Doctoral Theses

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The involvement of men in maternity care in Dodoma region, Tanzania
(The University of Dodoma, 2015) Gibore, Nyasiro S
Men‘s involvement in maternity care has been recognized as one of the key strategies in improving maternal health and accelerating reduction of maternal mortality. Men impact women‘s reproductive health through their role as partners, fathers and close family providers in terms of financial power and decision control they have. Factors that determine men‘s involvement in maternity care have been documented in other parts of the globe, but very little research has been conducted in Tanzania to identify the factors that determine men‘s involvement in maternity care. This study was conducted in Dodoma Region in central Tanzania to explore the factors that determine the involvement of men in maternity care. The study also looked at the level of men‘s involvement in maternity care and the initiatives carried out by the community to promote their involvement. A cross-sectional survey using interviewer-administered structured questionnaire was conducted among randomly selected 966 men aged 18 years and above. The survey was complemented by 32 focus group discussions (16 women‘s FGDs and 16 men‘s FGDs) and 34 in-depth interviews (20 IDIs with community leaders and 14 IDIs with health care providers). The involvement of men in maternity care was measured using a combined measure of four (4) key points and then a factor analysis was used to obtain an overall men‘s involvement index. Analyses were carried out using SPSS version 21.0 and NVivo 8 computer software packages. Pearson Chi-Square was used to test association between the background characteristics of the respondents and the level of men‘s involvement in maternity care. A multinomial logistic regression analysis was carried out to determine the predictors for men‘s involvement in maternity care. Thematic Content Analysis of the focus-group discussions and in-depth interviews was also conducted. Overall, with regard to the level of men‘s involvement in maternity care about 20.3% of men had high level of involvement, 52.6% had moderate level of involvement and 27.1% had low level of involvement. With regard to the three periods of maternity care, antenatal and postnatal periods had over half the proportion of high men‘s involvement while the natal period had less than a quarter proportion of high men‘s involvement. Results of bivariate analysis showed a significant association with ethnicity (χ2=26.808, p<0.001), number of children (χ2=11.360, p<0.05), occupation (χ2=9.558, p<0.01), religion ((χ2=14.220, p<0.001), place of residence (χ2=8.290, p<0.05), distance to the health care unit (χ2=24.708, p<0.001), information regarding the involvement of men in maternal health care services (χ2=28.048, p<0.001) and spousal communication (χ2=69.621, p<0.001). Results of multinomial logistic regression analysis showed that ethnicity, number of children, place of residence, time spent to receive maternal health care service, distance to the health care facility, information regarding the involvement of men in maternal health care services and spousal communication were the predictors of men‘s involvement in maternity care. Qualitative study revealed that traditional gender role norms, beliefs and health care system issues were the barriers for men‘s involvement in maternity care. The study also found that at the community level, very few initiatives were taking place to encourage men‘s involvement in maternity care in terms of economic, social and cultural measures. This study concludes that the level of men‘s involvement in maternity care was moderate. Therefore, there is a need to increase men‘s involvement through creating male-friendly health facilities, increasing community awareness and sensitization on men‘s involvement in maternity care in order to remove the cultural barriers for men‘s involvement.
Prevalence of and risk factors for diabetes mellitus among adults in Dodoma region, Tanzania
(The University of Dodoma, 2015) Munyogwa, Mariam J
The prevalence of diabetes mellitus is increasing at an alarming rate in most places of the world. Tanzania is among sub-Saharan African countries with many people currently living with diabetes mellitus. Despite of that, information about diabetes and its associated risk factors are still scarce. The main objective of this study was to determine the prevalence of and risk factors for diabetes mellitus in Dodoma Region. The study was cross sectional design. Stratified sampling technique, simple random sampling and Kish Selection Table were used to select participants for the study. A total of 840 people agreed and participated in the study. Overall prevalence of DM was found to be 86 (11.8%) with majority of them 61 out of 86 (70.9%) being unaware of their condition. Unit increase in WC, WHtR, systolic B. P, triglycerides, age and living in urban areas were associated with the risk of developing DM. The prevalence of MetS was found to be 22.4% and 32.2% by using NCEP ATP-III and IDF criteria, respectively. Obesity, reduced HDL cholesterol and impaired fasting plasma glucose were highly prevalent components of metabolic syndrome. The current findings indicate that, there is high prevalence of diabetes and metabolic syndrome in Dodoma Region. Without appropriate interventions, the region will likely see an increasing risk of other chronic diseases. This might result into double burden of diseases due to the existence of chronic malnutrition in the region However, the presence of modifiable risk factors and high proportion of undiagnosed diabetes indicates an opportunity for prevention. Therefore, investments in preventive measures, screening services and increasing health education are highly needed to reduce the future burden.
