Experiences of Internalized and Enacted Stigma among Women with Obstetric Fistula in Tanzania

Background: Obstetric fistula is the development of a necrosis between the bladder and the vagina and/or the bladder and the rectum as a result of prolonged obstructed labor, resulting in urinary or fecal incontinence. In Tanzania surgical repair for obstetric fistula is provided freely by the government but it is estimated that there are over 25,000 women living with an untreated fistula. These women experience high degrees of psycho-social stresses exacerbated by the stigma surrounding their condition. There is a dire need to explore stigma within this population in order to better understand its impact, as stigma affects both treatment seeking behavior as well as long term recovery of those who access surgical repair.

Study Aims: This study aims to understand the experiences of stigma among women with obstetric fistulas by examining both internalized and enacted stigma, and by identifying pertinent correlates of internalized stigma.

Methods: This mixed-methods study utilized both quantitative and qualitative data collected in two related studies at a single hospital in Moshi, Tanzania. All study participants were women receiving surgical repair for an obstetric fistula. In the quantitative portion, cross-sectional survey data were collected from 52 patients. The primary outcome was fistula-related stigma, measured using an adaptation of the HASI-P stigma scale, which included constructs of both internalized and enacted stigma. In the qualitative portion, 45 patients participated in a semi-structured in-depth interview, which explored topics such as stressors caused by the fistula, coping mechanisms, and available support. The transcripts were analyzed using analytic memos and an iterative process of thematic coding using the framework of content analysis.

Results: Expressions of internalized stigma were common in the sample, with a median score of 2.1 on a scale of 0 – 3. Internalized was significantly correlated with negative religious coping, social participation, impact of incontinence and enacted stigma. Qualitative analysis was consistent and demonstrated widespread themes of shame and embarrassment. Experiences of enacted stigma were not as common (median score of 0), although some items, like those pertaining to mockery and blame, were endorsed by up to 25% of the study sample. Themes of anticipated stigma (isolation and non-disclosure due to the possibility of stigmatization) were also evident in the qualitative sample and may explain the low enacted stigma scores observed.

Conclusion: In this sample of women receiving surgical repair for an obstetric fistula, stigma was evident, with internalized stigma resulting in psychological impacts for patients. Experiences of both anticipated and enacted stigma were also observed. There is a need to explore interventions that would decrease stigma while also increasing support for these women, as stigma may be a barrier towards accessing surgical repair and reintegration following surgery.

Keywords: Tanzania, obstetric fistula, stigma, maternal health

Comparative Administrative Reform: The Rhetoric and Reality of the Civil Service Reform Programs in Uganda and Tanzania

Administrative reform is a challenging endeavor for both developed and developing countries alike. For developing countries, the challenge is greater because numerous reforms are implemented concurrently sometimes under conditions of resource scarcity and political instability. So far there is no consensus as to what makes some reforms succeed and others fail. The current study seeks to fill that gap by offering an empirical comparative analysis of the administrative reforms initiated in Uganda and Tanzania since the early 1990s. The purpose of the study is to explain the similarities and differences, and give reasons for the successes and failures of the reform programs in the two countries. It focuses on four major areas; the size of the civil service, pay reform, capacity building, and ethics and accountability. Data were collected via in-depth face to face interviews with 35 key government officials and the content analysis of various documents. The results indicate that the reforms generated initial substantial reduction in the size of the public services in both countries. In Uganda, the traditional civil service was reduced from 140,500 in 1990 to 41,730 in 2004; while in Tanzania Ministries, Departments, and Agencies were reduced by 25%. Pay reform has generated substantial increases in civil servants’ salaries in both countries but in Uganda, the government has not been able to abide by the pay strategy while in Tanzania the strategy guides the increments. Civil Service capacity building efforts have focused on enhancing the skills of the personnel. Training needs assessments were undertaken in all ministries in Uganda and a training policy was formulated. In Tanzania, the training needs assessments are still under way and a training policy has not yet been developed. Ethics and accountability are great challenges in both countries, but in Tanzania, there is more political will and commitment to improve the integrity of the civil service. The findings reveal that although Uganda started the reform with much more rigor and initial success, Tanzania has surpassed it and has a more stable, consistent, and promising reform record. This is because Uganda’s leadership lacks political legitimacy. The country has since the late 1990s experienced a civil war in the northern and western parts of the country while Tanzania has benefitted from relative peace and high level political legitimacy.

