programming for women in LMICs to supplement micronutrients in pregnancy and lactation. The review will also identify any gaps in the existing evidence. Systematic review registration: PROSPERO ID: CRD42022308715

The COVID-19 pandemic has had serious negative health and economic impacts in sub-Saharan Africa. Continuous monitoring of these impacts is crucial to formulate interventions to minimize the consequences of COVID-19. This study surveyed 2,829 adults in urban and rural sites among five sub-Saharan African countries: Burkina Faso, Ethiopia, Nigeria, Tanzania, and Ghana. Participants completed a mobile phone survey that assessed self-reported sociodemographics, COVID-19 preventive practices, psychological distress, and barriers to healthcare access. A modified Poisson regression model was used to estimate adjusted prevalence ratios (aPRs) and 95% CIs to investigate potential factors related to psychological distress and barriers to reduced healthcare access. At least 15.6% of adults reported experiencing any psychological distress in the previous 2 weeks, and 10.5% reported that at least one essential healthcare service was difficult to access 2 years into the pandemic. The majority of participants reported using several COVID-19 preventive methods, with varying proportions across the sites. Participants in the urban site of Ouagadougou, Burkina Faso (aPR: 2.29; 95% CI: 1.74–3.03) and in the rural site of Kintampo, Ghana (aPR: 1.68; 95% CI: 1.21–2.34) had a higher likelihood of experiencing any psychological distress compared with those in the rural area of Nouna, Burkina Faso. Loss of employment due to COVID-19 (aPR: 1.77; 95% CI: 1.47–2.11) was also associated with an increased prevalence of psychological distress. The number of children under 5 years in the household (aPR: 1.23; 95% CI: 1.14–1.33) and participant self-reported psychological distress (aPR: 1.83; 95% CI: 1.48–2.27) were associated with an increased prevalence of reporting barriers to accessing health services, whereas wage employment (aPR: 0.67; 95% CI: 0.49–0.90) was associated with decreased prevalence of reporting barriers to accessing health services. Overall, we found a high prevalence of psychological distress and interruptions in access to healthcare services 2 years into the pandemic across five sub-Saharan African countries. Increased effort and attention should be given to addressing the negative impacts of COVID-19 on psychological distress. An equitable and collaborative approach to new and existing preventive measures for COVID-19 is crucial to limit the consequences of COVID-19 on the health of adults in sub-Saharan Africa.

COVID-19 vaccine hesitancy among adolescents poses a challenge to the global effort to control the pandemic. This multi-country survey aimed to assess the levels and determinants of COVID-19 vaccine hesitancy among adolescents in sub-Saharan Africa between July and December 2021. The survey was conducted using computer-assisted telephone interviewing among adolescents in five sub-Saharan African countries, Burkina Faso, Ethiopia, Ghana, Nigeria, and Tanzania. A rural area and an urban area were included in each country (except Ghana, which only had a rural area), with approximately 300 adolescents in each area and 2803 in total. Sociodemographic characteristics and perceptions and attitudes on COVID-19 vaccines were measured. Vaccine hesitancy was defined as definitely not getting vaccinated or being undecided on whether to get vaccinated if a COVID-19 vaccine were available. Log-binomial models were used to calculate the adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for associations between potential determinants and COVID-19 vaccine hesitancy. The percentage of COVID-19 vaccine hesitancy was 15% in rural Kersa, 24% in rural Ibadan, 31% in rural Nouna, 33% in urban Ouagadougou, 37% in urban Addis Ababa, 48% in rural Kintampo, 64% in urban Lagos, 76% in urban Dar es Salaam, and 88% in rural Dodoma. Perceived low necessity, concerns about vaccine safety, and concerns about vaccine effectiveness were the leading reasons for hesitancy. Healthcare workers, parents or family members, and schoolteachers had the greatest impacts on vaccine willingness. Perceived lack of safety (aPR: 3.61; 95% CI: 3.10, 4.22) and lack of effectiveness (aPR: 3.59; 95% CI: 3.09, 4.18) were associated with greater vaccine hesitancy. The levels of COVID-19 vaccine hesitancy among adolescents are alarmingly high across the five sub-Saharan African countries, especially in Tanzania. COVID-19 vaccination campaigns among sub-Saharan African adolescents should address their concerns and misconceptions about vaccine safety and effectiveness.

