Health & Demographic Surveillance System Profile: The Rufiji Health and Demographic Surveillance System (Rufiji HDSS)

Women's input and decision-making in agriculture are associated with diet quality in rural Tanzania

Background

Women's empowerment is one critical pathway through which agriculture can impact women's nutrition; however, empirical evidence is still limited. We evaluated the associations of women's participation, input, and decision-making in key agricultural and household activities with women's diet quality.

Methods

We analyzed data from a cross-sectional study of 870 women engaged in homestead agriculture. We used food frequency questionnaires to assess women's diets and computed women's diet quality using the Prime Diet Quality Score (PDQS) (range 0-42), which captures healthy and unhealthy foods. We evaluated women's decision-making in 8 activities, food crop farming, cash crop farming, livestock raising, non-farm economic activities, wage/salary employment, fishing, major household expenditures, and minor household expenditures. Generalized estimating equations (GEE) linear models were used to evaluate associations between (a) women's participation, (b) decision-making, (c) adequate input, (d) adequate extent of independence in decision-making in agriculture, and (e) adequate input in use of agricultural income with their PDQS. Adequate input was defined as input into some, most or all decisions compared to input into few decisions or none. Adequate extent of independence was defined as input to a medium or high extent compared to input to a small extent or none.

Findings

Median PDQS was 19 (IQR: 16-21). Women's adequate input in decision-making on wage and salary employment (estimate: 4.19, 95% CI: 2.80, 5.57) and minor expenditures were associated with higher PDQS vs. inadequate input. Women with independence in decision-making on livestock production (estimate: 0.97, 95% CI: 0.05, 1.90) and minor household expenditures, and women with adequate decision-making in the use of income from wages/salaries (estimate: 3.16, 95% CI: 2.44, 3.87) had higher PDQS. Participation in agricultural activities was positively associated with PDQS.

Conclusions

Women's participation and input in decision-making in wage and salary employment, livestock production, and minor household expenditures were strongly associated with the consumption of better-quality diets. Women participating in multiple farm activities were also likely to have better diet quality. This study adds to the growing evidence on the pathways through which women's empowerment may influence women's nutrition in rural Tanzania.

The Impact of Childhood Mortality on Fertility in Rural Tanzania: Evidence From the Ifakara and Rufiji Health and Demographic Surveillance Systems

This manuscript examines the relationship between child mortality and subsequent fertility using longitudinal data on births and childhood deaths occurring among 15,291 Tanzanian mothers between 2000 and 2015. Generalized hazard regression analyses assess the effect of child loss on the hazard of conception, adjusting for child-level, mother-level, and contextual covariates. Results show that time to conception is most reduced if an index child dies during the subsequent birth interval, representing the combined effect of biological and volitional replacement. Deaths occurring during prior birth intervals were associated with accelerated time to conception during future intervals, consistent with hypothesized insurance effects of anticipating future child loss, but this effect is smaller than replacement effects. The analysis reveals that residence in areas of relatively high child mortality is associated with hastened parity progression, again consistent with the insurance hypothesis. Investigation of high-order interactions suggests that insurance effects tend to be greater in low-mortality communities, replacement effects tend to be stronger in high-mortality community contexts, and wealthier families tend to exhibit a weaker insurance response but a stronger replacement response to childhood mortality relative to poorer families.

The implementation and effectiveness of multi-tasked, paid community health workers on maternal and child health: A cluster-randomized pragmatic trial and qualitative process evaluation in Tanzania

Community health worker programs have proliferated worldwide based on evidence that they help prevent mortality, particularly among children. However, there is limited evidence from randomized studies on the processes and effectiveness of implementing community health worker programs through public health systems. This paper describes the results of a cluster-randomized pragmatic implementation trial (registration number ISRCTN96819844) and qualitative process evaluation of a community health worker program in Tanzania that was implemented from 2011-2015. Program effects on maternal, newborn and child health service utilization, childhood morbidity and sick childcare seeking were evaluated using difference-in-difference regression analysis with outcomes measured through pre- and post-intervention household surveys in intervention and comparison trial arms. A qualitative process evaluation was conducted between 2012 and 2014 and comprised of in-depth interviews and focus group discussions with community health workers, community members, facility-based health workers and staff of district health management teams. The community health worker program reduced incidence of illness and improved access to timely and appropriate curative care for children under five; however, there was no effect on facility-based maternal and newborn health service utilization. The positive outcomes occurred because of high levels of acceptability of community health workers within communities, as well as the durability of community health workers' motivation and confidence. Implementation factors that generated these effects were the engagement of communities in program startup; the training, remuneration and supervision of the community health workers from the local health system and community. The lack of program effects on maternal and newborn health service utilization at facilities were attributed to lapses in the availability of needed care at facilities. Strategies that strengthen and align communities' and health systems core capacities, and their ability to learn, adapt and integrate evidence-based interventions, are needed to maximize the health impact of community health workers.

