Alfa Muhihi

Introduction Iron-folic acid (IFA) supplementation in pregnancy is recommended by the WHO, with a dose of 60 mg of iron in contexts where anaemia remains a severe public health problem. Iron-containing supplements may cause side effects that affect acceptability and adherence in a dose-response manner. Maternal multiple micronutrient supplements (MMS), which include iron and folic acid plus additional micronutrients, are also recommended in the context of rigorous research, and programmes are considering transitioning from IFA to MMS containing 30 mg of iron. We will evaluate the effect of iron dose in MMS on maternal acceptability, side effects, adherence and preferences. Methods and analysis The Multiple Micronutrient Supplementation (MMS) Iron Dose Acceptability Crossover Trial is an individually randomised, quadruple-blind, non-inferiority crossover trial of daily antenatal MMS supplementation formulations that contain 60 mg, 45 mg and 30 mg elemental iron among pregnant women in Dar es Salaam, Tanzania. A total of 156 pregnant participants will be randomised to a sequence in which they receive each of the three MMS formulations for 1 month. Participants, investigators, outcome assessors and data analysts will be blinded to the treatment sequence. The primary trial outcome is participant-reported acceptability of each MMS formulation, measured on a Likert scale. Secondary and tertiary outcomes include preferred and least preferred formulation, identification of MMS formulation, reported side effects and adherence assessed by pill count. Regression analyses will be used to assess differences between formulations and will account for sequence and period effects of the crossover trial design. Qualitative in-depth interviews from a subsample of participants will be conducted to understand women’s perceptions and experiences taking the different MMS formulations. Ethics and dissemination The trial protocol was approved by Harvard T. H. Chan School of Public Health Institutional Review Board (IRB), the Ifakara Health Institute IRB, the Muhimbili University of Health and Allied Sciences IRB, the National Health Research Ethics Sub-Committee and the Tanzania Medicine and Medical Device Authority. Results will be shared through publications and presentations at the local, regional and international levels. Trial registration number ClinicalTrials.gov Identifier: NCT06069869.

Introduction: Community Health Workers (CHWs) have significantly improved maternal and child health outcomes in low and middle-income countries (LMICs). There is growing evidence of their expanding role in providing health education to enhance public knowledge of cardiovascular disease (CVD) risk factors. We evaluated the effects of a short training for CHWs on their knowledge of risk factors and warning signs for heart attack and stroke, unhealthy dietary habits, and appropriate actions to be taken in the event of CVD-related emergencies. Methods: This evaluation was conducted as part of a cluster-randomised controlled trial of CHWs interventions to reduce blood pressure in rural Morogoro, Tanzania. A written content knowledge test was administered before and after the training to assess changes in CHWs’ knowledge. Pre- and post-training comparisons of mean scores and proportions were performed using a paired samples t-test and Fisher’s exact test, respectively. A minimum post-training knowledge pass mark was set at 75%. Results: Before training, less than half (44.4%) of the CHWs scored above the passing mark, indicating limited knowledge. After the training, all CHWs scored above the passing mark. We observed significantly improved mean knowledge scores for risk factors and warning signs for heart attack and stroke, and healthy dietary habits (all p<0.001). Increase in mean knowledge score for appropriate actions to take in case of CVD-related emergency did not reach statistical significance. The proportion of participants demonstrating good knowledge of CVD risk factors increased from 44.4% to 100%(p<0.001)., while that of warning signs for CVD increased from 16.7% to 100.0% (p<0.001). Conclusions: A short, focused training program significantly enhanced CHWs’ knowledge of CVDs. Given the rising burden of CVD risk factors, trained CHWs provide an opportunity to tackle the problem at the community level by providing health education, promoting healthy lifestyles, and supporting routine screening for early detection and referral of individuals at high risk for CVD. Trial registration: PACTR201801002959401