The provision of high-quality antenatal care (ANC) is important for preventing maternal and newborn mortality and morbidity, but only around half of pregnant women in Tanzania attended four or more ANC visits in 2019. Although there is emerging evidence on the benefit of community health worker (CHW) interventions on ANC uptake, few large-scale pragmatic trials have been conducted. This pragmatic cluster-randomized trial, implemented directly through the public sector health system, assessed the impact of an intervention that trained public sector CHWs to promote the uptake of ANC. We randomized 60 administrative wards in Dar es Salaam to either a targeted CHW intervention or a standard of care. The impact of the intervention was assessed using generalized estimating equations with an independent working correlation matrix to account for clustering within wards. A total of 243 908 women were included in the analysis of our primary outcome of four or more ANC visits. The intervention significantly increased the likelihood of attending four or more ANC visits [relative risk (RR): 1.42; 95% confidence interval (CI): 1.05, 1.92] and had a modest beneficial effect on the total number of ANC visits (percent change: 7.7%; 95% CI: 0.2%, 15.5%). While slightly more women in the intervention arm attended ANC in their first trimester compared with the standard-of-care arm (19% vs 18.7%), the difference was not significant (RR: 1.02; 95% CI: 0.84, 1.22). Our findings suggest that trained CHWs can increase attendance of ANC visits in Dar es Salaam and similar settings. However, additional interventions appear necessary to promote the early initiation of ANC. This study demonstrates that routine health system data can be leveraged for outcome assessment in trials and programme evaluation and that the results are likely superior, both in terms of bias and precision, to data that are collected specifically for science.

IntroductionAdolescence is a critical time for growth and development, but this age group is often neglected in research and development of nutrition interventions. Despite recommendations from the WHO to provide nutrient supplements to adolescents, evidence remains scarce on the most effective supplementation strategy. This study aims to compare weekly iron and folic acid (IFA) supplementation with daily multiple micronutrient supplements (MMSs) in prevention of anaemia and improvement of school outcomes among adolescents in Burkina Faso and Tanzania.Methods and analysisA three-arm cluster-randomised, school-based supplementation trial will be conducted among 84 schools (42 schools per site) and roughly 4500 students aged 10–17. Schools will be matched on three characteristics: number of students, school ranking profile, distance to main road (Tanzania) or distance to city council (Burkina Faso). Each school will be randomised to receive either weekly IFA, daily MMSs or serve as a control. Supplements will be delivered to students by teachers, who will provide monitoring data to the study team. Baseline and endline surveys will be conducted prior to and after each supplementation cycle (12 weeks in Burkina Faso; 1 year in Tanzania) to assess haemoglobin, anthropometry and sociodemographic variables. The primary outcome of haemoglobin will be analysed continuously using linear regression, and anaemia status will be analysed using logistic or multinomial regression, depending on categorisation level of the outcome. Secondary analyses of school performance indicators will also be conducted with either logistic or linear regression.Ethics and disseminationThis protocol has been approved by the Institutional Review Board of the Harvard TH Chan School of Public Health (IRB20-1108) and the Research Ethics Committees for the Ministries of Health in Tanzania (Zanzibar) and Burkina Faso. Results will be disseminated during meetings with the Ministries of Health and the participating communities as well as through peer-reviewed publications.Trial registration numberNCT04657640;NCT05104554