Health and demographic surveillance systems in low- and middle-income countries: history, state of the art and future prospects

Health and Demographic Surveillance Systems (HDSS) have been developed in several low- and middle-income countries (LMICs) in Africa and Asia. This paper reviews their history, state of the art and future potential and highlights substantial areas of contribution by the late Professor Peter Byass.Historically, HDSS appeared in the second half of the twentieth century, responding to a dearth of accurate population data in poorly resourced settings to contextualise the study of interventions to improve health and well-being. The progress of the development of this network is described starting with Pholela, and progressing through Gwembe, Balabgarh, Niakhar, Matlab, Navrongo, Agincourt, Farafenni, and Butajira, and the emergence of the INDEPTH Network in the early 1990'sThe paper describes the HDSS methodology, data, strengths, and limitations. The strengths are particularly their temporal coverage, detail, dense linkage, and the fact that they exist in chronically under-documented populations in LMICs where HDSS sites operate. The main limitations are generalisability to a national population and a potential Hawthorne effect, whereby the project itself may have changed characteristics of the population.The future will include advances in HDSS data harmonisation, accessibility, and protection. Key applications of the data are to validate and assess bias in other datasets. A strong collaboration between a national HDSS network and the national statistics office is modelled in South Africa and Sierra Leone, and it is possible that other low- to middle-income countries will see the benefit and take this approach.

The Crucial Role of Mothers and Siblings in Child Survival: Evidence From 29 Health and Demographic Surveillance Systems in Sub-Saharan Africa

A considerable body of research has studied the effects of siblings on child mortality through birth intervals. This research has commonly focused on older siblings. We argue that birth intervals with younger siblings may have equal or stronger effects on child mortality, even during a mother's pregnancy. Moreover, we contend that birth interval effects need to be considered only when siblings are coresident. Using longitudinal data from 29 Health and Demographic Surveillance Systems across sub-Saharan Africa, covering more than 560,000 children, we examine the proximate role of siblings and mothers in child mortality. We find that a birth interval of 24 months or more is advantageous for both older and younger siblings. The effect of a younger sibling on child mortality is more pronounced than that of an older sibling and adds to the effect of an older sibling. Moreover, child mortality is particularly low during a mother's subsequent pregnancy, contrasting the shock resulting from a younger sibling's birth. Further, we find that a mother's or sibling's absence from the household results in a higher risk of mortality, and the death of either reduces child survival up to six months before the death.

Pregnancy Surveillance Methods within Health and Demographic Surveillance Systems

Background: Pregnancy identification and follow-up surveillance can enhance the reporting of pregnancy outcomes, including stillbirths and perinatal and early postnatal mortality. This paper reviews pregnancy surveillance methods used in Health and Demographic Surveillance Systems (HDSSs) in low- and middle-income countries. Methods: We searched articles containing information about pregnancy identification methods used in HDSSs published between January 2002 and October 2019 using PubMed and Google Scholar. A total of 37 articles were included through literature review and 22 additional articles were identified via manual search of references. We reviewed the gray literature, including websites, online reports, data collection instruments, and HDSS protocols from the Child Health and Mortality Prevention Study (CHAMPS) Network and the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH). In total, we reviewed information from 52 HDSSs described in 67 sources. Results: Substantial variability exists in pregnancy surveillance approaches across the 52 HDSSs, and surveillance methods are not always clearly documented. 42% of HDSSs applied restrictions based on residency duration to identify who should be included in surveillance. Most commonly, eligible individuals resided in the demographic surveillance area (DSA) for at least three months. 44% of the HDSSs restricted eligibility for pregnancy surveillance based on a woman's age, with most only monitoring women 15-49 years. 10% had eligibility criteria based on marital status, while 11% explicitly included unmarried women in pregnancy surveillance. 38% allowed proxy respondents to answer questions about a woman's pregnancy status in her absence. 20% of HDSSs supplemented pregnancy surveillance with investigations by community health workers or key informants and by linking HDSS data with data from antenatal clinics. Conclusions: Methodological guidelines for conducting pregnancy surveillance should be clearly documented and meticulously implemented, as they can have implications for data quality and accurately informing maternal and child health programs.

Births and deaths in Sidama in southern Ethiopia: findings from the 2018 Dale-Wonsho Health and Demographic Surveillance System (HDSS)

Background

Sidama is one of the most densely populated areas in Ethiopia. Information about the demographic characteristics is scarce, and most studies were census based on interviews. Earlier population studies from Ethiopia did not sufficiently address the validity of measuring births, deaths, and age-composition.