Enhancing community knowledge about risk factors and warning signs for stroke and heart attack is important for effective prevention and control. This study evaluated the effects of home-based health education and healthy lifestyle interventions delivered by community health workers (CHWs) on knowledge of risk factors and warning signs for stroke and heart attack. We conducted a 1:1 cluster-randomized trial in twelve villages in rural Morogoro, Tanzania. Participants in the intervention received monthly home-based health education and healthy lifestyle promotion from CHWs for 6 months, followed by bi-monthly follow-up visits until 12 months. Participants in the control group followed the standard of care. Knowledge regarding risk factors and warning signs for stroke and heart attack was assessed through two independent cross-sectional surveys, one before and another after the intervention. The analyses were adjusted for baseline factors. Both intervention and control groups experienced an increase in mean knowledge scores between baseline and evaluation survey, with a significant increase in the intervention group. Mean knowledge for risk factors increased by 4.0 (SD 2.7) in the intervention compared to 2.5 (SD 3.1) in the control group. That of warning signs increased by 3.1 (SD 2.4) in the intervention group compared to 2.4 (SD 2.8) in the control group. Overall, mean knowledge of risk factors and warning signs increased by 7.1 (SD 4.3) in the intervention group and by 4.9 (SD 5.3) in the control group. After adjusting for selected baseline characteristics, participants in the intervention group experienced a 2.1 greater increase in mean knowledge of risk factors and warning signs [difference in differences 2.1 (95% CI, 1.4 to 2.8)]. CHWs’ home-delivered health education and healthy lifestyle promotion interventions resulted in a significant enhancement in knowledge of risk factors and warning signs for stroke and heart attack. These findings provide insight into the potential of CHW-led interventions in the prevention and control of stroke and heart attacks in Tanzania. Pan African Clinical Trial Registry (PACTR201801002959401).

Background: Infants born to pregnant women living with HIV (WLHIV) are at greater risk for morbidity and mortality and may also have poorer developmental outcomes as compared with infants who are not exposed to HIV. Nutrition interventions in pregnancy may affect developmental outcomes. Objectives: This study evaluated the effect of maternal vitamin D supplementation on infant development outcomes. Design: We conducted a secondary analysis of a randomised, triple-blind, placebo-controlled trial of maternal vitamin D supplementation from June 2015 to October 2019. Setting: Antenatal care clinics in Dar es Salaam, Tanzania. Participants: Pregnant WLHIV and their offspring. Interventions: Daily 3000 IU vitamin D ₃ or placebo supplements taken during pregnancy and lactation. Outcome measures: Infants were assessed for cognitive, language and motor development at 1 year of age with the Caregiver Reported Early Development Instruments (CREDI). Results: A total of 2167 infants were eligible, and 1312 of them completed CREDI assessments at 1 year of age. Vitamin D supplementation had no effect on overall CREDI z-scores (standardised mean difference (SMD) 0.03, 95% CI −0.09, 0.15, p value 0.66). There was also no evidence of a difference between vitamin D and placebo groups in language (SMD 0.06, 95% CI −0.08, 0.21, p value 0.40), motor (SMD 0.02, 95% CI −0.09, 0.14, p value 0.69) or cognitive domain z-scores (SMD 0.05, 95% CI −0.08, 0.17, p 0.48). Conclusions: Maternal vitamin D supplementation during pregnancy and lactation did not affect infant development outcomes. Trial registration number: ClinicalTrials.gov identifier: NCT02305927 .

Calcium supplementation in pregnancy is recommended in contexts with low dietary calcium intake to reduce the risk of pre‐eclampsia and its complications. The World Health Organisation suggested high‐dose calcium supplementation (1500–2000 mg/day), divided into three doses and taken at different times from daily iron‐folic supplements. We conducted a mixed methods evaluation study to assess experiences, acceptability and barriers to high‐dose calcium supplementation from the perspectives of pregnant women and antenatal health care providers at two public health facilities in Dar es Salaam, Tanzania. Descriptive statistics and thematic analysis were used to characterise acceptability, barriers and overall experiences of using high‐dose calcium supplementation. Pregnant women in the cohort were aged 19–41 years, with 32.4% being primiparous. The proportion of pregnant women who liked calcium supplements ‘a lot’ decreased from 50.2% at the first visit to 31.8% at the last antenatal follow‐up visit. Adherence was 71.3% (interquartile range: 50.5%, 89.3%), with only 24.0% of the participants taking 90% or more of the required supplements. Although participants expressed positive attitudes towards using calcium supplements, they also voiced concerns about the large size, side effects, the potential to forget and the burden of taking calcium supplements three times per day. Antenatal health care providers also affirmed the high burden of taking calcium supplements in addition to iron‐folic acid supplements. Participants expressed the acceptability of using calcium supplements during pregnancy, but adherence to three doses per day posed challenges to pregnant women. Reducing the number of calcium supplement doses per day may improve adherence.