To examine knowledge of menstruation, HIV and STIs other than HIV across eight sites in SSA to develop effective programmatic interventions enabling adolescents to achieve positive SRH as their transition to adulthood.We combine data from eight Health and Demographic Surveillance Sites across sub-Saharan Africa, from an adolescent-specific survey that included 7116 males and females age 10-19 years old. We provide pooled and site-specific estimates from multiple analytic models examining the how year-specific age, school attendance and work correlate with knowledge of menstruation, HIV knowledge and knowledge of sexually transmitted infections (STIs) other than HIV.Many adolescents lack knowledge of menstruation (37.3%, 95% CI 31.8, 43.1 do not know of menstruation) and STIs other than HIV (55.9%, 95% CI 50.4, 61.3 do not know of other STIs). In multivariate analysis, older age, being in school and wealth are significant positive correlates of STI knowledge. Older adolescent age, female sex and being in school are significant positive correlates of knowledge of menstruation. Knowledge of HIV is high (89.7%, 95% CI 8.3, 12.7 know of HIV) and relatively similar across adolescent age, sex, wealth and school and work attendance.Knowledge of HIV is widespread across adolescents in these communities in sub-Saharan Africa, but knowledge of other dimensions of sexual and reproductive health - menstruation and other STIs in this study - is lacking especially for early adolescents (10- to 14-year olds). The dissemination of more comprehensive sexual and reproductive health information is needed within these and similar communities in SSA to help adolescents gain insight on how to make their own decisions towards positive adolescent sexual and reproductive health and protect them from risks.Examiner les connaissances sur la menstruation, le VIH et les IST autres que le VIH dans huit sites d’Afrique subsaharienne (ASS) afin d’élaborer des programmes d’interventions efficaces permettant aux adolescents d’obtenir une santé sexuelle et reproductive (SSR) positive lorsqu’ils passent à l’âge adulte. MÉTHODES: Nous combinons ici les données de huit sites de Surveillance Démographique et de Santé en Afrique subsaharienne, à partir d'une enquête spécifique réalisée auprès d'adolescents et comprenant 7.116 hommes et femmes âgés de 10 à 19 ans. Nous fournissons des estimations poolées et spécifiques à chaque site à partir de plusieurs modèles analytiques examinant la corrélation entre l'âge, la fréquentation scolaire et le travail, avec les connaissances sur la menstruation, sur le VIH et sur les IST autres que le VIH. RÉSULTATS: Beaucoup d'adolescents manquaient de connaissance sur les menstruations (37,3% ; IC95%: 31,8-43,1 ne connaissaient pas les menstruations) et les IST autres que le VIH (55,9% ; IC95%: 50,4-61,3 ne connaissent pas d'autres IST). Dans l'analyse multivariée, l'âge plus avancé, la fréquentation scolaire et la richesse sont des corrélats positifs significatifs des connaissances sur les IST. L’âge adolescent plus avancé, le sexe féminin et le fait d’être à l’école sont des corrélats positifs significatifs pour les connaissances sur la menstruation. Les connaissances sur le VIH sont élevées (89,7%, IC95%: 8,3-12,7 sont au courant du VIH) et relativement similaires selon les âges des adolescents, le sexe, la richesse et la fréquentation scolaire et le travail.Les connaissances sur le VIH semblent être répandues parmi les adolescents de ces communautés en Afrique subsaharienne, mais les connaissances sur les autres aspects de la santé sexuelle et reproductive - menstruations et autres IST dans cette étude - semblent faire défaut, en particulier chez les jeunes adolescents (âgés de 10 à 14 ans). La dissémination de telles informations plus complètes est nécessaire au sein de ces communautés et de communautés similaires en ASS afin d’aider les adolescents à comprendre comment prendre leurs propres décisions en matière de santé sexuelle et reproductive et de les protéger contre les risques.