Objective

To investigate the population characteristics in Sidama with an emphasis on fertility estimates, age, and death reporting.

Methods

This is a mixed-method cross-sectional study, conducted in Sidama in southern Ethiopia, using baseline data of newly established Dale-Wonsho Health and Demographic Surveillance System site in 2018. We used quantitative data of 5179 randomly selected households having 25,144 individuals. We collected information on deaths in the same study period and population from the traditional burial associations (Iddir). Qualitative data were collected using focus group discussions, and in-depth interviews. Life tables, age reliability indices and logistic regression were used to analyse the data.

Results

The total fertility rate was 2.9 children/woman, the crude birth rate was 22.8/1000 population and the crude death rate was 5.2/1000 population. The dependency ratio was 66/100 working-age population. Urban residents had higher birth rates (OR = 1.4 (95% CL: 1.05–1.78), and women with basic education had lower birth rates (OR = 0.6 (95% CL: 0.46–0.78) compared to those with no education. The age accuracy indices showed unreliable age reporting. The number of deaths increased from 29 to 132 when death reports from the Iddirs were included. There was under-reporting of neonatal and deaths of young children. Substituting national and regional mortality estimates, the life expectancy declined to an average of 53 years (range 48–58 years).

Conclusion

The fertility rate in Sidama is lower than previously reported and is affected by age, residence and education. As we have identified important measurement and reporting errors, future demographic surveillance sites should consider these limitations.

The impact of paid community health worker deployment on child survival: the connect randomized cluster trial in rural Tanzania

Background

This paper reports on a rigorously designed non-masked randomized cluster trial of the childhood survival impact of deploying paid community health workers to provide doorstep preventive, promotional, and curative antenatal, newborn, child, and reproductive health care in three rural Tanzanian districts.

Methods

From August, 2011 to June 2015 ongoing demographic surveillance on 380,000 individuals permitted monitoring of neonatal, infant and under-5 mortality rates for 50 randomly selected intervention and 51 comparison villages. Over the initial 2 years of the project, logistics and supply support systems were managed by the Ifakara Health Institute. In 2013, the experiment transitioned its operational design to logistical support managed by the Ministry of Health and Social Welfare with the goal of enhancing government operational ownership and utilization of results for policy.

Results

The baseline under 5 mortality rate was 81.3 deaths per 1000 live births with a 95% confidence interval (CI) of 77.2–85.6 in the intervention group and 82.7/1000 (95% CI 78.5–87.1) in the comparison group yielding an adjusted hazard ratio (HR) of 0.99 (95% CI 0.88–1.11, p = 0.867). After 4 years of implementation, the under 5 mortality rate was 73.2/1000 (95% CI 69.3–77.3) in the intervention group and 77.4/1000 (95% CI 73.8–81.1) in the comparison group (adjusted HR 0.95 [95% CI 0.86–1.07], p = 0.443). The intervention had no impact on neonatal mortality in either the first 2 years (HR 1.10 [95% CI 0.89–1.36], p = .392) or last 2 years of implementation (HR 0.98 [95% CI 0.74–1.30], p = .902). Although community health worker deployment significantly reduced mortality among children aged 1–59 months during the first 2 years of implementation (HR 0.85 [95% CI 0.76–0.96], p = 0.008), mortality among post neonates was the same in both groups in years three and four (HR 1.03 [95% CI 0.85–1.24], p = 0.772). Results adjusted for stock-out effects show that diminishing impact was associated with logistics system lapses that constrained worker access to essential drugs and increased post-neonatal mortality risk in the final two project years (HR 1.42 [95% CI 1·07–1·88], p = 0·015).

Conclusions

Community health worker home-visit deployment had a null effect among neonates, and 2 years of initial impact among children over 1 month of age, but a null effect when tests were based on over 1 month of age data merged for all four project years. The atrophy of under age five effects arose because workers were not continuously equipped with essential medicines in years three and four. Analyses that controlled for stock-out effects suggest that adequately supplied workers had survival effects on children aged 1 to 59 months.

Trial registration

Registration for trial number ISRCTN96819844 was retrospectively completed on June 21, 2012.

