BackgroundAn often-used tool to measure adherence to antiretroviral therapy (ART) is the Medication Event Monitoring System (MEMS), an electronic pill-cap that registers date and time of pill-bottle openings. Despite its strengths, MEMS-data can be compromised by inaccurate use and acceptability problems due to its design. These barriers remain, however, to be investigated in resource-limited settings. We evaluated the feasibility and acceptability of using MEMS-caps to monitor adherence among HIV-infected patients attending a rural clinic in Tanzania's Kilimanjaro Region.MethodsEligible patients were approached and asked to use the MEMS-caps for three consecutive months. Thereafter, qualitative, in-depth interviews about the use of MEMS were conducted with the patients. MEMS-data were used to corroborate the interview results.ResultsTwenty-three of the 24 patients approached agreed to participate. Apart from MEMS-use on travel occasions, patients reported no barriers regarding MEMS-use. Unexpectedly, the MEMS-bottle design reduced the patients' fear for HIV-status disclosure. Patients indicated that having their behavior monitored motivated them to adhere better. MEMS-data showed that most patients had high levels of adherence and there were no bottle-openings that could not be accounted for by medication intake. Non-adherence in the days prior to clinic visits was common and due to the clinic dispensing too few pills.ConclusionMEMS-bottle use was readily accepted by patients. Although the MEMS-bottle was used accurately by most patients, patients need to be more explicitly instructed to continue MEMS-use when travelling. Even HIV-clinics with sufficient staff and free medication may impose structural adherence barriers by supplying an insufficient amount of pills.

BackgroundStrengthening the communication and professional relationships between clinicians and laboratory workers is essential in order to positively change clinicians’ attitudes about the reliability of diagnostic tests, enhancing the use of laboratory diagnostics and, ultimately, improving patient care. We developed an analytical framework to gain insight into the factors that influence communication amongst health professionals.ObjectiveTo explore whether the interaction between clinicians and laboratory workers influences the use of laboratory test results in clinical decision making.MethodsFour health facilities in northern Tanzania were selected using convenience sampling, whereas study participants were selected using purposive sampling. The quantitative and qualitative data collection methods included self-administered questionnaires; semi-structured, individual interviews; in-depth, individual interviews; and/or focus group discussions with clinicians and laboratory workers. Thematic content analyses were performed on qualitative data based on the framework. Descriptive statistical analyses of quantitative data were conducted using Microsoft Excel.ResultsContact between clinicians and laboratory professionals is seldom institutionalised and collaboration is rare. The clinicians believe collaboration with laboratory staff is a challenge because of the gap in education levels. Laboratory workers’ education levels are often lower than their positions require, leading to clinicians’ lack of respect for and confidence in laboratory professionals, which compromises the laboratory staff’s motivation.ConclusionsHospital managers, clinicians and laboratory workers need to recognise the critical and complementary roles each professional plays and the importance of addressing the gap between them. Field application of the framework proved successful, justifying the expansion of this study to a larger geographical area to include additional healthcare institutions.

Background The current Coronavirus disease pandemic reveals political and structural inequities of the world’s poorest people who have little or no access to health care and yet the largest burdens of poor health. This is in parallel to a more persistent but silent global health crisis, antimicrobial resistance (AMR). We explore the fundamental challenges of health care in humans and animals in relation to AMR in Tanzania. Methods We conducted 57 individual interviews and focus groups with providers and patients in high, middle and lower tier health care facilities and communities across three regions of Tanzania between April 2019 and February 2020. We covered topics from health infrastructure and prescribing practices to health communication and patient experiences. Results Three interconnected themes emerged about systemic issues impacting health. First, there are challenges around infrastructure and availability of vital resources such as healthcare staff and supplies. Second, health outcomes are predicated on patient and provider access to services as well as social determinants of health. Third, health communication is critical in defining trusted sources of information, and narratives of blame emerge around health outcomes with the onus of responsibility for action falling on individuals. Conclusion Entanglements between infrastructure, access and communication exist while constraints in the health system lead to poor health outcomes even in ‘normal’ circumstances. These are likely to be relevant across the globe and highly topical for addressing pressing global health challenges. Redressing structural health inequities can better equip countries and their citizens to not only face pandemics but also day-to-day health challenges.

Infectious diseases are a leading cause of mortality in low-and middle-income countries (LMICs) despite effective treatments. To study the sociocultural and health system barriers to care, we conducted a qualitative social autopsy study of patients who died from febrile illness in northern Tanzania. From December 2016 through July 2017, we conducted in-depth interviews in Arusha and Kilimanjaro regions with a purposive sample of 20 family members of patients who had died at two regional referral hospitals. Of the deceased patients included in this study, 14 (70%) were adults and 10 (50%) were female. Patients identified their religion as Catholic (12, 60%), Lutheran (six, 30%), and Muslim (two, 10%), and their ethnicity as Chagga (14, 70%) and Sambaa (two, 10%), among others. Family members reported both barriers to and facilitators of receiving health care. Barriers included a perceived lack of capacity of local health facilities, transportation barriers, and a lack of formal referrals to higher levels of care. Family members also reported the cost of health care as a barrier. However, one facilitator of care was access to financial resources via families' social networks-a phenomenon we refer to as social capital. Another facilitator of care was families' proactive engagement with the health system. Our results suggest that further investment in lower level health facilities may improve care-seeking and referral patterns and that future research into the role of social capital is needed to fully understand the effect of socioeconomic factors on healthcare utilization in LMICs.

ObjectivesEarly diagnosis and timely treatment are key elements of a successful healthcare system. We assessed the role of socioeconomic and cultural norms in accelerating or decelerating uptake and utilisation of health technologies into policy and practice.SettingSecondary and tertiary level healthcare facilities (HCFs) in three East African countries. Level of HCF was selected based on the WHO recommendation for implantation of tuberculosis (TB) molecular diagnostics.ParticipantsUsing implementation of TB diagnostics as a model, we purposively selected participants (TB patients, carers, survivors, healthcare practitioners, community members, opinion leaders and policy-makers) based on their role as stakeholders. In-depth interviews, key informant interviews and focus group discussions were held to collect the data between 2016 and 2018. The data were transcribed, translated, coded and analysed by thematic-content analysis.ResultsA total of 712 individuals participated in the study. Socioeconomic and cultural factors such as poverty, stigma and inadequate knowledge about causes of disease and available remedies, cultural beliefs were associated with low access and utilisation of diagnostic and treatment tools for TB. Poverty made people hesitate to seek formal healthcare resulting in delayed diagnosis and resorting to self-medication and cheap herbal alternatives. Fear of stigma made people hide their sickness and avoid reporting for follow-up treatment visits. Inadequate knowledge and beliefs were fertile ground for aggravated stigma and believing that diseases like TB are caused by spirits and thus cured by spiritual rituals or religious prayers. Cultural norms were also the basis of gender-based imbalance in accessing care, ‘I could not go to hospital without my husband’s permission’, TB survivor.ConclusionOur findings show that socioeconomic and cultural factors are substantial ‘roadblocks’ to accelerating the uptake and utilisation of diagnostic and treatment tools. Resolving these barriers should be given equal attention as is to health system barriers.