Randomized Trial for a Mobile Health Approach to Increase Uptake of Cervical Cancer Screening in Tanzania

Background: Largely due to low availability and uptake of screening in low- and middle-income countries, cervical cancer is the second ranked cancer among women in these countries. This is a tragedy because cervical cancer is one of the most preventable carcinomas. This thesis will investigate behaviour change methods, which capitalize on the recent exponential increase in ownership of mobile phones in Tanzania, to increase uptake of cervical cancer screening (CCS) in the Kilimanjaro region of Tanzania. Objectives: 1) To evaluate the effectiveness of behaviour change messages delivered via short message service (SMS) on the uptake of CCS in the Kilimanjaro region; 2) to evaluate the effectiveness of a transportation eVoucher on the uptake of CCS in the Kilimanjaro region; 3) to explore characteristics associated with CCS uptake in the Kilimanjaro region; and 4) to determine the attitudes towards and perceived benefit of behaviour change SMS messages and eVouchers intended to increase uptake of CCS. Methods: In the Kilimanjaro Region, 853 women participated in a randomized controlled trial. Baseline data was collected through self-report through systematic stratified random sampling. Participants were randomized to one of three groups: a control group, a group receiving behaviour change messages delivered via SMS, or a group receiving a travel eVoucher and identical SMS as the SMS group. A fieldworker recorded participants attending screening at the CCS clinics and administered a post-screening survey. The follow-up period was two months from the time of the participant’s enrolment. Logistic regression (both for the combined and stratified data sets) was used to determine associations between the behaviour change interventions, baseline characteristics and cervical cancer screening uptake. Results: All participants receiving SMS messages (SMS or eVoucher group) were more likely to attend cervical cancer screening in comparison with the control group. 83% of participants who attended screening shared the information contained in the messages with others. Conclusions: Behaviour change messages delivered via SMS and transportation eVouchers have the potential to increase uptake of cervical cancer screening in the Kilimanjaro region of Tanzania. Harnessing this potential will require implementing these interventions alongside other methods to achieve maximum impact.

Determination of multi-mycotoxin occurrence in maize based porridges from selected regions of Tanzania by liquid chromatography tandem mass spectrometry (LC-MS/MS), a longitudinal study

Residents of certain areas of Tanzania are exposed to mycotoxins through the consumption of contaminated maize based foods. In this study, 101 maize based porridge samples were collected from villages of Nyabula, Kikelelwa and Kigwa located in different agro-ecological zones of Tanzania. The samples were collected at three time points (time point 1, during maize harvest; time point 2, 6 months after harvest; time point 3, 12 months after harvest) over a 1-year period. Ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) was used to detect and quantify 9 mycotoxins: aflatoxin B1 (AFB1), aflatoxin B2 (AFB2), aflatoxin G1 (AFG1), aflatoxin G2 (AFG2), fumonisin B1 (FB1), fumonisin B2 (FB2), deoxynivalenol (DON), ochratoxin A (OTA) and zearaleneone (ZEN) in the samples following a QuEChERS extraction method. Eighty two percent of samples were co-contaminated with more than one group of mycotoxins. Fumonisins (FB1 + FB2) had the highest percentage occurrence in all 101 samples (100%) whereas OTA had the lowest (5%). For all three villages the mean concentration of FB1 was lowest in samples taken from time point 2. Conversely, In Kigwa village there was a distinct trend that AFB1 mean concentration was highest in samples taken from time point 2. DON concentration did not differ greatly between time points but the percentage occurrence varied between villages, most notably in Kigwa where 0% of samples tested positive. ZEN occurrence and mean concentration was highest in Kikelelwa. The results suggest that mycotoxin contamination in maize can vary based on season and agro-ecological zones. The high occurrence of multiple mycotoxins found in maize porridge, a common weaning food in Tanzania, presents a potential increase in the risk of exposure and significant health implications in children.