Does it Take a Village? Kin Coresidence and Child Survival in Tanzania

Children in Tanzania live in a variety of family structures, many of which contain related and unrelated non-parental adults. In this article, I use data from the Rufiji Health and Demographic Surveillance System in Tanzania to examine the role of coresident non-parental adults in childrearing. First, I use quantitative demographic data to investigate the association between kin coresidence and child survival, differentiating by lineage. I also examine the role of unrelated coresident adults. Second, I test whether coresident non-parental adults moderate the association between parental absence and child survival. Finally, I draw from qualitative interview data to investigate childrearing practices and beliefs, with a particular focus on parental absence and kin coresidence. I find that, despite the institutionalization of kin caregiving, coresidence with kin is not beneficial, and kin are unable to compensate for parental absence. The two-parent living arrangement is viewed as ideal, although the reality of childrearing in the setting is complex and fluid. While absent parents try to maintain support of their children, such assistance is insufficient in times of health crisis. Kin care for children with absent parents, but their willingness to assist depends on the reason for the absence.

Mortality of neurological disorders in Tanzania: analysis of baseline data from sample vital registration with verbal autopsy (SAVVY)

Background: Neurological disorders (ND) have a profound consequence on human productivity, quality of life and survival. There are limited data on the burden of ND in Tanzania due to insufficient coverage of civil and vital registration systems. Objectives: This study was conducted to estimate mortality of ND in all ages in Tanzania using data from the Sample Vital Registration with Verbal Autopsy (SAVVY) study. Methods: Multistage random sampling was employed to select 23 districts, 1397 census enumeration areas and 154,603 households. During the baseline survey conducted between 2011 and 2014, deaths which occurred 12 months prior to the baseline survey were documented followed by verbal autopsy interviews. Causes of death were certified using International Classification of Diseases. Results: The baseline survey enrolled a total of 650,864 residents. A total of 6645 deaths were reported to have occurred 12 months before the date of survey. Death certification was available for 5225 (79%) deaths. The leading causes of death were cerebrovascular diseases with a cause-specific mortality fraction (CSMF) of 1.64% (95% CI: 1.30-1.99) and 3.82% (95% CI: 2.92-4.72) in all ages and adults older than 50 years, respectively. Stroke accounted for 92% of all cerebrovascular deaths. Mortality of epilepsy was estimated with a CSMF of 0.94% (95% CI: 0.68-1.20); meningitis with a CSMF of 0.80% (95% CI: 0.56-1.04); cerebral palsy and other paralytic syndromes with a CSMF of 0.46% (95% CI: 0.27-0.65); and intrauterine hypoxia in neonates with a CSMF of 2.06% (95% CI: 1.12-3.01). Overall, mortality of ND was estimated with a CSMF of 4.99% (95% CI: 4.40-5.58). Conclusions: The SAVVY survey provides estimates of mortality burden of ND in Tanzania. The study provides a basis for monitoring trends of ND and contributes to advancing knowledge of the burden of diseases. Integrating morbidities measures into the SAVVY design will provide comprehensive measures of burden of ND taking into account lifetime disabilities created by ND.

Estimating drowning mortality in Tanzania: a systematic review and meta-analysis of existing data sources

Background

The WHO advocates a 7-step process to enable countries to develop and implement drowning prevention strategies. We sought to assess, using existing data sources, the drowning situation in Tanzania as a first step in this process.

Methods

We searched for data on causes of death in Tanzania by reviewing existing literature and global datasets and by in-country networking. Authors and institutions were then contacted to request aggregate data on drowning mortality. Site-specific drowning estimates were combined using a random effects meta-analytic approach. We also tested for evidence of variations in drowning estimates by sex and by age group.

Results

We acquired partial or complete information on drowning deaths for 13 data sources. We found strong evidence for substantial variations between study sites (p<0.001). Combining population-based data, we estimated an average of 5.1 drowning deaths per 100 000 persons per year (95% CI 3.8 to 6.3). The proportions of deaths due to drowning were 0.72% (95% CI 0.55 to 0.88) and 0.94% (95% CI 0.09 to 1.78) combining population-based data and hospital-based data, respectively. Males were at greater risk than females, while both under-five children and adults aged 45 years or more were at greater risk than those aged 5–44 years.

Conclusion

Our estimates of drowning burden are broadly in line with the 2016 Global Burden of Disease and the 2015 WHO Global Health Estimates. While this exercise was useful in raising the burden of drowning in Tanzania with policy makers, planning drowning prevention strategies in this country will require a better understanding of which subpopulations are at high risk.

The impact of integrated nutrition-sensitive interventions on nutrition and health of children and women in rural Tanzania: study protocol for a cluster-randomized controlled trial

Background

Nutrition-sensitive interventions such as homestead production of diverse, nutrient-rich foods, coupled with behavior change communication, may have positive effects on the nutritional status and health of rural households engaged in agriculture, particularly among women and young children. Engagement of agriculture and health extension workers in these communities may be an effective way of delivering nutrition-sensitive interventions given the dearth of trained health care providers in many developing countries. This study aims to assess the effects of integrated homestead food production, food consumption and women’s empowerment interventions using a multi-sectoral approach on women’s and child’s health and nutrition.

