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Background Vaccine hesitancy has been recognized as an important barrier to timely vaccinations around the world, including in sub-Saharan Africa. In Tanzania, 1 in 4 children is not fully vaccinated. The objective of this mixed methods study was to describe and contextualize parental concerns towards vaccines in Tanzania. Methods Between 2016 and 2017, we conducted a cross-sectional survey ( n  = 134) and four focus group discussions (FGDs, n  = 38) with mothers of children under 2 years of age residing in Mtwara region in Southern Tanzania. The survey and FGDs assessed vaccination knowledge and concerns and barriers to timely vaccinations. Vaccination information was obtained from government-issued vaccination cards. Results In the cross-sectional survey, 72% of mothers reported missed or delayed receipt of vaccines for their child. Although vaccine coverage was high, timeliness of vaccinations was lower and varied by vaccine. Rural mothers reported more vaccine-related concerns compared to urban mothers; literacy and access to information were identified as key drivers of the difference. Mothers participating in FGDs indicated high perceived risk of vaccine-preventable illnesses, but expressed concerns related to poor geographic accessibility, unreliability of services, and missed opportunities for vaccinations resulting from provider efforts to minimize vaccine wastage. Conclusions Findings from our cross-sectional survey indicate the presence of vaccination delays and maternal concerns related to childhood vaccines in Tanzania. In FGDs, mothers raised issues related to convenience more often than issues related to vaccine confidence or complacency. Further research is necessary to understand how these issues may contribute to the emergence and persistence of vaccine hesitancy and to identify effective mitigation strategies.

Globally, those who live in rural areas experience significant barriers to accessing health care due to a maldistribution of health care providers. Those who live in rural areas in the Appalachian region of the United States face one of the worst shortages of health care providers despite experiencing more complex health needs compared to Americans in more affluent, urban areas. Prior research has failed to identify effective solutions to narrow the provider maldistribution, despite it being a policy focus for decades. More work is needed to better understand the complex, multidimensional process in which health care providers select jobs and how job, community, and providers’ intrapersonal characteristics influence job selection. This paper is a protocol for a study aimed at identifying effective policies and incentives to improve recruitment of healthcare providers for their first job in rural Appalachia. We will use rigorous, theoretically grounded discrete choice experiment methodology (DCE) to accomplish the study’s objective. The main outcome will be the relative importance of alternative community and job characteristics for trainees’ choices of jobs in rural Appalachia. secondary outcomes of interest will be trade-offs that these trainees make when selecting a job, described in the form of marginal rates of substitution (mRS). Participants include medical residents and fellows, PA students and NP students in their final year of training. The choice context will be the recruitment of these trainees for their first job. Data will be analyzed using mixed logit analysis. Results from this DCE will improve our understanding of the job selection process for health care providers. The identification and prioritization of predictors of trainees’ rural job choices will allow for the development of policies and incentives that will enable policymakers and health care systems to recruit more providers to rural and underserved areas.

Background Non-pharmacologic treatments such as physical therapy (PT) are advocated for musculoskeletal pain. Early access to PT through self-referral has been shown to decrease costs and improve outcomes. Although self-referral is permitted in most U.S. states and supported by some health insurance plans, patients’ utilization of self-referral remains low. Objective To identify factors, beyond legislative policies and health insurance, associated with patients’ decisions to access physical therapy through self-referral or provider-referral. Methods We recruited 26 females and 6 males whose employer-sponsored insurance benefits included financial incentives for self-referral to physical therapy. Between August 2017 and March 2018, participants completed semi-structured interviews about their beliefs about physical therapy and reasons for choosing self-referral (15 participants) or provider referral (17 participants) for accessing physical therapy. Grounded theory approach was employed to identify themes in the data. Results Patients selecting self-referral reported major thematic differences compared to the provider-referral patients including knowledge of the direct access program, attitudes and beliefs about physical therapy and pharmacologic treatment, and prior experiences with physical therapy. Self-referral patients were aware that their plan benefits included reduced cost for self-referral and felt confident in selecting that pathway. They also had negative beliefs about the effectiveness of pharmacological treatments and surgery, and previously had positive direct or indirect experiences with physical therapy. Conclusion Knowledge of the ability to self-refer, attitudes and beliefs about treatment, and prior experience with physical therapy were associated with self-referral to physical therapy. Interventions aimed at improving knowledge and changing attitudes toward self-referral to physical therapy to increase utilization appear warranted.