From local scenarios to national maps: a participatory framework for envisioning the future of Tanzania

Tackling societal and environmental challenges requires new approaches that connect top-down global oversight with bottom-up subnational knowledge. We present a novel framework for participatory development of spatially explicit scenarios at national scale that model socioeconomic and environmental dynamics by reconciling local stakeholder perspectives and national spatial data. We illustrate results generated by this approach and evaluate its potential to contribute to a greater understanding of the relationship between development pathways and sustainability. Using the lens of land use and land cover changes, and engaging 240 stakeholders representing subnational (seven forest management zones) and the national level, we applied the framework to assess alternative development strategies in the Tanzania mainland to the year 2025, under either a business as usual or a green development scenario. In the business as usual scenario, no productivity gain is expected, cultivated land expands by ~ 2% per year (up to 88,808 km²), with large impacts on woodlands and wetlands. Despite legal protection, encroachment of natural forest occurs along reserve borders. Additional wood demand leads to degradation, i.e., loss of tree cover and biomass, up to 80,426 km² of wooded land. The alternative green economy scenario envisages decreasing degradation and deforestation with increasing productivity (+10%) and implementation of payment for ecosystem service schemes. In this scenario, cropland expands by 44,132 km² and the additional degradation is limited to 35,778 km². This scenario development framework captures perspectives and knowledge across a diverse range of stakeholders and regions. Although further effort is required to extend its applicability, improve users’ equity, and reduce costs the resulting spatial outputs can be used to inform national level planning and policy implementation associated with sustainable development, especially the REDD+ climate mitigation strategy.

Tanzania: learning, sharing, acting

A workshop held at the coastal town of Bagamoyo during 17—18 August 2015 addressed the role of the SSF Guidelines in meeting the challenges of coastal communities in Tanzania.

Perceptions of climate change, environmental variability and the role of agricultural adaptation strategies by small-scale farmers in Africa: the case of Mwanga district in Northern Tanzania

Abstract The potential impacts of climate change and environmental variability are already evident in most parts of the world, which is witnessing increasing temperature rates and prolonged flood or drought conditions that affect agriculture activities and nature-dependent livelihoods. This study was conducted in Mwanga District in the Kilimanjaro region of Tanzania to assess the nature and impacts of climate change and environmental variability on agriculture-dependent livelihoods and the adaptation strategies adopted by small-scale rural farmers. To attain its objective, the study employed a mixed methods approach in which both qualitative and quantitative techniques were used. The study shows that farmers are highly aware of their local environment and are conscious of the ways environmental changes affect their livelihoods. Farmers perceived that changes in climatic variables such as rainfall and temperature had occurred in their area over the period of three decades, and associated these changes with climate change and environmental variability. Farmers’ perceptions were confirmed by the evidence from rainfall and temperature data obtained from local and national weather stations, which showed that temperature and rainfall in the study area had become more variable over the past three decades. Farmers’ knowledge and perceptions of climate change vary depending on the location, age and gender of the respondents. The findings show that the farmers have limited understanding of the causes of climatic conditions and environmental variability, as some respondents associated climate change and environmental variability with social, cultural and religious factors. This study suggests that, despite the changing climatic conditions and environmental variability, farmers have developed and implemented a number of agriculture adaptation strategies that enable them to reduce their vulnerability to the changing conditions. The findings show that agriculture adaptation strategies employ both planned and autonomous adaptation strategies. However, the study shows that increasing drought conditions, rainfall variability, declining soil fertility and use of cheap farming technology are among the challenges that limit effective implementation of agriculture adaptation strategies. This study recommends further research on the varieties of drought-resilient crops, the development of small-scale irrigation schemes to reduce dependence on rain-fed agriculture, and the improvement of crop production in a given plot of land. In respect of the development of adaptation strategies, the study recommends the involvement of the local farmers and consideration of their knowledge and experience in the farming activities as well as the conditions of their local environment. Thus, the findings of this study may be helpful at various levels of decision making with regard to the development of climate change and environmental variability policies and strategies towards reducing farmers’ vulnerability to current and expected future changes.