Background: Observational studies suggest that vitamin D deficiency among people living with HIV is associated with a greater risk of disease progression and death. Low levels of vitamin D in pregnancy are also associated with poor fetal and infant growth. Therefore, vitamin D supplementation may improve clinical outcomes for pregnant women living with HIV and improve fetal and postnatal growth for their infants. Methods and findings: We conducted a randomized, triple-blind, placebo-controlled trial of vitamin D₃ supplementation among pregnant and lactating women living with HIV in Dar es Salaam, Tanzania (ClinicalTrials.gov NCT02305927). Participants were randomized with 1:1 allocation stratified by study clinic to receive either daily 3,000 IU vitamin D₃ supplements or matching placebo supplements from the second trimester of pregnancy (12–27 weeks) until 1 year postpartum. The primary outcomes were (i) maternal HIV progression or death, (ii) small-for-gestational-age (SGA) live births (z-score < −2). We also examined the effect of vitamin D₃ supplementation on secondary maternal and infant health outcomes, maternal and infant serum 25-hydroxyvitamin D (25[OH]D) concentrations, and maternal hypercalcemia. An intent-to-treat analysis was used as the primary analytic approach. We enrolled 2,300 pregnant women between June 15, 2015, and April 17, 2018, and follow-up of mothers and infants was completed on October 20, 2019. There were 1,148 pregnant women randomly assigned to the vitamin D₃ group, and 1,152 to the placebo group. The proportion of mothers lost to follow-up at 1 year postpartum was 6.6% in the vitamin D₃ group (83 of 1,148) and 6.6% in the placebo group (76 of 1,152). The proportion of children lost to follow-up at 1 year of age was 5.5% in the vitamin D₃ group (59 of 1,074 live births) and 5.2% in the placebo group (57 of 1,093 live births). There was no difference in the risk of maternal HIV progression or death, with 166 events during 1,461 person-years of follow-up in the vitamin D₃ group and 141 events during 1,469 person-years of follow-up in the placebo group (hazard ratio 1.21, 95% CI 0.97 to 1.52, p = 0.09). There was no difference in the risk of SGA birth between the vitamin D₃ (229 SGA births among 1,070 live births) and placebo groups (236 SGA births among 1,091 live births) (relative risk 1.03, 95% CI 0.87 to 1.22, p = 0.70). There was also no difference in the risk of infant stunting at 1 year of age between the vitamin D₃ (407 events among 867 infants) and placebo groups (413 events among 873 infants) (relative risk 1.00, 95% CI 0.92 to 1.10, p = 0.95). In terms of adverse events, no cases of maternal hypercalcemia were identified. One hypersensitivity reaction to the trial supplements occurred for a pregnant woman in the placebo group. A limitation of our study is that our findings may not be generalizable to HIV-negative pregnant women or contexts where severe vitamin D deficiency is prevalent. Conclusions: The trial findings do not support routine vitamin D supplementation for pregnant and lactating women living with HIV in Tanzania. Trial registration: ClinicalTrials.gov Identifier: NCT02305927.

Willingness and ability to pay for insurance that would cover primary healthcare services has not been evaluated consistently in different African communities. We conducted a cross-sectional community health survey and examined willingness and ability to pay in 3676 adults in seven communities in four countries: Nigeria, Tanzania, Uganda and Kenya. We used an open-ended contingency valuation method to estimate willingness to pay and examined ability to pay indirectly by calculating the ratio of healthcare expenditure to total household income. Slightly more than three quarters (78.8%) of participants were willing to pay for a health insurance scheme, and just a little above half (54.7%) were willing to pay for all household members. Across sites, median amount willing to pay was $2 per person per month. A little above half (57.6%) of households in Nigeria were able to pay the premium. The main predictors of likelihood of being unwilling to pay for the health insurance scheme were increasing age [aOR 0.99 (95% CI 0.98, 1.00)], being female [0.68 (0.51, 0.92], single [0.32 (0.21, 0.49)], unemployment [0.54 (0.34, 0.85)], being enrolled in another health insurance scheme [0.45 (0.28, 0.74)] and spending more on healthcare [1.00 (0.99, 1.00)]. But being widow [2.31 (1.30, 4.10)] and those with primary and secondary education [2.23 (1.54, 3.22)] had increased likelihood of being willing to pay for health insurance scheme. Retired respondents [adjusted mean difference $-3.79 (-7.56, -0.02)], those with primary or secondary education [$-3.05 (-5.42, -0.68)] and those with high healthcare expenditure [$0.02 (0.00, 0.04)] predicted amount willing to pay for health insurance scheme. The willingness to pay for health insurance scheme is high among the seven communities studied in East and West Africa with socio-demography, economic and healthcare cost as main predictive factors.

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.

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.