BACKGROUND: Perinatal women accessing prevention of mother-to-child transmission of HIV (PMTCT) services are at an increased risk of depression; however, in Tanzania there is limited access to services provided by mental health professionals. This paper presents a protocol and baseline characteristics for a study evaluating a psychosocial support group intervention facilitated by lay community-based health workers (CBHWs) for perinatal women living with HIV and depression in Dar es Salaam. METHODS: A cluster randomized controlled trial (RCT) is conducted comparing: 1) a psychosocial support group intervention; and 2) improved standard of mental health care. The study is implemented in reproductive and child health (RCH) centers providing PMTCT services. Baseline characteristics are presented by comparing sociodemographic characteristics and primary as well as secondary outcomes for the trial for intervention and control groups. The trial is registered under clinicaltrials.gov (NCT02039973). RESULTS: Among 742 women enrolled, baseline characteristics were comparable for intervention and control groups, although more women in the control group had completed secondary school (25.2% versus 18.2%). Overall, findings suggest that the population is highly vulnerable with over 45% demonstrating food insecurity and 17% reporting intimate partner violence in the past 6 months. CONCLUSIONS: Baseline characteristics for the cluster RCT were comparable for intervention and control groups. The trial will examine the effectiveness of a psychosocial support group intervention for the treatment of depression among women living with HIV accessing PMTCT services. A reduction in the burden of depression in this vulnerable population has implications in the short-term for improved HIV-related outcomes and for potential long-term effects on child growth and development. TRIAL REGISTRATION: The trial is registered under clinicaltrials.gov (NCT02039973). Retrospectively registered on January 20, 2014.

OBJECTIVE: To test the success of a maternal healthcare quality improvement intervention in actually improving quality. DESIGN: Cluster-randomized controlled study with implementation evaluation; we randomized 12 primary care facilities to receive a quality improvement intervention, while 12 facilities served as controls. SETTING: Four districts in rural Tanzania. PARTICIPANTS: Health facilities (24), providers (70 at baseline; 119 at endline) and patients (784 at baseline; 886 at endline). INTERVENTIONS: In-service training, mentorship and supportive supervision and infrastructure support. MAIN OUTCOME MEASURES: We measured fidelity with indictors of quality and compared quality between intervention and control facilities using difference-in-differences analysis. RESULTS: Quality of care was low at baseline: the average provider knowledge test score was 46.1% (range: 0-75%) and only 47.9% of women were very satisfied with delivery care. The intervention was associated with an increase in newborn counseling (β: 0.74, 95% CI: 0.13, 1.35) but no evidence of change across 17 additional indicators of quality. On average, facilities reached 39% implementation. Comparing facilities with the highest implementation of the intervention to control facilities again showed improvement on only one of the 18 quality indicators. CONCLUSIONS: A multi-faceted quality improvement intervention resulted in no meaningful improvement in quality. Evidence suggests this is due to both failure to sustain a high-level of implementation and failure in theory: quality improvement interventions targeted at the clinic-level in primary care clinics with weak starting quality, including poor infrastructure and low provider competence, may not be effective.

Background: Despite the need for mental health surveillance in humanitarian emergencies, there is a lack of validated instruments. This study evaluated a sequential screening process for major depressive disorder (MDD) using the two- and eight-item Patient Health Questionnaires (PHQ-2 and PHQ-8, respectively). Methods: This study analyzed data collected during a cross-sectional survey in a Syrian refugee camp in Greece (n = 135). The response rate for each instrument was assessed, and response burden was calculated as the number of items completed. The sequential screening process was simulated to replicate the MDD classifications captured if the PHQ-2 was used to narrow the population receiving the full PHQ-8 assessment. All respondents were screened using the PHQ-2. Only respondents scoring ≥ 2 are considered at risk for symptoms of MDD and complete the remaining six items. The positive and negative percent agreement of this sequential screening process were evaluated. Results: The PHQ-2, PHQ-2/8 sequential screening process, and PHQ-8 were completed by 91%, 87%, and 84% of respondents, respectively. The sequential screening process had a positive percent agreement of 89% and a negative percent agreement of 100%, and eliminated the need to complete the full PHQ-8 scale for 34 (25%) respondents. Conclusions: The benefits of the sequential screening approach for the classification of MDD presented here are twofold: preserving classification accuracy relative to the PHQ-2 alone while reducing the response burden of the PHQ-8. This sequential screening approach is a pragmatic strategy for streamlining MDD surveillance in humanitarian emergencies.