Adaptability, Transformation and Complex Changes in Namibia and Tanzania: Resilience and Innovation System Development in Local Communities

This thesis is a research about the recent complex spatial changes in Namibia and Tanzania and local communities’ capacity to cope with, adapt to and transform the unpredictability engaged to these processes. I scrutinise the concept of resilience and its potential application to explaining the development of local communities in Southern Africa when facing various social, economic and environmental changes. My research is based on three distinct but overlapping research questions: what are the main spatial changes and their impact on the study areas in Namibia and Tanzania? What are the adaptation, transformation and resilience processes of the studied local communities in Namibia and Tanzania? How are innovation systems developed, and what is their impact on the resilience of the studied local communities in Namibia and Tanzania? I use four ethnographic case studies concerning environmental change, global tourism and innovation system development in Namibia and Tanzania, as well as mixed-methodological approaches, to study these issues. The results of my empirical investigation demonstrate that the spatial changes in the localities within Namibia and Tanzania are unique, loose assemblages, a result of the complex, multisided, relational and evolutional development of human and non-human elements that do not necessarily have linear causalities. Several changes co-exist and are interconnected though uncertain and unstructured and, together with the multiple stressors related to poverty, have made communities more vulnerable to different changes. The communities’ adaptation and transformation measures have been mostly reactive, based on contingency and post hoc learning. Despite various anticipation techniques, coping measures, adaptive learning and self-organisation processes occurring in the localities, the local communities are constrained by their uneven power relationships within the larger assemblages. Thus, communities’ own opportunities to increase their resilience are limited without changing the relations in these multiform entities. Therefore, larger cooperation models are needed, like an innovation system, based on the interactions of different actors to foster cooperation, which require collaboration among and input from a diverse set of stakeholders to combine different sources of knowledge, innovation and learning. Accordingly, both Namibia and Tanzania are developing an innovation system as their key policy to foster transformation towards knowledge-based societies. Finally, the development of an innovation system needs novel bottom-up approaches to increase the resilience of local communities and embed it into local communities. Therefore, innovation policies in Namibia have emphasised the role of indigenous knowledge, and Tanzania has established the Living Lab network.

Leptospirosis in northern Tanzania: exploring the role of rodents and ruminant livestock in a neglected public health problem

Leptospirosis is an important but neglected zoonotic disease that is often overlooked in Africa. Although comprehensive data on the incidence of human disease are lacking, robust evidence of infection has been demonstrated in people and animals from all regions of the continent. However, to date, there are few examples of direct epidemiological linkages between human disease and animal infection. In East Africa, awareness of the importance of human leptospirosis as a cause of non-malarial febrile illness is growing. In northern Tanzania, acute leptospirosis has been diagnosed in 9% of patients with severe febrile illness compared to only 2% with malaria. However, little is known about the relative importance of different potential animal hosts as sources of human infection in this area. This project was established to investigate the roles of rodents and ruminant livestock, important hosts of Leptospira in other settings, in the epidemiology of leptospirosis in northern Tanzania. A cross-sectional survey of rodents living in and around human settlements was performed alongside an abattoir survey of ruminant livestock. Unusual patterns of animal infection were detected by real-time PCR detection. Renal Leptospira infection was absent from rodents but was detected in cattle from several geographic areas. Infection was demonstrated for the first time in small ruminants sub-Saharan Africa. Two major Leptospira species and a novel Leptospira genotype were detected in livestock. L. borgpetersenii was seen only in cattle but L. kirschneri infection was detected in multiple livestock species (cattle, sheep and goats), suggesting that at least two distinct patterns of Leptospira infection occur in livestock in northern Tanzania. Analysis of samples from acute leptospirosis in febrile human patients could not detect Leptospira DNA by real-time PCR but identified social and behavioural factors that may limit the utility of acute-phase diagnostic tests in this community. Analysis of serological data revealed considerable overlap between serogroups detected in cattle and human leptospirosis cases. Human disease was most commonly attributed to the serogroups Mini and Australis, which were also predominant reactive serogroups in cattle. Collectively, the results of this study led to the hypothesis that livestock are an important reservoir of Leptospira infection for people in northern Tanzania. These results also challenge our understanding of the relationship between Leptospira and common invasive rodent species, which do not appear to maintain infection in this setting. Livestock Leptospira infection has substantial potential to affect the well-being of people in East Africa, through direct transmission of infection or through indirect effects on food production and economic security. Further research is needed to quantify the impact of livestock leptospirosis in Africa and to develop effective interventions for the control of human and animal disease.