Methods

This is a cluster-randomized community-based prospective study set in Rufiji district, a rural area in Eastern Tanzania. Ten randomly selected villages within the Rufiji Health and Demographic Surveillance Site (HDSS) in Eastern-Tanzania were paired and randomly assigned to the intervention or control arm. The Rufiji HDSS dataset was used to randomly sample households with women of reproductive age and children 6–36 months. The intervention includes provision of small agricultural inputs, garden training support, and nutrition and health counseling. This is delivered by community health workers and agriculture extension workers through home visits and farmer field schools. There are three time points for data collection: baseline, midline, and endline. Primary outcomes are women’s and children’s dietary diversity, maternal and child anemia status and growth (child stunting, child wasting, women’s BMI, and women and child hemoglobin).

Discussion

This integrated agriculture and nutrition intervention among rural farming households is a simple and innovative solution that may contribute to the reduction of undernutrition and disease burden among women and children in developing countries. Engaging already existing workforce in the community may facilitate sustainability of the intervention package.

Trial registration

ClinicalTrials.gov NCT03311698, Retrospectively registered on October 17, 2017.

Verbal autopsy in health policy and systems: a literature review

Introduction

Estimates suggest that one in two deaths go unrecorded globally every year in terms of medical causes, with the majority occurring in low and middle-income countries (LMICs). This can be related to low investment in civil registration and vital statistics (CRVS) systems. Verbal autopsy (VA) is a method that enables identification of cause of death where no other routine systems are in place and where many people die at home. Considering the utility of VA as a pragmatic, interim solution to the lack of functional CRVS, this review aimed to examine the use of VA to inform health policy and systems improvements.

Methods

A literature review was conducted including papers published between 2010 and 2017 according to a systematic search strategy. Inclusion of papers and data extraction were assessed by three reviewers. Thereafter, thematic analysis and narrative synthesis were conducted in which evidence was critically examined and key themes were identified.

Results

Twenty-six papers applying VA to inform health policy and systems developments were selected, including studies in 15 LMICs in Africa, Asia, the Middle East and South America. The majority of studies applied VA in surveillance sites or programmes actively engaging with decision makers and governments in different ways and to different degrees. In the papers reviewed, the value of continuous collection of cause of death data, supplemented by social and community-based investigations and underpinned by electronic data innovations, to establish a robust and reliable evidence base for health policies and programmes was clearly recognised.

Conclusion

VA has considerable potential to inform policy, planning and measurement of progress towards goals and targets. Working collaboratively at sub-national, national and international levels facilitates data collection, aggregation and dissemination linked to routine information systems. When used in partnerships between researchers and authorities, VA can help to close critical information gaps and guide policy development, implementation, evaluation and investment in health systems.

Predictors of Health Care Seeking Behavior During Pregnancy, Delivery, and the Postnatal Period in Rural Tanzania

Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are the World Health Organization recommendations for women to optimize maternal health outcomes. This study examines maternal compliance with the full recommended maternal health visits in rural Tanzania with the goal of illuminating interventions to reduce inequalities in maternal health. Methods Analysis included 907 women who had given birth within two years preceding a survey of women of reproductive age. Multinomial logistic regression was used to assess the influence of maternal, household, and community-level characteristics on four alternative classes defining relative compliance with optimal configuration of maternal health care seeking behavior. Results Parity, wealth index, timeliness of ANC initiation, nearest health facility type, religion, and district of residence were significant predictors of maternal health care seeking when adjusted for other factors. Multiparous women compared to primiparous were less likely to seek care at the high level [RRR 0.16, 95 % confidence interval (CI) 0.06-0.46], at the mid-level (RRR 0.22, 95 % CI 0.09-0.58), and the mid-low level (RRR 0.27, 95 % CI 0.09-0.80). Women in the highest wealth index compared to those in the poorest group were almost three times more likely to seek the highest two levels of care versus the lowest level (high RRR 2.92, 95 % CI 1.27-6.71, mid-level RRR 2.71, 95 % 1.31-5.62). Conclusion Results suggest that efforts to improve the overall impact of services on the continuum of care in rural Tanzania would derive particular benefit from strategies that improve maternal health coverage among multiparous and low socioeconomic status women.