Factors influencing utilization of maternal health care services among women in Dodoma region, Tanzania
(The University of Dodoma, 2015) Ngowi, Agatha F
This study examined the extent of maternal health care utilization and assessed factors influencing antenatal, delivery and postnatal care utilization among women in Dodoma Region. The study employed cross sectional study methods using both quantitative and qualitative methods. Structured questionnaires, focus group discussion guides and interview guide were used. Quantitative data analysis was done, using SPSS Version 21. The confidence interval of 95% was used to assess statistical significance of a P level of 0.05. Binary logistic regression model was applied to determine the significant associations between selected dependent and independent variables. Qualitative content analysis was done whereby Computer Assisted Qualitative Data Analysis (CAQDA) using NVIVO version 7 software packages aided in the sorting of the data The study revealed that 99.6% of respondents attended antenatal visits at least once during pregnancy and 68.1% respondents started antenatal visit in their second and third trimester of pregnancy. Regarding the place of delivery, 78.6% of respondents delivered at health facilities while 18.6% delivered at home and 2.6 % delivered while travelling to the health facility. About three quarter (72.5%) of respondents received postnatal care service at least once after delivery. The results from bivariate logistic regression analysis showed that factors such as age of respondents, number of children, cost of transport, distance to the health facility, perceived quality of health services, source of information and place of delivery were significant associated with maternal health care utilization during pregnancy, delivery and postnatal period (P<0.05). Qualitative finding also showed that perceived quality of health care, attitude towards health care providers, transport cost, unsupportive partners and traditional practices were among the factors hindering utilization of maternal health services. Again limited number of health facilities, health care providers and supplies of drugs and equipments also affect utilization of maternal health care services in the study area. In conclusion, maternal health care services among women in Dodoma Region were not adequately utilised. It is, therefore, recommended that the health care practitioners, policymakers, planners and other stakeholders should scale-up the existing programmes and interventions for maternal health. Strengthening health system functioning and clients- service providers relationship, effective community mobilization and improve policies surrounding maternal health services were identified as a possible solution. Designing effective programs should be base on the identified determinants for low utilization of maternal health care in the study area.
Influence of HIV serodiscordancy and concordancy on infected partners’ depression symptomatology, intimacy and relationship functioning in the southern highlands zone of Tanzania
(The University of Dodoma, 2017) Mwakalapuka, Amani Angumbwike
As treatment and health care related to HIV/AIDS improve, infected partners now have a chance to live longer than before, thus, HIV concordancy and discordancy have become quite common among partners in union. The infected partners, however, increasingly face emotional and psychosocial challenges associated with HIV infection. These challenges expose them to the risk of developing depression symptoms, declined intimacy and dysfunctional relationships, with considerable variations among concordant and discordant partners. This has resulted into marital separations and divorce, with negative implications on the partners' wellbeing and that of the family at large. The quantitative part of this study, sought to investigate the magnitude of HIV sero-discordancy and concordancy in the Southern Highlands Zone of Tanzania, and the influence that the two conditions have on infected couples’ emotional patterns, particularly, depression symptoms, intimate bond and relationship functioning. The qualitative part served to explore the dynamics and experiences of living in a discordant relationship, partners’ awareness and perceptions regarding protected sex. Using the mixed approach, 623 participants were recruited, among which, 537 respondents’ questionnaires were complete and admissible. Out of the 537, about 84 respondents were either no longer in union, or had no disclosure of serostatus with spouses: data from these were, thus, excluded in analyses of scaled measures. Finally, a sample of 343, including 153 male