To maintain HIV care during the COVID-19 pandemic, many HIV clinics across the United States adopted telehealth. However, not everyone participated in telehealth equally. This study assessed the use and disparities in telehealth and in-person HIV care at a large academic medical center in North Carolina (NC) relative to the COVID-19 pandemic. Data from the Duke University Infectious Disease clinic in NC were extracted from electronic health records (EHR), aggregated across persons with HIV (PWH) by calendar month, visit type (in-person vs. telehealth HIV care), and by key sociodemographic and clinical characteristics. Variation in HIV care over time was analyzed graphically by age, sex, race and ethnicity, county of residence, and viral load (VL) history. EHR data from 2,623 PWH receiving care between January 2019 and March 2023 were included. Telehealth use sharply increased in the first months of the pandemic and decreased thereafter. Telehealth use was higher among non-Hispanic Whites compared to People of Color. Most PWH (93%) had a first post-onset-of-the-pandemic (pop) HIV care visit on March 16, 2020 and thereafter. The proportion of telehealth first pop visits peaked in April 2020 with 88% telehealth visits. Telehealth bridged the initial COVID-19 pandemic phase with drastically reduced in-person visit availability, yet it was not equally utilized across race and ethnicity groups. To guide the optimal integration of telehealth in HIV care and promote equitable care in the future, HIV care outcomes need to be closely monitored, and strategies designed to promote access for Communities of Color are needed.

Efforts to reduce Human Immunodeficiency Virus (HIV) transmission through treatment rely on HIV testing programs that are acceptable to broad populations. Yet, testing preferences among diverse at-risk populations in Sub-Saharan Africa are poorly understood. We fielded a population-based discrete choice experiment (DCE) to evaluate factors that influence HIV-testing preferences in a low-resource setting. Using formative work, a pilot study, and pretesting, we developed a DCE survey with five attributes: distance to testing, confidentiality, testing days (weekday vs. weekend), method for obtaining the sample for testing (blood from finger or arm, oral swab), and availability of HIV medications at the testing site. Cluster-randomization and Expanded Programme on Immunization (EPI) sampling methodology were used to enroll 486 community members, ages 18-49, in an urban setting in Northern Tanzania. Interviewer-assisted DCEs, presented to participants on iPads, were administered between September 2012 and February 2013. Nearly three of five males (58%) and 85% of females had previously tested for HIV; 20% of males and 37% of females had tested within the past year. In gender-specific mixed logit analyses, distance to testing was the most important attribute to respondents, followed by confidentiality and the method for obtaining the sample for the HIV test. Both unconditional assessments of preferences for each attribute and mixed logit analyses of DCE choice patterns suggest significant preference heterogeneity among participants. Preferences differed between males and females, between those who had previously tested for HIV and those who had never tested, and between those who tested in the past year and those who tested more than a year ago. The findings suggest potentially significant benefits from tailoring HIV testing interventions to match the preferences of specific populations, including males and females and those who have never tested for HIV.