Beyond Orphanhood: Parental Nonresidence and Child Well-being in Tanzania

This article used data from the Rufiji Health and Demographic Surveillance System in Tanzania to examine the influence of parental non-residence on child survival and school entry. Using survival analysis methods, the article tested variations by parent and by cause, examining parental death, non-residence due to parental relationship status, and migration. In general, maternal non-residence was more consequential for child survival, while paternal non-residence influences school entry. This is consistent with gendered parenting patterns in the setting. There was important variation by cause and by outcome, particularly for paternal non-residence. Paternal non-residence due to non-marital birth was associated with increased risk of child death, while paternal migration was associated with improved survival. Paternal death and migration were associated with lower odds of school entry. This article moves beyond orphanhood to consider multiple causes of parental non-residence simultaneously, demonstrating that parental non-residence is not uniformly deleterious for children.

Assessing the effects of mosquito nets on malaria mortality using a space time model: a case study of Rufiji and Ifakara Health and Demographic Surveillance System sites in rural Tanzania

Background

Although malaria decline has been observed in most sub-Saharan African countries, the disease still represents a significant public health burden in Tanzania. There are contradictions on the effect of ownership of at least one mosquito net at household on malaria mortality. This study presents a Bayesian modelling framework for the analysis of the effect of ownership of at least one mosquito net at household on malaria mortality with environmental factors as confounder variables.

Methods

The analysis used longitudinal data collected in Rufiji and Ifakara Health Demographic Surveillance System (HDSS) sites for the period of 1999–2011 and 2002–2012, respectively. Bayesian framework modelling approach using integrated nested laplace approximation (INLA) package in R software was used. The space time models were established to assess the effect of ownership of mosquito net on malaria mortality in 58 villages in the study area.

Results

The results show that an increase of 10 % in ownership of mosquito nets at village level had an average of 5.2 % decrease inall age malaria deaths (IRR = 0.948, 95 % CI = 0.917, 0.977) in Rufiji HDSS and 12.1 % decrease in all age malaria deaths (IRR = 0.879, 95 % CI = 0.806, 0.959) in Ifakara HDSS. In children under 5 years, results show an average of 5.4 % decrease of malaria deaths (IRR = 0.946, 95 % CI = 0.909, 0.982) in Rufiji HDSS and 10 % decrease of malaria deaths (IRR = 0.899, 95 % CI = 0.816, 0.995) in Ifakara HDSS. Model comparison show that model with spatial and temporal random effects was the best fitting model compared to other models without spatial and temporal, and with spatial–temporal interaction effects.

Conclusion

This modelling framework is appropriate and provides useful approaches to understanding the effect of mosquito nets for targeting malaria control intervention. Furthermore, ownership of mosquito nets at household showed a significant impact on malaria mortality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1311-9) contains supplementary material, which is available to authorized users.

Why women bypass front-line health facility services in pursuit of obstetric care provided elsewhere: a case study in three rural districts of Tanzania

OBJECTIVES

In the Tanzanian health system, women are expected to first visit their nearest front-line health facility (FLF) for delivery. However, women frequently bypass these FLF. Our study estimates the extent of bypassing for childbirth and assesses factors associated with this behaviour.

METHODS

Data describing the experiences of 597 women who recently delivered at a facility and the EmONC service capability at 107 health facilities were collected in 2011. Women who did not deliver at their nearest FLF were considered 'bypassers'. Factors associated with bypassing were assessed using multivariate logistic regression models. Three sets of analyses were conducted: among 597 women who delivered at the first facility they visited, among 521 women with no previous complications, and among 407 women not primigravida and without previous complications.

RESULTS

More than 75.4% of women bypassed. In the fully adjusted model of all 597 women those who had experienced complications were more likely to bypass for delivery [OR = 6.31 (2.36, 16.86)]. In the fully adjusted model excluding women with previous complications, primigravida women were more likely to bypass [OR = 3.70 (1.71, 8.01)]. Fully adjusted models for each set of analysis found that, for each additional emergency obstetric and newborn care signal function (EmONC SF) available at the nearest FLF, women's odds of bypassing almost halved.

CONCLUSIONS

Bypassing is highly associated with EmONC SF score at nearest FLF, controlling for individual and community-level factors.

Factors associated with compliance with the recommended frequency of postnatal care services in three rural districts of Tanzania

Background

High neonatal mortality persists in Tanzania. Rates of decline are slow, in part because postnatal care (PNC) services for addressing this problem remain severely underutilized. This study assesses factors associated with utilization of PNC among mothers in rural Tanzania.

Methods

This study analyzed household survey data collected in 2011 to understand health service utilization patterns among women of reproductive age and children less than 5 years of age in the Rufiji, Kilombero, and Ulanga districts of Tanzania. A total of 889 mothers were eligible for the current analysis. Multinomial logistic regression was used to determine factors associated with the likelihood of mothers seeking the WHO recommended PNC visits.