and 190 female partners was obtained and used in the quantitative research phase. In addition, 58 were randomly picked from those identified as being discordant and were enlisted in the qualitative research phase. Findings in this study revealed that 237 (69%) of the infected partners in union were HIV concordant, while 106 (31%) were discordant. Concordant female partners were 137 (72%), whereas, concordant male partners were 100 (65%). Severe depression was observed among 38 (16%) concordant and 22 (20.8%) discordant partners. Regarding sex, 20 (13.1%) of the males and 40 (21.1%) of the females experienced severe depression. Depression was significantly associated with sex (Wald χ2=6.551, p=0.011), age (Wald χ2=4.478, p=0.034), geographical area (Wald χ2=3.733, p=0.053), number of dependants/children (Wald χ2=6.136, p=0.013) and spouse's education (Wald χ2=5.348, p=0.021). Results also showed that intimate caring was significantly associated with the respondents' sex (Wald χ2 =4.171, p=0.041) and serodifference (Wald χ2=7.982, p=0.005). Relationship functioning among the partners was significantly associated with sex (Wald χ2=4.352, p=0.037) and serodifference (Wald χ2=7.175, p=0.007). The qualitative findings showed that financial dependence, serodifference, disclosure and counselling had a great influence on the partners' depressive feelings, perceptions of intimacy particularly among the females, and the partners' consistence in protected sex. It was therefore concluded that the infected partners' relationship functioning was partly influenced by emotional challenges, self-efficacy and access to both psychosocial and physical resources and serodifference. This calls for a broader HIV prevention framework that incorporates physical, psychosocial, emotional and financial aspects of couples in union, particularly, those who are in discordant relationships.
Effectiveness of simulation based training on knowledge, skills and attitude of nurses in managing maternal and newborn emergencies in primary health care settings in Dodoma region
(The University of Dodoma, 2019) Joho, Angelina Alphonce
Background: Incompetence of nurses in the prevention and management of postpartum hemorrhage, eclampsia and neonatal resuscitation may lead to severe complications and deaths for both mothers and babies. Simulation-based training on obstetric and neonatal emergencies management has demonstrated promising results. However, its impact has not been well documented particularly in low and middle income countries. Objective: The objective of this study was to determine the effectiveness of simulation based training on knowledge, skills, and attitude of nurses in managing maternal and newborn emergencies in primary health care settings in Dodoma region Methods: A Quasi experimental study was conducted in 39 primary health centers covering all districts of the Dodoma region. A total of 176 nurses working in maternal and neonatal units were randomly selected to participate in the study. Knowledge on postpartum hemorrhage (PPH), eclampsia and Helping Babies Breathe (HBB) were assessed using validated tools. At baseline binary logistic regression analysis was used to dertemine independent predictors of knowledge, skills and attitude. The paired samples t test was run to determine mean difference before and after intervention. Multiple linear regression models were constructed to adjust for possible confounders of change in knowledge, skills and attitude at six months after intervention. Results: At baseline mean (SD) knowledge scores for PPH, eclampsia and HBB was 10.041(± 2.161), 13.401(±2.658) and 12.954(±2.506) respectively. Changes in mean knowledge scores were observed; Immediately after the training; PPH vi (12.07±3.169), eclampsia (15.14 ±1.738) and HBB (14.70 ±1.738) respectively. Six months after the training; PPH (10.99 ±3.176), eclampsia (14.82±1.419) and HBB (14,13±1.174) respectively. All changes observed were statistically significant (P < 0.001). At baseline mean skills scores for PPH, eclampsia and HBB were 13.349 (±8.376), 9.081(±5.311) and 8.552(±5.055) respectively. Changes in mean skills scores were observed; Immediately after training; PPH (23.895±9.793), eclampsia (14.797±6.256) and HBB (14.715±4.382) respectively. Six months PPH (15.529±5.939), eclampsia (10.826±4.394) and HBB (13.895±5.355) respectively. Significant changes in attitude were observed. All changes observed were statistically significant (P = 0.001). Conclusions and recommendations. Simulation-based training resulted on an improvement of knowledge, skills and attitude. Future research should focus on its impact on maternal and neonatal outcome.