To measure health-related behaviours and risk factors among sub-Saharan African adolescents.Cross-sectional study in nine communities in Burkina Faso, Ethiopia, Eswatini, Ghana, Nigeria, Tanzania and Uganda between 2015 and 2017. Community-representative samples of males and females 10-19 years of age were selected. All communities used a uniform questionnaire that was adapted from the WHO Global School-based Student Health Survey. Weighted prevalence estimates and 95% confidence intervals were calculated for each indicator and stratified by age and sex using SAS version 9.4. All prevalence estimates were pooled across communities through random-effects meta-analyses in Stata version 14.A total of 8075 adolescents participated in the study. We observed a high prevalence of inadequate fruit consumption (57-63%) and low physical activity (82-90%); a moderate prevalence of inadequate vegetable consumption (21-31%), unprotected last sex (38-45%), age at first sex15 years (21-28%) and bullying and physical fighting (12-35%); and a low prevalence of mental health risk factors (1-11%) and alcohol and substance use risk factors (0-6%). We observed a moderate to high prevalence of daily soft drink consumption (21-31%) for all adolescents. Among sexually active adolescents 15-19 years, 37% of females reported ever being pregnant and 8% of males reported to have ever made someone pregnant. Bullying (23%) and physical fighting (35%) were more common among younger male adolescents . The prevalence of low mood was generally higher among older (15-19 years) than younger adolescents (10-14 years). The proportion of adolescents reporting alcohol, drug or cigarette use was very small, with the exception of khat use in Ethiopia.Overall, diet and physical activity, violence, sexual and reproductive health, and depression are important risk factors for these sub-Saharan African communities. These findings suggest that more evidence is needed including novel efforts for the collection of sensitive information, as well as a need to move towards community-tailored interventions to reach adolescent populations with varying needs.Mesurer les comportements liés à la santé et les facteurs de risque chez les adolescents africains subsahariens. MÉTHODES: Etude transversale dans neuf communautés au Burkina Faso, en Ethiopie, à Eswatini, au Ghana, au Nigéria, en Tanzanie et en Ouganda entre 2015 et 2017. Des échantillons représentatifs de la communauté composés d'hommes et de femmes âgés de 10 à 19 ans ont été sélectionnés. Toutes les communautés ont utilisé un questionnaire uniforme adapté de l'Enquête Mondiale sur la Santé des Elèves de l'OMS. Les estimations de prévalence pondérée et les intervalles de confiance à 95% ont été calculés pour chaque indicateur et stratifiées par âge et sexe à l'aide de la version 9.4 de SAS. Toutes les estimations de prévalence ont été poolées dans les communautés via des méta-analyses à effets aléatoires dans Stata, version 14. RÉSULTATS: 8.075 adolescents ont participé à l'étude. Nous avons observé une prévalence élevée de consommation insuffisante de fruits (57-63%) et de faible activité physique (82-90%); une prévalence modérée de consommation insuffisante de légumes (21-31%), du dernier rapport sexuel non protégé (38-45%), du premier rapport sexuel à moins de 15 ans (21-28%) et de l'intimidation et des combats physiques (12-35%), une faible prévalence de facteurs de risque pour la santé mentale (1-11%) et de facteurs de risque pour la consommation d'alcool et de substances (0-6%). Nous avons observé une prévalence modérée à élevée de consommation quotidienne de boissons gazeuses (21-31%) chez tous les adolescents. Parmi les adolescents sexuellement actifs âgées de 15 à 19 ans, 37,0% des femmes ont déclaré avoir déjà été enceintes et 8,0% des hommes ont rapporté avoir déjà enceinté une femme. L'intimidation (23%) et les combats physiques étaient plus fréquents chez les adolescents plus jeunes (35%). La prévalence de la mauvaise humeur était généralement plus élevée chez les adolescents d’âge plus élevé (de 15 à 19 ans) que chez les plus jeunes (de 10 à 14 ans). La proportion d'adolescents déclarant avoir consommé de l'alcool, des drogues ou des cigarettes était très faible, à l'exception de la consommation de khat en Ethiopie.Dans l’ensemble, le régime alimentaire et l’activité physique, la violence, la santé sexuelle et reproductive et la dépression sont des facteurs de risque importants pour ces communautés d’Afrique subsaharienne. Ces résultats suggèrent que davantage de données sont nécessaires, notamment de nouveaux efforts pour la collecte d'informations sensibles, ainsi que la nécessité de passer à des interventions adaptées aux communautés pour atteindre les populations adolescentes avec des besoins variés.