OBJECTIVE: To evaluate the association between US state policies that establish age 18 or 21 years as the minimum purchaser age for the sale of handguns and adolescent suicide rate. DESIGN: Regression discontinuity and difference-in-differences analyses. SETTING: 46 US states without policy changes between 2001 and 2017; Missouri and South Carolina, which lowered the age for handgun sales in 2007 and 2008, respectively; and West Virginia and Wyoming, which increased the age for handgun sales in 2010. PARTICIPANTS: Adolescents aged 13 to 20 years(554 461 961 from 2001 to 2017) in the regression discontinuity analysis, and adolescents aged 18 to 20 years (168 934 041 from 2002 to 2014) in the main difference-in-differences analysis. MAIN OUTCOME MEASURE: Suicide rate per 100 000 adolescents. RESULTS: In the regression discontinuity analysis, state policies that limited the sale of handguns to those aged 18 or older (relative to 21 or older) were associated with an increase in suicide rate among adolescents aged 18 to 20 years equivalent to 344 additional suicides in each state where they were in place between 2001 and 2017. In the difference-in-differences analysis, state policies that limited the sale of handguns to those aged 21 or older were associated with 1.91 fewer suicides per 100 000 adolescents aged 18 to 20 years (95% confidence interval -3.13 to -0.70, permutation adjusted P=0.025). In the difference-in-differences analysis, there were 1.83 fewer firearm related suicides per 100 000 adolescents (-2.66 to -1.00, permutation adjusted P=0.002), with no association between age 21 handgun sales policies and non-firearm related suicides. Separate event study estimates indicated increases in suicide rates in states that lowered the age of handgun sales, with no association in states that increased the age of handgun sales. CONCLUSIONS: A clear discontinuity was shown in the suicide rate by age at age 18 in states that limited the sale of handguns to individuals aged 18 or older. State policies to limit the sale of handguns to individuals aged 21 or older were associated with a reduction in suicide rates among adolescents. Increases in suicide rates were observed after states lowered the age of handgun sales, but no effect was found in states that increased the age of handgun sales.

BACKGROUND: Access to high-quality, person-centred care during pregnancy and childbirth is a global priority. Positive experience of care is key in particular, because it is both a fundamental right and can influence health outcomes and future healthcare utilisation. Despite its importance for accountability and action, systematic guidance on measuring experience of care is limited. METHODS: We conducted a scoping review of published literature to identify measures/instruments for experience of facility-based pregnancy and childbirth (abortion, antenatal, intrapartum, postnatal and newborn) care. We systematically searched five bibliographic databases from 1 January 2007 through 1 February 2019. Using a predefined evidence template, we extracted data on study design, data collection method, study population and care type as reported in primary quantitative articles. We report results narratively. RESULTS: We retrieved 16 528 unique citations, including 171 eligible articles representing, 157 unique instruments and 144 unique parent instruments across 56 countries. Half of the articles (90/171) did not use a validated instrument. While 82% (n=141) of articles reported on labour and childbirth care, only one reported on early pregnancy/abortion care. The most commonly reported sub-domains of user experience were communication (84%, 132/157) and respect and dignity (71%, 111/157). The primary purpose of most papers was measurement (70%, 119/171), largely through cross-sectional surveys. CONCLUSION: There are alarming gaps in measurement of user experience for abortion, antenatal, postnatal and newborn care, including lack of validated instruments to measure the effects of interventions and policies on user experience. PROTOCOL REGISTRATION DETAILS: This review was registered and published on PROSPERO (CRD42017070867). PROSPERO is an international database of prospectively registered systematic reviews in health and social care.

OBJECTIVES: Reduction in maternal and newborn mortality requires that women deliver in high quality health facilities. However, many facilities provide sub-optimal quality of care, which may be a reason for less than universal facility utilisation. We assessed the impact of a quality improvement project on facility utilisation for childbirth. METHODS: In this cluster-randomised experiment in four rural districts in Tanzania, 12 primary care clinics and their catchment areas received a quality improvement intervention consisting of in-service training, mentoring and supportive supervision, infrastructure support, and peer outreach, while 12 facilities and their catchment areas functioned as controls. We conducted a census of all deliveries within the catchment area and used difference-in-differences analysis to determine the intervention's effect on facility utilisation for childbirth. We conducted a secondary analysis of utilisation among women whose prior delivery was at home. We further investigated mechanisms for increased facility utilisation. RESULTS: The intervention led to an increase in facility births of 6.7 percentage points from a baseline of 72% (95% Confidence Interval: 0.6, 12.8). The intervention increased facility delivery among women with past home deliveries by 18.3 percentage points (95% CI: 10.1, 26.6). Antenatal quality increased in intervention facilities with providers performing an additional 0.5 actions across the full population and 0.8 actions for the home delivery subgroup. CONCLUSIONS: We attribute the increased use of facilities to better antenatal quality. This increased utilisation would lead to lower maternal mortality only in the presence of improvement in care quality.