Between Stimulation and Overwhelming: Reflections on the Usage of Videos for Teacher Training in Tanzania

The article reflects on a pilot teacher training programme in Tanzania, where videos are used for implementing new teaching methods, but also for initiating a discourse about corporal punishment. The culture of instruction in Tanzania is strictly based on a teacher-centred approach which leaves all activity to the teacher and turns students into passive listeners. In most cases, teachers deal with up to 80 students in one classroom. Therefore, discipline is an important matter of instruction and many teachers still use corporal punishment that is widely accepted in Tanzania. The launched training programme has the aim of implementing learner-centred teaching methods without using corporal punishment and offers Tanzanian teachers the possibility to participate in a workshop that connects these methods with subject-related topics. In the English teaching workshop, the facilitator used filmed English lessons from a German school to discuss with the participants both the application of learner-centred methods and the absence of corporal punishment. The use of these German videos shows advantages but also limitations that are strongly related to the European versus African setting. The article discusses these dimensions on the basis of data that are generated by ethnographical observation and audiotranscripts of the piloted workshop.

Exclusive breastfeeding practices in the Coast region, Tanzania.

Background: Although breastfeeding in general is common and culturally accepted in many sub-Saharan countries, recommended exclusive breastfeeding infants to 6 months is rare. In rural Tanzania, data on infant feeding practices is rare. Objective: To examine and describe exclusive breastfeeding practices in rural settings (Coast Region) of Tanzania. Methods: A cross-sectional study was conducted in Coast Region of Tanzania involving 342 mothers. Only mothers with children aged between 6 and 23 months were interviewed in their residences. Data analyses included descriptive and logistic regression analyses. Results: The majority, 66%, of mothers reported to have breastfed their new born within the first hour of life. About 30% reported to have breastfed exclusively for up to at least six months. Those who did not practice complete exclusive breastfeeding mentioned insufficient milk as the main reason. Correlates of exclusive breastfeeding included maternal education and attitudes towards exclusive breastfeeding. Conclusion: The rate of exclusive breastfeeding in rural areas like the Coast Region of Tanzania is still very low. Programs aimed to promote exclusive breastfeeding must take multi-factorial considerations.

Knowledge of pre-eclampsia in women living in Makole Ward, Dodoma, Tanzania.

Background: Pre-eclampsia is a hypertensive disorder specific to pregnancy responsible for significant maternal morbidity and mortality in Africa. The majority of deaths related to pre-eclampsia could be avoided with timely and effective care. “Phase one delays” arise because of lack of knowledge. Objectives: This study aimed to assess the knowledge levels of women living in Makole ward, comparing respondent subgroups with different demographic characteristics. It also aimed to compare knowledge levels in respect to six subtopics of pre-eclampsia. This was to allow for planning of appropriate activities to reduce delays in seeking health care. Methods: This study surveyed 200 adult women randomly identified in the community. They were asked 36 questions on preeclampsia requiring yes / no answers. The data was analysed quantitatively. Results: Overall knowledge levels were low with an average of 41% of correct answers. Minor differences in the knowledge levels of demographic subgroups were found. Statistically significant differences were identified between sub-topics of preeclampsia; signs and symptoms were the least well known. Conclusion: Educational systems (formal and informal) are failing to provide communities with potentially life-saving information. Health centre, community and school based education programmes are recommended.

On the way to universal coverage of maternal services in Iringa rural District in Tanzania. Who is yet to be reached?

Background: Strategies to tackle maternal mortality in sub-Saharan Africa include expanding coverage of reproductive services.Even where high, more vulnerable women may not access services. No data is available on high coverage determinants. We investigated this in Tanzania in a predicted high utilization area. Methods: Data was collected through a household survey of 464 women with a recent delivery. Primary outcomes were facility delivery and ≥4 ANC visits. Determinants were analysed using multivariate regression. Results: Almost all women had attended ANC, though only 58.3% had ≥4 visits. ≥4 visits were more likely in the youngest age group (OR 2.7 95% CI 1.32–5.49, p=0.008), and in early ANC attenders (OR 3.2 95% CI 2.04–4.90, p<0.001). Facility delivery was greater than expected (87.7%), more likely in more educated women (OR 2.7 95% CI 1.50–4.75, p=0.002), in those within 5 kilometers of a facility (OR 3.2 95% CI 1.59–6.48, p=0.002), and for early ANC attenders (OR 2.4 95% CI 1.20–4.91, p=0.02). Conclusion: Rural contexts can achieve high facility delivery coverage. Based on our findings, strategies to reach women yet unserved should include promotion of early ANC start particularly for the less educated, and improvement of distant communities' access to facilities.