Background Priority setting process for the health care sector in low- and middle-income countries involves multiple agencies, each with their unique power, decision-making and funding mechanisms. Methods This paper developed and applied a new framework to analyze priority setting processes in Ethiopia, Nigeria, and Tanzania, from a scoping review of literature. Interviews were then conducted using a pre-determined interview guide developed by the research team. Transcripts were reviewed and coded based on the framework to identify what principles, players, processes, and products were considered during priority setting. Those elements were further used to identify where the potential capacity of local decision-makers could be harnessed. Results a framework was developed based on 40 articles selected from 6860 distinct search records. 21 interviews were conducted in three case countries from 12 institutions. Transcripts or meeting notes were analyzed to identify common practices and specific challenges faced by each country. We found that multiple stakeholders working around one national plan was the preferred approach used for priority setting in the countries studied. Conclusions Priority setting process can be further strengthened through better use of analytical tools, such as the one described in our study, to enhance local ownership and improve aid effectiveness.

Background SMS for Life was one of the earliest large-scale implementations of mHealth innovations worldwide. Its goal was to increase visibility to antimalarial stock-outs through the use of SMS technology. The objective of this case study was to show the multiple innovations that SMS for Life brought to the Tanzanian public health sector and to discuss the challenges of scaling up that led to its discontinuation from a health systems perspective. Methods A qualitative case-study approach was used. This included a literature review, a document review of 61 project documents, a timeline of key events and the collection and analysis of 28 interviews with key stakeholders involved in or affected by the SMS for Life programme. Data collection was informed by the health system building blocks. We then carried out a thematic analysis using the WHO mHealth Assessment and Planning for Scale (MAPS) Toolkit as a framework. This served to identify the key reasons for the discontinuation of the programme. Results SMS for Life was reliable at scale and raised awareness of stock-outs with real-time monitoring. However, it was discontinued in 2015 after 4 years of a national rollout. The main reasons identified for the discontinuation were the programme’s failure to adapt to the continuous changes in Tanzania’s health system, the focus on stock-outs rather than ensuring appropriate stock management, and that it was perceived as costly by policy-makers. Despite its discontinuation, SMS for Life, together with co-existing technologies, triggered the development of the capacity to accommodate and integrate future technologies in the health system. Conclusion This study shows the importance of engaging appropriate stakeholders from the outset, understanding and designing system-responsive interventions appropriately when scaling up and ensuring value to a broad range of health system actors. These shortcomings are common among digital health solutions and need to be better addressed in future implementations.

Background Overweight and obesity have increased considerably in low- and middle-income countries over the past few decades, particularly among women of reproductive age. This study assessed the role of physical activity, nutrient intake and risk factors for overweight and obesity among women in Dar es Salaam, Tanzania. Methods We conducted a cross-sectional survey among 1004 women aged 15–49 years in the Dar es Salaam Urban Cohort Study (DUCS) from September 2018 to January 2019. Dietary intake was assessed using a food frequency questionnaire (FFQ). Physical activity was assessed using the Global Physical Activity Questionnaire (GPAQ) using metabolic equivalent tasks (MET). Modified poison regression models were used to evaluate associations between physical activity and nutrient intake with overweight/obesity in women, controlling for energy and other factors. Results The mean (±SD) age of study women was 30.2 (±8.1) years. Prevalence of overweight and obesity was high (50.4%), and underweight was 8.6%. The risk of overweight/obesity was higher among older women (35–49 vs 15–24 years: PR 1.59; 95% CI: 1.30–1.95); women of higher wealth status (PR 1.24; 95% CI: 1.07–1.43); and informally employed and married women. Attaining moderate to high physical activity (≥600 MET) was inversely associated with overweight/obesity (PR 0.79; 95% CI: 0.63–0.99). Dietary sugar intake (PR 1.27; 95% CI: 1.03–1.58) was associated with increased risk, and fish and poultry consumption (PR 0.78; 95% CI: 0.61–0.99) with lower risk of overweight/obesity. Conclusion Lifestyle (low physical activity and high sugar intake), age, wealth status, informal employment and marital status were associated with increased risk of overweight/obesity, while consumption of fish and poultry protein was associated with lower risk. The study findings underscore the need to design feasible and high-impact interventions to address physical activity and healthy diets among women in Tanzania.