Objectives. We examined associations between trust of health care providers and the government and health service use and outcomes. Methods. Interviews with a sample of 611 HIV-positive individuals included an attitudinal assessment measuring beliefs concerning the creation of AIDS, information being withheld about the disease, and trust of care providers. Results. Trust in care providers was associated with increased HIV-related out-patient clinic visits, fewer emergency room visits, increased use of antiretroviral medications, and improved reported physical and mental health. Trusting the government was associated with fewer emergency room visits and better mental and physical health. More than one quarter of the respondents believed that the government created AIDS to kill minorities, and more than half believed that a significant amount of information about AIDS is withheld from the public. Ten percent did not trust their provider to give them the best care possible. Conclusions. Distrust may be a barrier to service use and therefore to optimal health. Distrust is not isolated in minority communities but also exists among members of nonminority communities and equally interferes with their use of services and health outcomes.

Background Vaccination is a cost-effective strategy for reducing morbidity and mortality among children under 5 years old. To be fully protected from diseases such as tuberculosis, diphtheria, pertussis, and polio, children must receive all recommended vaccinations in a timely manner. In many countries, including Tanzania, high overall vaccination rates mask substantial regional variation in vaccination coverage and low rates of vaccination timeliness. This study evaluates the efficacy of mobile phone-based (mHealth) reminders and incentives for improving vaccination timeliness in the first year of life. Methods The study, conducted in Mtwara Region in Tanzania, includes 400 late-stage pregnant women enrolled from rural and urban health facilities and surrounding communities. The primary outcome is timeliness of vaccinations among their children at 6, 10, and 14 weeks after birth. Timeliness is defined as vaccination receipt within 28 days after the vaccination due date. The quasi-randomized controlled trial includes three arms: (1) standard of care (no reminders or incentives), (2) mobile phone-based reminders, and (3) mobile phone-based reminders and incentives in the form of conditional financial transfers. Assignment into study arms is based on scheduled vaccination dates. Reminder messages are sent to arms 2 and 3 participants via mobile phones 1 week and 1 day prior to each scheduled vaccination. For arm 3 participants, reminder messages offer an incentive that is provided in the form of a mobile phone airtime recharge voucher code for each timely vaccination. Vaccination dates are recorded via participant contact with an mHealth system, phone calls with mothers, and a review of government-issued vaccination cards during an end-line survey. Random effects logistic regression models will be used to estimate the effects of reminders and incentives on the timeliness of vaccinations. Discussion The results will inform implementation science research on the effectiveness of reminders and incentives as a means of improving vaccination timeliness. Trial registration ClinicalTrials.gov, NCT03252288 . Registered on 17 August 2017 (retrospectively registered).

Background In Tanzania, residential treatment centers for alcohol and other drugs, locally known as “sober houses,” play a critical role in the treatment of people living with a substance use disorder (SUD), but little is known about the services they offer and service users’ and providers’ perceptions of those services. We aimed to address these gaps in knowledge and to better understand where evidence-based interventions may be able to address gaps in service provision. Materials and methods This study used a mixed-methods approach across four sober houses in Dar es Salaam, Tanzania. We conducted 48 semi-structured interviews with a sub-sample of sober house service users ( n  = 38) and service providers ( n  = 10). Eighty-six (86) service users also completed a written survey to capture demographic information and assess knowledge of HIV and willingness to use HIV preventive care. All interviews were audio-recorded, translated into English, and then coded according to constructs developed with the Recovery Capital Framework. Following coding, a thematic analysis was conducted for the qualitative data using the framework developed by Braun and Clarke. Results Service users were generally positive about the treatment they were receiving but identified gaps in health service provision related to HIV, as well as a lack of preparation to address the employment-related challenges they face in the community after completing treatment. Service providers largely agreed with users’ perceptions of needs and identified a lack of clinical personnel in sober houses and funding challenges as barriers to meeting these needs. Conclusion Sober houses provide treatment services to Tanzanians with SUD that service users largely view as positive. This evaluation identified employment challenges after treatment completion and gaps related to HIV care in the sober house. Further research is needed to investigate how interventions can be adapted to the sober house setting to meet these needs.