Results

The percent of newborns and their mothers with full PNC was low (10.4 %). Factors explaining PNC completion were district of residence, ethnic group, pregnancy wantedness, ANC attendance, place of delivery, and any incidence of newborn. Mothers of unwanted pregnancies were less likely to attend PNC services compared to mothers of wanted pregnancies [for at least two PNC: aRRR = 0.57, 95 % CI 0.35–0.94]. Sick newborns were more likely to receive PNC than newborns who were not sick during the first month after childbirth [for at least two PNC, aRRR = 3.52, 95 % CI 2.12–5.86]. Mothers who attended ANC services more frequently were more likely to receive PNC services compared to those who had attended fewer than 2 ANC services [for 1 PNC, aRRR = 1.89, 95 % CI 1.23–2.90]. Mothers who delivered at a health facility were less likely to attend PNC services compared to mothers who delivered outside a facility [for at least 2 PNC: aRRR = 0.42, 95 % CI 0.26–0.76]. Model with interactions between ANC attendance and place of delivery shown that only ANC attendance had a positive and statistically significant effect on PNC visit.

Conclusion

To achieve the WHO recommended number of PNC in rural Tanzania, our findings suggest the need to provide PNC through the community-based primary health care. Efforts to improve coverage of PNC should include expanding health education and counseling during childbirth and neonatal period to more effectively advocate PNC for newborns perceived to be healthy.

Multilevel Analysis of Childbearing in Childhood in Tanzania's Rufiji District

OBJECTIVES

To examine levels, trends and correlates of childbearing in childhood (CiC) in the Rufiji district of Tanzania from 2002 to 2010.

METHODS

Using longitudinal data collected in, and by, the Rufiji health and demographic surveillance system in Tanzania from 2002 to 2010, all women who initiated childbearing in this period (n = 5491) were selected for analysis. CiC was defined as childbearing initiation before age 18. Data analysis involved one-way tabulations of each variable-most of which were socio-demographic-to obtain frequency distributions, cross-tabulations of CiC and each of the independent variables with a Chi square test for associations, and multivariate analysis using multilevel logistic regression to examine covariates of CiC.

RESULTS

CiC was 44 % and remained constant over the 2002-2010 period (P = 0.623). The relative odds of CiC was significantly reduced by 83 percent among women with secondary or higher educational attainment relative to CiC among uneducated women (OR = 0.17, CI 0.12-0.23). Moreover, the odds of CiC significantly declines monotonically as relative household wealth increases by quintile (OR = 0.70, CI 0.57-0.86). CiC also declines significantly with employment and marital status of the respondent.

CONCLUSIONS

CiC represents a challenging social and health problem. Forty-four percent of first time mothers in Rufiji district of Tanzania are of childhood age, and this has not changed over the past 9 years since 2002. Prioritizing girls' formal education-especially up to secondary level or higher-as well as devising some economic empowerment modalities, may be worthwhile measures towards curbing CiC in the study area.

Spatial and space-time clustering of mortality due to malaria in rural Tanzania: evidence from Ifakara and Rufiji Health and Demographic Surveillance System sites

BACKGROUND

Although, malaria control interventions are widely implemented to eliminate malaria disease, malaria is still a public health problem in Tanzania. Understanding the risk factors, spatial and space-time clustering for malaria deaths is essential for targeting malaria interventions and effective control measures. In this study, spatial methods were used to identify local malaria mortality clustering using verbal autopsy data.

METHODS

The analysis used longitudinal data collected in Rufiji and Ifakara Health Demographic Surveillance System (HDSS) sites for the period 1999-2011 and 2002-2012, respectively. Two models were used. The first was a non-spatial model where logistic regression was used to determine a household's characteristic or an individual's risk of malaria deaths. The second was a spatial Poisson model applied to estimate spatial clustering of malaria mortality using SaTScan™, with age as a covariate. ArcGIS Geographical Information System software was used to map the estimates obtained to show clustering and the variations related to malaria mortality.

RESULTS

A total of 11,462 deaths in 33 villages and 9328 deaths in 25 villages in Rufiji and Ifakara HDSS, respectively were recorded. Overall, 2699 (24 %) of the malaria deaths in Rufiji and 1596 (17.1 %) in Ifakara were recorded during the study period. Children under five had higher odds of dying from malaria compared with their elderly counterparts aged five and above for Rufiji (AOR = 2.05, 95 % CI = 1.87-2.25), and Ifakara (AOR = 2.33, 95 % CI = 2.05-2.66), respectively. In addition, ownership of mosquito net had a protective effect against dying with malaria in both HDSS sites. Moreover, villages with consistently significant malaria mortality clusters were detected in both HDSS sites during the study period.