In many regions of the world, little is known about meal structures, meal patterns, and nutrient intake because the collection of quantitative dietary intake is expensive and labor-intensive.We describe the development and field feasibility of a tablet-based Tanzania 24-h recall tool (TZ-24hr-DR) and dietary intakes collected from adults and children in rural and urban settings.Using the Tanzanian food-composition table, the TZ-24hr-DR tool was developed on an Android platform using the Open Data Kit. The module provides food lists, meal lists, ingredient lists, quantity and amount consumed, breastfeeding frequency, and a recipe feature. Similar to the USDA Automated Multiple Pass Method, this TZ-24hr-DR contains review features such as time in-between meals, a summary of meals, and portion sizes.Dietary intake using TZ-24hr-DR was collected amongThe TZ-24hr-DR is a field- and user-friendly tool that can collect large samples of dietary intakes. Further validation is needed. The tool is available freely for research purposes and can be further adapted to other contexts in East Africa.

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.

BackgroundThe objective of this study was to apply systems thinking to examine the opportunities and challenges of scaling up and integrating a new electronic health technology into a complex health system. We used the implementation cycle of the supply chain management solution (SMS for Life 1.0) in Tanzania as a case study. SMS for Life was one of the earliest large-scale implementations of mHealth innovations worldwide. It aimed to bring visibility to antimalarial stock-outs through the use of SMS technology.MethodsA qualitative case-study approach was used. This included a literature review, a document review of 61 project documents, a timeline of key events and the collection and analysis of 28 interviews with key stakeholders involved in or affected by the SMS for Life programme. Using the WHO mHealth Assessment and Planning for Scale (MAPS) Toolkit as a framework, we carried out a joint thematic analysis and identified the key reasons for the discontinuation of the programme.ResultsSMS for Life was reliable at scale and raised awareness of stock-outs with real-time monitoring. However, it was discontinued in 2015 after four years of a national rollout. The main reasons identified for the discontinuation were the programme’s failure to adapt to the continuous changes in Tanzania’s health system, the focus on stock-outs rather than ensuring appropriate stock management, and that it was perceived as costly by policy-makers.Despite its discontinuation, SMS for Life, together with co-existing technologies, triggered the development of the capacity to accommodate and integrate future technologies in the health system.ConclusionThis study shows the importance of engaging appropriate stakeholders from the outset, understanding and designing system-responsive interventions appropriately when scaling up and ensuring value to a broad range of health system actors. These shortcomings are common among digital health solutions and need to be better addressed in future implementations.

We study the relationship between the food environment (FE) and the food purchase patterns, dietary intakes, and nutritional status of individuals in peri-urban Tanzania. In Africa, the prevailing high density of informal vendors creates challenges to characterizing the FE. We present a protocol and tool developed as part of the Diet, Environment, and Choices of positive living (DECIDE) study to measure characteristics of the FE. We mapped 6627 food vendors in a peri-urban settlement of Dar es Salaam, of which over 60% were semi-formal and informal (mobile) vendors. We compute and compare four FE metrics inspired by landscape ecology—density, dispersion, diversity, and dominance—to better understand how the informal food environment relates to food purchase patterns, diets, and nutritional status among households with persons living with human immunodeficiency virus (PLHIV)., Highlights • In Tanzania, a high density of informal vendors within this transitioning food system creates challenges to characterizing the food environment. • We develop four metrics inspired by landscape ecology to characterize formal, semi-formal, and informal food environments. • We use these metrics to evaluate associations to household food purchase patterns, energy intake, and nutritional status. • Vegetables, especially green leafy vegetables, were primarily sold by informal mobile food vendors, most of whom were women. • A greater density of vegetable vendors or informal vendors within 500 meters of a household is associated with a higher likelihood of vegetable purchases and lower energy intake. • The role of informal and semi-formal food vendors in supporting consumption of nutritious diets should not be discounted, and gender sensitive actions to promote their livelihoods is needed.