Sero-prevalence and associated factors of Helicobacter pylori infection among adult patients with dyspepsia attending the gastroenterology unit in a tertiary hospital in Mwanza, Tanzania.

Background: Prevalence of H. pylori infection varies greatly between populations in different countries. This study was conducted to determine the magnitude of H.pylori among adult patients with dyspepsia attending the gastroenterology unit at Bugando medical centre. Methods: A cross sectional study involving 202 dyspeptic patients was conducted between June and July 2014. A Standardized data collection tool was used to collect socio-demographic characteristics. H.pylori antibodies were detected using rapid immunochromatographic tests according to manufacturer’s instructions. Results: The median age of study population was 42 (IQR: 33-54). Females 105 (51.9%) formed majority of the population studied. Of 202 participants; 119 (58.9%) were from rural areas. Seroprevalence of H.pylori infection was found to be 79/202 (39.1%, 95% CI: 32.3 -45.7). As the age increased the risk of having H.pylori infection also increased (OR: 1.02 95% CI: 1-1.04, P=0.02). On multivariate logistic regression analysis untreated drinking water was found to predict H.pylori seropositivity (OR: 2.33, CI: 1.09-4.96, p=0.028). Conclusion: The seroprevalence of H.pylori among dyspeptic patients is high in this setting. Therefore the community in Mwanza should be educated on the use of safe drinking water in order to minimize H. pylori infections.

Transient hyperglycemia in patients with tuberculosis in Tanzania: implications for diabetes screening algorithms.

BACKGROUND: Diabetes mellitus (DM) increases tuberculosis risk while tuberculosis, as an infectious disease, leads to hyperglycemia. We compared hyperglycemia screening strategies in controls and patients with tuberculosis in Dar es Salaam, Tanzania. METHODS: Consecutive adults with tuberculosis and sex- and age-matched volunteers were included in a case-control study between July 2012 and June 2014. All underwent DM screening tests (fasting capillary glucose [FCG] level, 2-hour CG [2-hCG] level, and glycated hemoglobin A1c [HbA1c] level) at enrollment, and cases were tested again after receipt of tuberculosis treatment. Association of tuberculosis and its outcome with hyperglycemia was assessed using logistic regression analysis adjusted for sex, age, body mass index, human immunodeficiency virus infection status, and socioeconomic status. Patients with tuberculosis and newly diagnosed DM were not treated for hyperglycemia. RESULTS: At enrollment, DM prevalence was significantly higher among patients with tuberculosis (n = 539; FCG level > 7 mmol/L, 4.5% of patients, 2-hCG level > 11 mmol/L, 6.8%; and HbA1c level > 6.5%, 9.3%), compared with controls (n = 496; 1.2%, 3.1%, and 2.2%, respectively). The association between hyperglycemia and tuberculosis disappeared after tuberculosis treatment (adjusted odds ratio [aOR] for the FCG level: 9.6 [95% confidence interval {CI}, 3.7-24.7] at enrollment vs 2.4 [95% CI, .7-8.7] at follow-up; aOR for the 2-hCG level: 6.6 [95% CI, 4.0-11.1] vs 1.6 [95% CI, .8-2.9]; and aOR for the HbA1c level, 4.2 [95% CI, 2.9-6.0] vs 1.4 [95% CI, .9-2.0]). Hyperglycemia, based on the FCG level, at enrollment was associated with tuberculosis treatment failure or death (aOR, 3.3; 95% CI, 1.2-9.3). CONCLUSIONS: Transient hyperglycemia is frequent during tuberculosis, and DM needs confirmation after tuberculosis treatment. Performance of DM screening at tuberculosis diagnosis gives the opportunity to detect patients at risk of adverse outcome.