CONCLUSIONS

Clustering of malaria mortality indicates heterogeneity in risk. Improving targeted malaria control and treatment interventions to high risk clusters may lead to the reduction of malaria deaths at the household and probably at country level. Furthermore, ownership of mosquito nets and age appeared to be important predictors for malaria deaths.

Childhood Illness Prevalence and Health Seeking Behavior Patterns in Rural Tanzania

INTRODUCTION

This paper identifies factors influencing differences in the prevalence of diarrhea, fever and acute respiratory infection (ARI), and health seeking behavior among caregivers of children under age five in rural Tanzania.

METHODS

Using cross-sectional survey data collected in Kilombero, Ulanga, and Rufiji districts, the analysis included 1,643 caregivers who lived with 2,077 children under five years old. Logistic multivariate and multinomial regressions were used to analyze factors related to disease prevalence and to health seeking behavior.

RESULTS

One quarter of the children had experienced fever in the past two weeks, 12.0 % had diarrhea and 6.7 % experienced ARI. Children two years of age and older were less likely to experience morbidity than children under one year [ORfever = 0.77, 95 % CI 0.61-0.96; ORdiarrhea = 0.26, 95 % CI 0.18-0.37; ORARI = 0.60 95 % CI 0.41-0.89]. Children aged two and older were more likely than children under one to receive no care or to receive care at home, rather than to receive care at a facility [RRRdiarrhea = 3.47, 95 % CI 1.19-10.17 for "No care"]. Children living with an educated caregiver were less likely to receive no care or home care rather than care at a facility as compared to those who lived with an uneducated caregiver [RRRdiarrhea = 0.28, 95 % CI 1.10-0.79 for "No care"]. Children living in the wealthiest households were less likely to receive no care or home care for fever as compared to those who lived poorest households. Children living more than 1 km from health facility were more likely to receive no care or to receive home care for diarrhea rather than care at a facility as compared to those living less than 1 km from a facility [RRRdiarrhea = 3.50, 95 % CI 1.13-10.82 for "No care"]. Finally, caregivers who lived with more than one child under age five were more likely to provide no care or home care rather than to seek treatment at a facility as compared to those living with only one child under five.

CONCLUSIONS

Our results suggest that child age, caregiver education attainment, and household wealth and location may be associated with childhood illness and care seeking behavior patterns. Interventions should be explored that target children and caregivers according to these factors, thereby better addressing barriers and optimizing health outcomes especially for children at risk of dying before the age of five.

Childhood Risk of Parental Absence in Tanzania

Although parents might not live with their children for a variety of reasons, existing accounts of parental absence often examine one cause in isolation. Using detailed longitudinal demographic surveillance data from Rufiji, Tanzania, this article examines parental absence due to death, migration, child relocation, union dissolution, and union formation from 2001-2011. Employing survival analysis, the article quantifies children's risk of absence by cause and investigates sociodemographic variation in this risk. Of children born into two-parent households, 25% experience maternal absence by age 10, and 40% experience paternal absence by the same age. Roughly one-quarter of children are born into single-mother families with an absent father at birth, and nearly 70% of these children experience maternal absence as well by age 10. Despite the emphasis on orphanhood in the research and policy communities, parental death is the least common cause of absence. Furthermore, although demographic and socioeconomic characteristics are strong predictors of absence, variation in these relationships across causes underscores the distinctiveness and similarity of different reasons for absence.

Trends in socioeconomic disparities in a rapid under-five mortality transition: a longitudinal study in the United Republic of Tanzania

Objective

To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011.

Methods

We used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. We estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models.

Findings

The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births (95% confidence interval, CI: 119.3–147.4) in 2000 to 66.2 (95% CI: 59.0–74.3) in 2011 and in Rufiji from 118.4 deaths per 1000 live births (95% CI: 107.1–130.7) in 2000 to 76.2 (95% CI: 66.7–86.9) in 2011. Combining both sites, in 2000–2001, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 1.08–1.92) higher than for children of mothers who had received education beyond primary school and in 2010–2011, the HR was 1.18 (95% CI: 0.90–1.55). In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 (95% CI: 0.99–1.47) in 2000–2001 to 1.48 (95% CI: 1.15–1.89) in 2010–2011, while in Ifakara, disparities narrowed from 1.30 (95% CI: 1.09–1.55) to 1.15 (95% CI: 0.95–1.39) in the same period.

Conclusion

While childhood survival has improved, mortality disparities still persist, suggesting a need for policies and programmes that both reduce child mortality and address socioeconomic disparities.