We present a set of indicators that could be used to measure the effects of programs on RMC. Integrating these indicators into programs to improve quality of care and other health system outcomes will facilitate routine monitoring and accountability around experience of care., Background: Some opportunities to routinely capture and improve respectful maternity care (RMC) during facility-based childbirth include quality improvement (QI) initiatives, community-based monitoring efforts through community score cards (CSC), and performance-based financing (PBF) initiatives. But there is limited guidance on which types of RMC indicators are best suited for inclusion in these initiatives. We sought to provide practical evidence-based recommendations on indicators that may be used for routine measurement of RMC in programs. Methods: We used a rapid review approach, which included (1) reviewing existing documents and publications to extract RMC indicators and identify which have or can be used in facility-based QI, CSCs, and PBF schemes; (2) surveying RMC and maternal health experts to rank indicators, and (3) analyzing survey data to select the most recommended indicators. Results: We identified 49 indicators spanning several domains of RMC and mistreatment including dignified/nondignified care, verbal and physical abuse, privacy/confidentiality, autonomy/loss of autonomy, supportive care/lack thereof, communication, stigma, discrimination, trust, facility environment/culture, responsiveness, and nonevidence-based care. Based on the analysis of the survey data, we recommend 33 indicators (between 2 and 6 indicators for each RMC domain) that may be suited for incorporation in both facility-based QI and CSC-related monitoring efforts. Conclusion: Integrating RMC indicators into QI and CSC initiatives, as well as in other maternal and neonatal health programs, could help improve RMC at the facility and community level. More research is needed into whether RMC can be integrated into PBF initiatives. Integration of RMC indicators into programs to improve quality of care and other health system outcomes will facilitate routine monitoring and accountability around experience of care. Measurement and improvement of women's experiences will increase maternal health service utilization and improve quality of care as a means of reducing maternal and neonatal morbidity and mortality.

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.

Parents across the world are faced with many challenges that can increase their levels of stress. Only a handful of studies have examined parenting stress in sub-Saharan African contexts, and most have focused only on mothers or at-risk populations. There is therefore a significant gap in our understanding of the factors that contribute to parenting stress in mothers and fathers in the general population across sub-Saharan Africa and how parents manage this stress. The objective of this study was to examine parenting-related stress in mothers and fathers with young children and how parents dealt with this stress in the Mara region of Tanzania. A qualitative phenomenological study was employed. Data were collected through in-depth interviews and focus group discussions with mothers and fathers. Data were analyzed using inductive thematic content analysis. Both mothers and fathers identified poverty and lack of consistent employment as two major contributors to parenting stress. These factors strained the marital relationship and impacted child illness and malnutrition, which further contributed to parenting stress. Parents primarily sought support for childcare, financial, and relationship stressors from their spouse and extended family members. Although parents commonly participated in formal social groups with peers, these groups were not a primary source of support in times of parenting stress. Collectively, these findings informed the development of a framework on the different types of stressors parents in rural Tanzania face and the interactions between them, the types of support they seek out or receive, and the individuals they turn to for support. This is the first study to examine both maternal and paternal experiences of parenting stress in a general population in a sub-Saharan African context. These findings can inform the development of interventions to promote the wellbeing of parents and families of young children.