The Effectiveness of Community Based Continuous Training on improving birth preparedness, male involvement and maternal services utilization in Rukwa Tanzania
(The University of Dodoma, 2019) Moshi, Fabiola Vincent
Background: It is widely accepted that community-based interventions are vital strategies towards reduction of maternal and neonatal mortalities in developing countries. This study has aimed at finding the effectiveness of a Community-Based Continuous Training (CBCT) project, on improving birth preparedness, male involvement and maternal services utilization in rural Tanzania. Method: The quasi-experimental study design with control was adopted to determine the effectiveness of CBCT project. The study was conducted from June 2017 until March 2018. A multi-stage sampling technique was employed to obtain 561 couples. Pre-test and end-line information were collected using semi-structured questionnaires. The effectiveness of the intervention was determined by using independent t-test and paired t-test. The effect size was calculated using Cohen’s d. Linear and logistic regression models were used to test the predictors of change. Results: At the end-line, knowledge mean scores were significantly higher in the intervention group among both pregnant women and their male partners as compared to control group. The predictors of change in knowledge scores among pregnant women were the CBCT project (β=0.346, p<0.000) and the ethnic group [Mambwe (β=-0.524, p=0.001)] while male partners were the CBCT project (β=1.058, p<0.001) and the walking distance [more than five kilometers (β=-0.55, p< 0.05)]. The predictor of change in attitudes and subjective norms towards birth preparedness scores, was the CBCT project (β=0.065, p<0.05) and (β=0.112, p=0.001) respectively while in perceived behavior control towards male involvement were the vi intention to accompany (β=-0.099, p=0.001), ethnic group (others, β=-0.063, p<0.05) and the CBCT project (β=0.067, p<0.05). There was a significant increase in mean scores in birth preparedness and maternal services utilization among couples in the intervention group as compared to control group. The CBCT project significantly predicted birth preparedness ((AOR=2.138; p<0.001), male involvement (AOR=1.638; p<0.05) and maternal services utilization (AOR= 3.368; p<0.001). Conclusion: This project which focused on knowledge empowerment and behavior change among the couples was both feasible and effective on improving knowledge, attitudes and subjective norms towards birth preparedness, perceived behavior control towards male involvements, birth preparedness and maternal services utilization. The project has potential to make a positive impact on maternal and newborn health.
Implementation of direct health facility financing in public primary health facilities in Tanzania: effects on health system performance.
(The University of Dodoma, 2020) Kapologwe, Ntuli Angyelile
Tanzania, like many countries globally, has continuously been implementing health sector reforms with the intent of ensuring affordable health services to the population, in alignment with the shift towards Universal Health Coverage as well as improving the quality of health services, among these reforms has been the introduction of Direct Health Facility Financing (DHFF), which has limited evidence on its implementation and outcomes with respect to its intended goals. This study aimed to assess the implementation of DHFF in the Public Primary Health Facilities (PPHFs) as well as its effects on health system performance in Tanzania. This study was conducted from January 2018 to September 2019 utilized a before and after non-controlled study design with a process evaluation embedded at midline. Both quantitative and qualitative methods were used for data collection. A structured questionnaire was used to obtain the quantitative data from exiting patients, and health care workers in 42 PPHFs. Qualitative data was collected using an interview guide through 14 in depth interviews and seven focus group discussions to health managers at council level from 14 councils in seven regions. Quantitaive data analysis was done using SPSS™ version 25 while for qualitative NVIVO QSR™ version 12 was used. A total of 844 exiting patients were studied on seven domains of Health System Responsiveness (HSR) at baseline and endline. All but one domain (i.e. communication) of HSR were found to have positive significant difference between baseline and endline. Overall HSR improved significantly from 62.84% at baseline to 71.20% at end line (p<0.0001). In a multivariable logistic regression model, patients who were studied at the end line were four times more likely to have experienced positive responsiveness as compared to those at the baseline. Forty-two (42) PPHFs were studied based on structural quality of maternal health services (MHS). The