Background Religion shapes everyday beliefs and activities, but few studies have examined its associations with attitudes about HIV. This exploratory study in Tanzania probed associations between religious beliefs and HIV stigma, disclosure, and attitudes toward antiretroviral (ARV) treatment. Methods A self-administered survey was distributed to a convenience sample of parishioners (n = 438) attending Catholic, Lutheran, and Pentecostal churches in both urban and rural areas. The survey included questions about religious beliefs, opinions about HIV, and knowledge and attitudes about ARVs. Multivariate logistic regression analysis was performed to assess how religion was associated with perceptions about HIV, HIV treatment, and people living with HIV/AIDS. Results Results indicate that shame-related HIV stigma is strongly associated with religious beliefs such as the belief that HIV is a punishment from God (p < 0.01) or that people living with HIV/AIDS (PLWHA) have not followed the Word of God (p < 0.001). Most participants (84.2%) said that they would disclose their HIV status to their pastor or congregation if they became infected. Although the majority of respondents (80.8%) believed that prayer could cure HIV, almost all (93.7%) said that they would begin ARV treatment if they became HIV-infected. The multivariate analysis found that respondents' hypothetical willingness to begin ARV treatme was not significantly associated with the belief that prayer could cure HIV or with other religious factors. Refusal of ARV treatment was instead correlated with lack of secondary schooling and lack of knowledge about ARVs. Conclusion The decision to start ARVs hinged primarily on education-level and knowledge about ARVs rather than on religious factors. Research results highlight the influence of religious beliefs on HIV-related stigma and willingness to disclose, and should help to inform HIV-education outreach for religious groups.

The global penetration of mobile phones has offered novel opportunities for communicating health-related information to individuals. A low-cost system that facilitates autonomous communication with individuals via mobile phones holds potential for expanding the reach of health messaging in settings with human resource and infrastructure limitations. We sought to design a flexible, low-code system using open-source software that could be adapted to different contexts and technical environments and accommodate a wide range of automation needs. We report on key details of the mobile phone-based appointment reminder and incentive system (mParis), document its use, review implementation challenges and adaptations to address these challenges in the context of a quasi-randomized trial of mobile phone-based reminders and incentives as means of increasing the timeliness of childhood vaccinations in Tanzania, and outline other use cases that highlight the versatility of the system. The mParis instance described in this paper, which is hosted in Tanzania, sent automated, individualized vaccination reminders in the form of SMS text messages to the mobile phones of mothers of young children. Process workflows, based on the national vaccination schedule of Tanzania, were programmed into mParis. Reminders for vaccinations due at ages 6, 10, and 14 weeks were sent 7 days and 1 day before and 14 days after each vaccination due date. A subset of messages included financial incentive offers to mothers for the timely vaccination of their children. We report on implementation outcomes, challenges, and adaptations to address these challenges. Between August and December 2017, a total of 412 pregnant women were enrolled in the trial. After mothers reported the birth of their children, individualized vaccination reminder messages were sent for vaccination due dates between January and July 2018. From March 2018, messages contained financial incentive offers. Of 1397 messages sent, 1122 (80.3%) messages were recorded as delivered, 249 (18.8%) as expired and resent; 23 (1.6%) as failed, and 3 (0.2%) as sent but lacking a delivery confirmation. In total, 633 (45.3%) messages contained incentive offers. Of 173 women who received at least 1 message, 67 (38.7%) were sent reminders only; 106 (61.3%) women were sent at least 1 incentivized message. Numerous challenges were encountered during the system's implementation, despite its deliberate design to accommodate basic problems, such as intermittent internet access and power failures. Continuous adaptation to increase the resilience of the system resulted in a successful deployment. mParis' open-source nature, auditability, and ability to autonomously execute algorithms in a low-resource setting with frequent infrastructure challenges suggest favorable prospects to automate health communication in a wide range of settings. mParis' use in other applications, including enrollment and follow-up for health-related research studies, demonstrates its versatility and ability to accommodate diverse challenges that may be encountered.