In 2018, three independent reports were published, emphasizing the need for attention to, and improvements in, quality of care to achieve effective universal health coverage. A key aspect of high quality health care and health systems is that they are person-centred, a characteristic that is at the same time intrinsically important (all individuals have the right to be treated with dignity and respect) and instrumentally important (person-centred care is associated with improved health-care utilization and health outcomes). Following calls to make 2019 a year of action, we provide guidance to policy-makers, researchers and implementers on how they can take on the task of measuring person-centred care. Theoretically, measures of person-centred care allow quality improvement efforts to be evaluated and ensure that health systems are accountable to those they aim to serve. However, in practice, the utility of these measures is limited by lack of clarity and precision in designing and by using measures for different aspects of person-centeredness. We discuss the distinction between two broad categories of measures of patient-centred care: patient experience and patient satisfaction. We frame our discussion of these measures around three key questions: (i) how will the results of this measure be used?; (ii) how will patient subjectivity be accounted for?; and (iii) is this measure validated or tested? By addressing these issues during the design phase, researchers will increase the usability of their measures.

Knowing how patients are treated in care is foundational for creating patient-centred, high-quality health systems and identifying areas where policies and practices need to adapt to improve patient care. However, little is known about the prevalence of disrespectful treatment of patients in sub-Saharan Africa outside of maternity care. We used data from a household survey of 2002 women living in rural Tanzania to describe the extent of disrespectful care during outpatient visits, who receive disrespectful care, and determine the association with patient satisfaction, rating of quality and recommendation of the facility to others. We asked about women's most recent outpatient visit to the local clinic, including if they were made to feel disrespected, if a provider shouted at or scolded them, and if providers made negative or disparaging comments about them. Women who answered yes to any of these questions were considered to have experienced disrespectful care. We report risk ratios with standard errors clustered at the facility level. The most common reasons for seeking care were fever or malaria (33.9%), vaccination (33.6%) and non-emergent check-up (13.4%). Disrespectful care was reported by 14.3% of women and was more likely if the visit was for sickness compared to a routine check-up [risk ratio (RR): 1.6, 95% confidence interval (CI): 1.1-2.2]. Women who did not report disrespectful care were 2.1 times as likely to recommend the clinic (95% CI: 1.6-2.7). While there is currently a lot of attention on disrespectful maternity care, our results suggest that this is a problem that goes beyond this single health issue and should be addressed by more horizontal health system interventions and policies.

BACKGROUND: Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home. METHODS AND FINDINGS: As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82-1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30-0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified. CONCLUSIONS: A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC. TRIAL REGISTRATION: ClinicalTrials.gov NCT01932138.

BACKGROUND: There is a dearth of evidence on the causal effects of different care delivery approaches on health system satisfaction. A better understanding of public satisfaction with the health system is particularly important within the context of task shifting to community health workers (CHWs). This paper determines the effects of a CHW program focused on maternal health services on public satisfaction with the health system among women who are pregnant or have recently delivered. METHODS: From January 2013 to April 2014, we carried out a cluster-randomized controlled health system implementation trial of a CHW program. Sixty wards in Dar es Salaam, Tanzania, were randomly allocated to either a maternal health CHW program (36 wards) or the standard of care (24 wards). From May to August 2014, we interviewed a random sample of women who were either currently pregnant or had recently delivered a child. We used five-level Likert scales to assess women's satisfaction with the CHW program and with the public-sector health system in Dar es Salaam. RESULTS: In total, 2329 women participated in the survey (response rate 90.2%). Households in intervention areas were 2.3 times as likely as households in control areas to have ever received a CHW visit (95% CI 1.8, 3.0). The intervention led to a 16-percentage-point increase in women reporting they were satisfied or very satisfied with the CHW program (95% CI 3, 30) and a 15-percentage-point increase in satisfaction with the public-sector health system (95% CI 3, 27). CONCLUSIONS: A CHW program for maternal and child health in Tanzania achieved better public satisfaction than the standard CHW program. Policy-makers and implementers who are involved in designing and organizing CHW programs should consider the potential positive impact of the program on public satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov, EJF22802.