The ARISE Network Adolescent Health Study is an exploratory, community-based survey of 8075 adolescents aged 10-19 in 9 communities in 7 countries: Burkina Faso, Eswatini, Ethiopia, Ghana, Nigeria, Tanzania and Uganda. Communities were selected opportunistically and existing population cohorts maintained by health and demographic surveillance systems (HDSSs). The study is intended to serve as a first round of data collection for African adolescent cohorts, with the overarching goal of generating community-based data on health-related behaviours and associated risk factors in adolescents, to identify disease burdens and health intervention opportunities. Household-based sampling frames were used in each community to randomly select eligible adolescents (aged 10-19 years). Data were collected between July 2015 and December 2017. Consenting participants completed face-to-face interviews with trained research assistants using a standardised questionnaire, which covered physical activity, cigarette and tobacco use, substance and drug use, mental health, sexual behaviours and practices, sexually transmitted infections, pregnancy, food security and food diversity, teeth cleaning and hand washing, feelings and friendship, school and home activities, physical attacks and injuries, health care, health status assessment and life satisfaction, as well as media and cell phone use and socio-demographic and economic background characteristics. Results from this multi-community study serve to identify major adolescent health risks and disease burdens, as well as opportunities for interventions and improvements through policy changes.L’étude ARISE du réseau sur la santé des adolescents est une étude exploratoire de surveillance basée sur la communauté portant sur 8.075 adolescents âgés de 10 à 19 ans dans 9 communautés de 7 pays: Burkina Faso, Eswatini, Ethiopie, Ghana, Nigéria, Tanzanie et Ouganda. Les communautés ont été sélectionnés de manière opportuniste et les cohortes de population existantes maintenues par des systèmes de surveillance de la santé et démographique (SSSD). L'étude est destinée à servir comme premier cycle de collecte de données pour les cohortes d’adolescents africains, dans le but primordial de générer des données communautaires sur les comportements liés à la santé et les facteurs de risque associés chez les adolescents, afin d'identifier la charge de morbidité et les opportunités d'intervention en matière de santé. Des cadres d'échantillonnage basés sur le ménage ont été utilisés dans chaque communauté pour sélectionner au hasard les adolescents admissibles (âgés de 10-19 ans). Les données ont été collectées entre juillet 2015 et décembre 2017. Les participants consentants ont participé à des entretiens de face à face avec des assistants de recherche formés, à l'aide d'un questionnaire standardisé couvrant l'activité physique, l’usage de la cigarette ou la consommation de tabac, l'usage de drogues et autres substances, la santé mentale, les comportements et pratiques sexuels, les infections sexuellement transmissibles, la grossesse, la sécurité et la diversité alimentaire, le nettoyage des dents et le lavage des mains, les sentiments et les amitiés, les activités scolaires et à domicile, les attaques et les blessures physiques, les soins de santé, l’évaluation de l’état de santé et la satisfaction à l’égard de la vie, l’utilisation des médias et du téléphone portable ainsi que les caractéristiques sociodémographiques et économiques. Les résultats de cette étude portant sur plusieurs communautés permettent d'identifier les principaux risques pour la santé des adolescents et les charges de morbidité, ainsi que les opportunités d'interventions et d'amélioration par le biais de changements de politiques.

OBJECTIVES: Nutrition interventions to improve infant and young child feeding (IYCF) and care in developing countries usually target mothers, while critical roles of other family members, particularly older siblings, are not well known. As part of the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) cluster-randomized trial (ClinicalTrials.gov: NCT03759821), we examined the roles of older children and adolescents in IYCF and care in rural Tanzania to develop and administer informed quantitative questionnaires on IYCF and care by older siblings. METHODS: Twelve mothers, 12 fathers, 4 grandmothers, and 4 older siblings (7–17 years of age) were purposively sampled for qualitative interviews conducted July-August 2018. Open-ended questions explored older siblings’ roles in IYCF and care, managing time for child care, and responsiveness to young children's hunger cues. Inductive and deductive approaches were used to identify themes from transcribed interviews. Findings supported development of two questionnaires on older children's roles in IYCF and care (14 questions each) that were administered to mothers and siblings in the EFFECTS baseline. RESULTS: Qualitative data indicate older siblings (male and female) are involved in food preparation (e.g., starchy staples), daily feeding, hygiene (e.g., washing baby after toileting) and care when the mother is unavailable due to other household activities. The EFFECTS study enrolled 960 households across 80 villages in Mara, Tanzania, and 53% of households identified at least one sibling who cares for an index child aged 0–18 months. Baseline data collection is ongoing and indicates prevalence and types of child care (e.g., feeding, playing, hygiene, responding to crying) provided by older siblings. CONCLUSIONS: To our knowledge, this is the first mixed methods study developing instruments to investigate the role of older siblings in providing IYCF and care in a rural, developing country setting. As parents seek to meet household and livelihood needs, older siblings are often engaged in child feeding and care. Nutrition interventions should consider roles of all family members, including older children, in child feeding and care. Further research is needed to evaluate the effect of family-based interventions. FUNDING SOURCES: Eleanor Crook Foundation and Conrad N. Hilton Foundation.