majority (71%) of the facilities were within 10 kilometers of participants’ residences. Of note, the majority (88.9%) of dispensaries and 60% of health centers were below the required staffing level. There were significant differences on structural quality of MHS between baseline and endline (2.38% and 30.9% respectively). With respect to maternal health services utilization, 42 facilities were studied on nine maternal health service consumption indicators before and after the introduction of the DHFF initiative. There were significant differences in all indicators after DHFF introduction except those for intermittent presumptive treatment for malaria second dose, use of modern family planning methods, and mebendazole use. Of 238 health care providers who participated in the Fidelity of Implementation (FoI) component of the study, the majority (76%) had adequate knowledge on the DHFF implementation issues while only 28% had high Fidelity of Implementation (FoI scores. For health service providers working in the rural settings, training and knowledge on the DHFF and Facility Financial Accounting and Reporting System (FFARS) were significantly associated with high FoI. In the multiple logistic regression model, both positive HSR (AOR 3.4 [95%CI: 1.637, 7.064]), and high maternal health service utilization (AOR 40.971[95%CI: 4.065, 412.927]) were strongly associated with high structural quality of MHS. Health service providers indicated an improvement in both governance and accountability, especially in the areas of planning and budgeting, financial management and transparency, with the implementation of the DHFF. However, the majority of health care providers admitted to have not received adequate supportive supervision and mentorship. The providers also felt that this initiative added an additional burden to their routine work. In general, the DHFF have affected the health system, specifically on health system performance in Tanzania. FoI was low despite training being offered to health care providers, which indicates a need for more investment on this aspect in order to have a resilient health system. Improved governance and accountability have been positive outcome on DHFF implementation, which indicate the merits in ongoing efforts to invest on governance and accountability at PPHFs.
The effectiveness of integrated reproductive health lesson materials in a problem-based pedagogy on knowledge, soft skills, and sexual behaviours among adolescents in Tanzania
(The University of Dodoma, 2021) Millanzi, Walter Cleophace
The majority of adolescents are currently becoming sexually active before their 18th birthday, hence having to battle with unsafe sexual behaviours, teenage pregnancies, sexually transmitted infections (STIs), and school dropouts. This study designed and tested the effect of integrated reproductive health (RH) lesson materials in a problem-based pedagogy (PBP) to empower adolescents with sexual and reproductive health knowledge, and soft skills for safe sexual behaviours in Tanzania. A sequential mixed-method design was employed. Phenomenological design using the individualized in-depth interview collected qualitative information among 6 experts and 36 research trainers and analysed it using thematic analysis. A Clustered Randomized Controlled Trial (RCT) among 660 randomly selected adolescents and the interviewer-administered structured questionnaires adapted from previous studies were used to collect quantitative data and analysed using Statistical Analysis Software (SAS) version 9.4. Repeated measure Linear Mixed Model (LMM) was used to determine the effect of the interventions between research arms over time. The adolescents’ mean age was 15±1.869 and 57.5% of them were females. Qualitative findings indicated that there was a felt need of facilitating sexual and reproductive health (SRH) learning among adolescents using PBP. The adjusted coefficient of adolescents' SRH knowledge, soft skills, and self-reported sexual behaviours was significantly higher in the Hybrid PBP and pure PBP (β=2.4980, p<0.001) and (β=1.7868, p<0.001); (β=9.0986, p<0.001) and (β=8.7114, p<0.001) and (β=0.30; p<0.001) and (β =0.30, p<0.002) against the control group respectively. The integrated RH lesson materials in a PBP were valid and practical in facilitating SRH learning for adolescents. The Hybrid PBP and pure PBP demonstrated a more significant effect on adolescents’ SRH knowledge, soft skills, and self-reported safe sexual behaviours than pure PBP against the control group though, a Hybrid PBP was significantly effective than the pure PBP. Those wishing to intervene in SRH issues may need to consider integrated RH lesson materials in PBP as a pedagogical guide to teachers and or health workers in facilitating SRH learning among adolescents in Tanzania.

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